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The Neural Basis of Cognition

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The Neurology of Acquired Pedophilia

Pedro Maranhão Gomes Lopes, Catarina Sodré de Castro Prado & Ricardo de
Oliveira-Souza

To cite this article: Pedro Maranhão Gomes Lopes, Catarina Sodré de Castro Prado &
Ricardo de Oliveira-Souza (2020): The Neurology of Acquired Pedophilia, Neurocase, DOI:
10.1080/13554794.2020.1727929

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NEUROCASE
https://doi.org/10.1080/13554794.2020.1727929

The Neurology of Acquired Pedophilia

a a a,b
Pedro Maranhão Gomes Lopes , Catarina Sodré de Castro Prado and Ricardo de Oliveira-Souza
a
Medical Internship Program, Gaffrée eGuinle University Hospital, the Federal University of the State of Rio de Janeiro, Rio de Janeiro, Brazil; bSenior
Researcher in the Clinical Neurosciences, the D ’Or Institute for Research & Education, and Department of Neurology, Gaffrée e Guinle University
Hospital, the Federal University of the State of Rio de Janeiro, Rio de Janeiro, Brazil

ABSTRACT ARTICLE HISTORY

The clinicoanatomic cases of acquired pedophilia that have been published in the medical and forensic Received 30 April 2019
literature up to 2019 are reviewed. Twenty-two cases fit our inclusion criteria. All but one were men, and Accepted 4 February 2020
in only one case the injury was localized to the left hemisphere. Hypersexuality was present in 18 cases. KEYWORDS
The damaged areas fell within the frontotemporoinsular cortices and related subcortical nuclei; however, Acquired pedophilia;
the anterior hypothalamus was spared. Damage to parts of the right frontotemporoinsular lobes with acquired sociopathy;
sparing of the anterior hypothalamus seems to be critical for the emergence of acquired pedophilia. frontotemporoinsular
cortices; medial forebrain
bundle; hypersexuality;
perifornical region

1. Introduction neurochemical substrates. Fewer investigations have been car-

Pedophilia consists of the persistent attraction to prepubescent
children as evinced in erotic fantasies and urges that may be
acted upon, in which case they are diagnosed as a pedophilic
disorder. With an estimated 3% prevalence in the general
population (Hall & Hall, 2007), pedophilia is a typical develop-
mental disorder of males (Fedoroff, Fishell, & Fedoroff, 1999), in
whom the pedophilic disorder seems to be intrinsic to biologic
maleness; accordingly, it is usually first noticed (at least by the
patient) in the early teens or even before. As a rule, at least two
paraphilic disorders co-occur in most pedophiles (Abel, Becker,
Cunningham-Rathner, Mittelman, & Rouleau, 1988). Over 90%
of patients with a diagnosis of pedophilia are also sexually
attracted to adults (Hall & Hall, 2007). Pedophilia stands as
a particularly relevant paraphilic disorder because of its fre-
quency, clinical significance, and moral and forensic implica-
tions (Finkelhor, 1979). The investigation of the neural basis of
pedophilia has grown in the past decades thanks to the devel-
opment of neuroimaging techniques that have probed the
anatomy and function of the human brain in vivo (Mohnke
et al., 2014).
Research on the neurology of pedophilia has far-reaching
implications, such as the definition of the critical neural struc-
tures that might be modified by chemical or surgical interven-
tions. It may also provide insights into the neurological
substrate of other paraphilic disorders (Berlin & Coyle, 1981).
Current research has focused on the neural correlates of devel-
opmental pedophilia with structural and functional magnetic
resonance imaging (MRI); to date, no postmortem verification
has been conducted on the brains of patients with develop-
mental pedophilia. Notwithstanding the obvious progress of
the past decade, the medical literature on pedophilia remains
fragmentary and controversial, such as its causes and
ried out on previously normal individuals who became pedo-
philes following an injury to the brain. These cases may
produce unique information on the cerebral underpinnings of
pedophilia by pinpointing its large-scale neuroanatomical cor-
relates. A better knowledge of the injured brain regions that
have been related to the emergence of pedophilia may inform
upcoming research on the neurobiology of developmental
pedophilia as well as on possible therapeutic targets for both
the acquired and developmental cases.
Acquired pedophilia is the focus of the present review;
developmental pedophilia and other paraphilic disorders will
only be mentioned to emphasize specific points related to
acquired pedophilia as needed.
2. Methods
PubMed, PsycInfo, and ISI Web of Science databases were
searched for cases of acquired pedophilia from brain damage
with sufficient anatomical information to allow clinicoanatomic
correlations that have been published up to 2019. The follow-
ing term combinations were used: (“pedophile” or “child moles-
ter” or “sexual abuse” or “sexual offender” or “pedophilia” or
“pedophilic behavior” or “paraphilia”) and (“neurobiology” or
“neuroimaging” or “brain” or “brain damage” or “neural lesion”).
Articles were included if they (i) reported on cases of acquired
pedophilia following brain damage whether circumscribed,
degenerative, or irritative, and (ii) identified a probable gross
anatomical correlate of the brain damage. The expression “irri-
tative focus” refers to the area of cortical tissue that generates
interictal electrographic spikes (Rosenow & Lüders, 2001),
which is thus consistent with the interictal manifestations of
these patients. The review covered all articles which were

CONTACT Ricardo de Oliveira-Souza rdeoliveira@gmail.com

Supplemental data for this article can be accessed here.
© 2020 Informa UK Limited, trading as Taylor & Francis Group
2 P. M. G. LOPES ET AL.
published in English, German, French or Portuguese up to
July 2019. Potentially relevant articles identified through cross-
reference search were also eligible and, in fact, constituted the
chief source of valid information.
For our current purposes, acquired pedophilia was defined
as the behavioral expression of pedophilic fantasies and urges
in previously normal individuals as a result of a brain injury
regardless of cause, pathological nature of the lesion, mode of
onset, and rate of progression. No attempt was made to
distinguish cases of developmental pedophilia that were
exposed by an acquired brain injury (e.g., frontotemporal
degeneration) from “true” acquired pedophilia (individuals
who were euphilic prior to the brain injury). “Normal” was
defined as the ability to be socially autonomous in the basic
domains of life, which includes the establishment and main-
tenance of productive interactions with sexual partners, rela-
tives, and friends as well as with clients, customers, and
colleagues (Endicott, Spitzer, Fleiss, & Cohen, 1976). For
these reasons, patients who were cognitively impaired to the
point of being incapable of judging the wrongness of their
acts were likewise excluded (e.g., Casanova, Mannheim, &
Kruesi, 2002). The cases included in the present survey were
selected on the basis of the behavioral criterion of acquired
pedophilia alone, not on anatomical criteria such as lesion
location or type. We did not follow up on the next logical
step of applying the inverse strategy of case selection begin-
ning with the collection of cases with intracranial lesions to
investigate their clinical manifestations. These two
approaches are not comparable, and the anatomical approach
may lead to quite different conclusions.
The following variables of interest were considered for analysis:
sex, age at which symptoms were first noticed, marital status, job
or occupation, treatment and outcome, comorbidities such as
hypersexuality, other paraphilias, and impulse control disorders,
hemispheric localization and side, and nature of the underlying
pathological process. Articles on developmental pedophilia (that
is, pedophilic disorder unrelated to acquired brain damage) and
other acquired paraphilias (e.g., Mitchell, Falconer, & Hill, 1954)
were excluded. Animal studies and publications without clinicoa-
natomical reports such as reviews, scientific comments, scientific
advisories were also excluded; in the case of duplicated articles,
only the original publication was cited.
Hypersexuality was operationally defined as
a heightening of sexual desire and activity taking as nor-
mal frames of reference (a) the individual’s own sexuality
at some arbitrary time frame (for example, before the
diagnosis of an olfactory groove meningioma), or (b) the
estimated population average of normality corrected for
sex and age (Baumeister, Bratslavsky, Finkenauer, & Vohs,
2001). Hypersexuality is experienced as an increase in
sexual desire and urges which are expressed through
behavioral strategies aimed at consummating them. The
outward expression of hypersexuality is an increase in the
frequency of attempts to engage in sexual intercourse and
its consummation as orgasm. Because sexual appetite fol-
lows an approximately normal distribution in the popula-
tion, hypersexuality may be normal for individuals who
deviate from the population mean. Pathological hyper-
sexuality is common to several neuropsychiatric conditions
(Krueger & Kaplan, 2000). In contrast to normal hypersexu-
ality, it implies the infliction of harm or suffering to the
individual himself or to others as a direct consequence of
his heightened propensity to engage in intercourse.
Because paraphilic disorders (Nelson et al., 2001) and
hypersexuality are common symptoms of mania
(American Psychiatric Association, 2013), cases of bipolar
mood disorder were excluded. We defined sexual disinhi-
bition as socially inappropriate sexual behavior; sexual
disinhibition is often associated with hypersexuality and
part of a broader picture of social disinhibition which
includes a disregard for morals, social adequacy, and the
law (Mendez, 2010), as expressed, for example, in moria
(Mendez, 2005), and kleptomania (Nyffeler & Regard,
2001),. However, social and sexual disinhibition often
occur independently from each other, indicating that
they reflect a disruption of different neural mechanisms.
3. Results
3.1. General findings
Only 22 cases fitting our inclusion criteria were published between
1972 and 2018. Potentially relevant cases that were published prior
to 1972 were excluded owing to insufficient information (e.g.,
Gelma, 1950). The age of the patients ranged from 20 to 82 years
(mean: 55 ± 15 years, median = 56 years), and all, but one (Ortego,
Miller, & Itabashi, 1993), were men. One patient, a man, was left-
handed (case 1, Mendez, Chow, Ringman, Twitchell, & Hinkin, 2000),
while all the other cases on which information was available were
right-handed (N = 12). Hypersexuality was present in 18 cases. Of
those in whom the marital status was reported, most were married
(N = 10): one was in the process of divorce (case 1 of Mendez et al.,
2000), another one (the only woman in the series) had been
divorced by her husband (Ortego et al., 1993), and a third had
married and divorced three times besides engaging in bigamy
during his last two relationships (Dimitrov, Phipps, Zahn, &
Grafman, 1999). In the three cases, pedophilia played a decisive
role in ending their marriages. Eleven cases were exclusively
attracted to prepubertal children (pedophiles in a narrow sense),
and four were exclusively attracted to pubertal children (hebe-
philes). Five were homosexual pedophiles, and three were bisexual
pedophiles. However, these figures are uncertain, because many
reports do not specify the age and sex of victims (Table 1).
Neuropathology and neuroanatomy of acquired pedophilia
The lesions are schematically presented in Figure 1. The
description of the lesion location was often too vague to
allow accurate anatomical charting. Yet, localization rather
than etiology seemed to be the primary determinant of
acquired pedophilia (Table 2). The nature of the lesions causing
pedophilia did not differ from the ordinary causes of intracra-
nial disease: different histopathological types of intracranial
tumors (N = 7), cortical degenerative diseases (N = 5), multiple
sclerosis (N = 2), traumatic brain injury (N = 3), ischemic cere-
brovascular disease (N = 2), temporal lobectomy (N = 1), palli-
dotomy (N = 1), and Huntington’s disease (N = 1). The lesions
were right-sided in 7 cases and bilateral in 14; only one case
had a lesion restricted to the left hemisphere (Gilbert & Vranič,
 NEUROCASE 3

Table 1. Demographic characteristics of patients with acquired pedophilia.

Case Number Author(s) Year Patient ID Sexa Age Side of Injuryb Handednessc Marital Status Occupation
1 Lesniak et al. 1972 NR M 56 R NR Married Farmer
2 Regestein et al. 1978 Case 1 M 56 R NR Married Musician
3 Miller et al. 1986 Case 5 M 50 R/L NR Married NR
4 Ortego et al. 1993 NR F 39 R/L R Divorced Nurse’s aide
5 Dimitrov et al. 1999 MGS M 50 R R Divorced; bigamist Retired from the Army
6 Mendez et al. 2000 Case 1 M 60 R/L L Process of divorce College professor
7 Case 2 M 67 R/L R NR Artist
8 Frohman et al. 2002 NR M 36 R/L R NR Production engineer
9 Burns & Swerdlow 2003 NR M 40 R R Married Schoolteacher
10 Devinsky et al. 2010 NR M 51 R R Married Pharmaceutical researcher
11 Rainero et al. 2011 NR M 49 R/L NR Married NR
12 Mendez et al. Case 2 M 67 R/L R NR NR
13 Case 3 M 76 R/L R NR NR
14 Case 4 M 82 R/L NR NR NR
15 Case 6 M 32 R/L NR NR NR
16 Case 7 M 59 R NR Married NR
17 Fumagalli et al. 2014 NR M 71 R/L R NR NR
18 Gilbert & Vranič 2015 NR M 48 Ld Rd Married NR
19 Sartori et al. 2016 NR M 64 R/L NR Married Pediatrician
20 Alnemari et al. NR NR 20 R/L NR NR NR
21 Scarpazza, Pennati et al. 2018 Case 1 M 70+ R/L Re Married Tradesman
22 Case 2 M 60+ R Re Married Unemployed
a
M: male; F: female
b
L: left, L/R: bilateral; R: right.
c
L: left, NR: not reported; R: right.
d
Information kindly provided by Dr. Andrej Vranič on 29 November 2019 by e-mail.
e
Information kindly provided by Dr. Giuseppe Sartori on 27 November 2018 by e-mail

Figure 1. Schematic rendering of lesions in acquired pedophilia. The lesions overlap (i) the cortical projection fields of the MFB and UF, (ii) the basal forebrain trajectory
of the ascending mesocorticolimbic dopaminergic fibers (via the MFB), or both. Please refer to supplementary text and table for a further account of the neuroanatomy
of male sexuality and the neuroanatomy of acquired pedophilia. MFB: medial forebrain bundle; UF: uncinate fascicle. Artwork: RO-S on MRIcron (http://people.cas.sc.
edu/rorden/mricron/index.html).

2015). In two cases acquired pedophilia was caused by an 4. Discussion

irritative focus (Devinsky, Sacks, & Devinsky, 2010; Poeppl,
Peytard, & Langguth, 2015). The patient reported on by
Poeppl et al. had no structural lesion on MRI and was therefore
left out of the present analysis.
4.1. General remarks
The main findings of the present survey may be thus summarized:
(i) there are very few cases of acquired pedophilia in the medical

Table 2. Behavioral and Neuroanatomic Affiliations of Acquired Pedophilia*.
Patient
N Author(s)
1 Lesniak, Szymusik, and
Chrzanowski (1972)
2 Regenstein and Reich Mr. AB
(1978)
3 Miller et al. (1986) Case 5
4 Ortego et al. (1993)
5 Dimitrov et al. (1999) MGS**
↑ Other
ID Sexuality Paraphilias Chief Clinical Manifestations
NR Yes Yes Hetero- and homosexual pedophilia,
increase of sexual drive, incest
against own daughter, sodomy,
exhibitionism, sadomasochism,
and coprolalia.
Yes No Increase of sexual drive with
pedophilic behavior; lack of
initiative (abulia minor).
Yes Yes Pedophilic behavior: sexual proposals CT: Neoplasm of L brainstem from pons to midbrain.
toward his 7-year-old daughter,
collecting pornography, public
sexual advances. L third nerve
palsy, R hemiparesis and
hemiataxia; urinary incontinence.
NR Yes Yes Pedophilia, zoophilia, incest,
hypersexuality, exhibitionism and
scoptophilia.
Yes Yes Post-injury development of
pedophilic behavior, increased
appetite for pornography, indecent
exposure, shoplifting, drastic mood
swings, lack of inhibition in social
intercourse, affective blunting;
dysexecutive syndrome: poor
handling of money, unable to stay
in jobs, and plan for the immediate
future; clonic seizures controlled
with carbamazepine.
4
Anatomical Findings Course Etiology
X-Ray: Fine-grained calcification in anterior cranial cavity Considerable bilateral impairment of Non-classified tumor
over R sphenoidal plane. smell and marked inequality of of parabaso-
Pneumoencephalogram: filling defect in the frontal horn reflexes of the lower extremities; central portions of
of R lateral ventricle, which was shifted dorsally. mental retardation. R FL
Flattening of the roof of the anterior portion of R lateral
ventricle and a shift of the anterior part of the
pericallosal cistern and of the sulcus of the cingulate
P. M. G. LOPES ET AL.
gyrus dorsally toward the vertex of the skull.
Radiological conclusion: tumor of R basal FL.
R FL meningioma. Residual lesion presumably caused by Meningioma removed; post- Supracellar
both tumor and surgery. operatory persistence of pedophilic meningioma
behaviors and increased sexual
drive.
1975: ventriculoatrial shunt inserted, Glioma
Necropsy: Infiltrating glioma of thalamus, hypothalamus, disappearance of urinary
ventral midbrain and pons, especially on the L. incontinence.
1979: arrested for pedophilic
behavior.
1981: hospitalized.
1984: deterioration of general
condition; death.
MRI: Cerebral hemispheres: extensive frontal, parietal and Treated with adrenocorticotropic Multiple sclerosis
temporal white matter lesions with extension into gray hormone and high-dose steroids.
matter of L FL. Large lesion in L dorsomedial thalamus Persistence of psychiatric symptoms.
and R midbrain just above the red nucleus.
Necropsy: Extensive irregular grayish areas of discoloration
in centrum semiovale primarily distributed along the
periventricular zone, and bilaterally in the forceps minor
and major. The frontal plaques, more severe on the L,
extended anteriorly to the subcortex of the frontal poles
and orbital surface. Confluent plaques in optic
radiations greater on the R. Bilateral thalamic atrophy
with grayish discoloration of R dorsomedial nucleus;
bilateral atrophy of lateral geniculate bodies. Brainstem
and cerebellum: bilateral abnormal areas in superior
cerebellar peduncles, corticospinal tracts in basis pontis
and pyramids, most of the medulla, and peridentate
zones.
Spinal cord: demyelinization at all levels.
Deep and near total demyelination in midbrain, pons,
medulla, and spinal cord.
TC: R medial FL lesion and frontopolar and anterior Missile wound due to
cingulate from shrapnel wound in Vietnam War. penetrating head
injury
(Continued)
Table 2. (Continued).
Patient
N Author(s)
6 Mendez et al. (2000)
7 Mendez et al. (2000)
8 Frohman, Frohman,
and Moreault (2002)
9 Burns and Swerdlow
(2003)
10 Devinsky et al. (2010)
11 Rainero, Rubino,
Negro, and Gallone
(2011)
↑ Other
ID Sexuality Paraphilias Chief Clinical Manifestations
Case Yes No Decline in memory and personality
1** over the preceding Hypersexuality
and pedophilic behavior.
Utilization behavior, hyperorality
and perseverations; sexually
molested his son 35 years
previously.
Case Yes Yes Hypersexuality and forgetfulness.
2** Sexually molested his son 30 years
previously. Multiple younger
girlfriends. Exposed himself to
a female physician. Depression
with suicidal ideation; bilateral
Babinski sign.
NR Yes No Pedophilic behavior and personality
changes, poor judgment,
impulsivity and inappropriate
sexual contact with strangers.
NR Yes No Increasing interest in pornography,
including child pornography. Slow
leftward saccades, wide-based gait,
bladder incontinence. Apraxia and
agraphia.
NR Yes Yes One month after surgery:
hypersexuality with pedophilic
behavior, coprophilia, irritability, R temporal lobectomy.
hyperphagia.
NR Yes No Heterosexual pedophilic disorder;
incest and aggressive behavior.
Mild episodic memory impairment.
Anatomical Findings Course Etiology
MRI FLAIR: bilateral symmetrical hyperintense signal along Paroxetine 20 mg + valproate 500/ bvFTD
hippocampal formation consistent with hippocampal 750 mg.
sclerosis. Conjugated estrogens 0.625 mg qd.
PET: prominent area of focal hypometabolism in the Increased supervision.
R inferior temporal region and subtler hypometabolism Significant behavioral improvement,
in L temporal lobe. including decrease of sexual
interest in children.
MRI: increased signal intensity and volume loss in mesial Sertraline therapy. Hippocampal
temporal lobe along the hippocampal formation, Carefully supervised environment. sclerosis possibly
consistent with bilateral hippocampal sclerosis. Behavior improvement. associated with
Serial PET scans over a 3-year period: stable area of ischemia from
decreased metabolism in R temporal lobe. a cardiac
arrhythmia
MRI (1993): multifocal, high-signal, T2-weighted white 1993: diagnosis of multiple sclerosis, Multiple sclerosis
matter abnormalities throughout the brain, especially in treated with methylprednisolone diagnosed in 1993
periventricular zone, hypothalamus, and brainstem. IV.
Axial proton density–weighted images showed 1994: IV methylprednisolone and
symmetric high-signal changes throughout the Interferon beta-1b.
hypothalamus and septal region. Coronal T2-weighted 1995: Therapy combined with
imaging revealed a large hyperintensity in the fluvoxamine and
hypothalamus adjacent to the third ventricle. T1- medroxyprogesterone acetate.
weighted images with gadolinium showed areas of Significant improvement in
punctate enhancement in subinsular, internal capsule, behavioral control.
hypothalamus, and deep white matter. High-signal After 9 months:: refractory orthostatic
intensity changes in mesencephalon adjacent to a low- hypotension; all medications were
signal appearance of the red nuclei, substantia nigra, discontinued, except the interferon
and superior colliculi (giant panda sign). beta-1b.
MRI (1995): extensive lesions in hypothalamus and septal
nuclei as previously observed.
T1 sagittal- and contrast-enhanced coronal cuts: tumor Legal removal from home. Hemangiopericytoma
mass extended from olfactory groove upwards Medroxyprogesterone and tumor
displacing the R orbitofrontal cortex and distorting resection.
R dorsolateral prefrontal cortex. Remission of pedophilia after tumor
resection.
MRI (at age 33): R mesial temporal lesion. Arrested. Treated with quetiapine and Right temporal
Video-EEG: R temporal seizure onset. sertraline. Remission of obsessive lobectomy to treat
sexual thoughts, became epilepsy
Pathology: Ganglioglioma. hyposexual.
Video-EEG (at age 39): R posterior temporal seizure focus.
R posterior temporal resection.
TC: mild asymmetric frontal atrophy. 5 mg olanzapine + 20 mg paroxetine. Frontotemporal
TC and MRI (6 years later): bilateral FL atrophy moderately Remission of pedophilic behavior in dementia
increased in comparison with previous one. a few weeks. Referred for
SPECT: bilateral frontal hypoperfusion. behavioral and legal counseling.
(Continued)
NEUROCASE
5
 6

Table 2. (Continued).
Patient ↑ Other
N Author(s) ID Sexuality Paraphilias Chief Clinical Manifestations Anatomical Findings Course Etiology
12 Mendez and Shapira Case 2 Yes No Gradual personality change; increased MRI: bilateral atrophy of FL, more extensive on the R. Haloperidol; behavioral management. Familial behavioral
(2011) sexual drive with pedophilic SPECT: bilateral frontotemporal hypoperfusion more variant
behavior toward his daughter. extensive on the R. frontotemporal
Disinhibited behavior, compulsive dementia.
acts, hyperorality, decreased verbal
fluency, impaired executive
functions. Dysarthria, bradykinesia,
P. M. G. LOPES ET AL.

mild lead-pipe rigidity.

13 Mendez and Shapira Case 3 No No Pedophilic behavior, declining MRI: marked bilateral temporal atrophy with enlarged Donepezil and memantine. FL variant
(2011) memory, cognition, and temporal horns with relative sparing of FLs. Alzheimer’s
disinhibited behavior. PET: mild global hypometabolism. disease.
(but possible bvFTD)
14 Mendez and Shapira Case 4 Yes Yes Sudden personality changes and CT: lacunes in L caudate head and R globus pallidus. Valproate and trazodone. Vascular dementia
(2011) markedly increased sexual drive. PET: additional hypometabolic in R posterior cingulate
Touched people inappropriately, gyrus.
including his stepdaughter.
Exhibitionism (walked naked in
public). Perseverative and
disinhibited behavior. Deficits on
memory, visuospatial
constructions, calculations, praxis,
and frontal-executive tests. Mild
bradykinesia.
15 Mendez and Shapira Case 6 No No Pedophilic behavior, personality MRI: bilateral atrophy of caudate and putamen nuclei. Haloperidol and sertraline. Isolation Huntington’s disease
(2011) changes with depression and PET: striatal hypometabolism. from children.
aggressiveness. Dysarthria, deficits
in memory and executive
functions, wide, slowed gait,
involuntary choreoathetoid
movements. Reflexes: 3
+ symmetrical
16 Mendez and Shapira Case 7 Yes No Increased sexual drive with pedophilic MRI: R pallidotomy. Decrease of antiparkinsonian Pallidotomy for
(2011) behavior toward his medication Parkinson’s disease
granddaughter after R pallidotomy.
Frequent masturbation,
propositioned to his wife’s friends,
hired strippers and prostitutes.
17 Fumagalli, Pravetoni, NR Yes Yes Pedophilic behavior, exhibitionism, TC (70-yearr-old): extensive hypodense area in NR Traumatic brain
and Priori (2015) frotteurism and voyeurism. Mild R ventromedial FL and medial temporal lobe, and injury
dysexecutive syndrome and L frontal pole and olfactory trigone.
seizures with L pyramidal EEG: slow wave abnormalities in R frontotemporal regions
hemisyndrome, with occasional paroxysms.
dysdiadochokinesia, dysmetria, and
hypoactive deep tendon reflexes.
18 Gilbert and Vranič NR Yes NR Sentenced to one year in prison for MRI: Large L FL tumor with subfalcine herniation. Surgical removal of tumor. After Glioblastoma
(2015) physical assault and sexual surgery cooperative without focal multiform
harassment of pubescent neurological deficits. Abnormal
stepdaughter. sexual behavior did not recur.
19 Sartori et al. (2016) NR No No Pedophilic behavior. Tunnel vision MRI: clivus chordoma displacing pituitary and Behavioral and neurologic Clivus chordoma
and diplopia. Impairments in compressing orbital cortex, optic chiasm and abnormalities receded following
emotion attribution, moral hypothalamus. surgical resection of tumor.
reasoning, and abstract thinking.
(Continued)
Table 2. (Continued).
N Author(s)
20 Alnemari, Mansour,
Buehler, and Gaudin
(2016)
21 Scarpazza, Pennati
et al. (2018))
22 Scarpazza, Pennati
et al. (2018)
** bvFTD: behavioral variant of frontotemporal degeneration; FL: frontal lobe; L: left; NR: not reported; R: right; R/L: bilateral.
** Evidence of developmental pedophilia predating brain injury.
Patient ↑ Other
ID Sexuality Paraphilias Chief Clinical Manifestations
NR Yes No Increase of sexual drive with
pedophilic behavior. Attention
deficit, difficulty sleeping,
irritability, and behavioral changes.
Case 1 Yes No Sexually-inappropriate behavior
toward boys and impulsivity.
A neurological examination
revealed a severe deficit in critical
thinking, abstract thinking and
logorrhea, suggestive of
a dysexecutive syndrome. Also
manifested a severe deficit in
attention, behavior control,
impulse inhibition, preservative
behavior, and an inability to
anticipate the consequences of his
actions. His family reported that he
became obsessed with hygiene
and cosmetics, dressed up
eccentrically, and became
affectively indifferent.
Case 2 No No Sexually inappropriate behavior
toward boys; pedophilic urges
carried out in a disorganized and
risky manner.
Anatomical Findings Course Etiology
TC: L frontobasal and bilateral temporal contusions. NR Traumatic brain
TC (3 months later): L basal temporal and L frontobasal injury; L epidural
encephalomalacia. hematoma
MRI: bilateral FL atrophy Decline in daily living autonomy; bvFTD
unable to understand the value of
money; acted erratically;
manifested obsessive behaviors;
become verbally aggressive toward
wife; manifested scarce empathy;
hyperphagia; hypersexuality
toward wife; impulsivity;
kleptomania.
TC: bulky meningioma of R frontal and parietal lobes, Clear improvement in cognitive Meningothelial
significant mass effect with lateral ventricles functions following tumor meningioma
compression and inter-hemispheric shifting of midline resection
structures. Neuropsychologic evaluation: severe
cognitive impairment characterized
by general cognition below the
normal range, constructional
apraxia and spatiotemporal
disorientation, impaired sustained
attention, difficulty to inhibit
automatic responses and
behaviors, impairment in problem
solving and planning.
NEUROCASE
7
8 P. M. G. LOPES ET AL.
and forensic literature, (ii) the poor quality of most reports has
hampered reliable clinicoanatomic inferences, (iii) acquired pedo-
philia occurs almost exclusively in men, (iv) a right hemisphere
lesion was sufficient to produce acquired pedophilia in nearly all
cases (Section 4.2), and (v) the distribution of lesions suggests that
acquired pedophilia is the clinical counterpart of a capricious inter-
action between the destruction and sparing of specific functional
brain systems (Sections 4.4 and 4.5).
4.2. Right hemisphere damage, hypersexuality, and
acquired pedophilia
Despite the low accuracy of the clinical and anatomical descrip-
tions of most reports, some clues on the probable as well as on
the improbable neuroanatomical correlates of acquired pedo-
philia have emerged from the present review (Figure 1). Most
cases of acquired pedophilia were the product of right or
bilateral hemisphere damage. The lesions were primarily
located within the limits of a region that encompasses the
frontal and temporal lobes, the insula, and related subcortical
structures. For reasons detailed further on, a critical anterior
hypothalamic region must also be spared (see supplementary
material, “A primer on the cerebral organization of male sexual
behavior”). The right parietal and occipital lobes, as well as the
left hemisphere, were not injured, except in one patient in
whom the left frontal lobe alone was the primary site of
damage (Gilbert & Vranič, 2015). Figure 1 also indicates that
the lesions fell within the cortical projection fields of the unci-
nate fasciculus and the medial forebrain bundle (MFB).
Pathological hypersexuality without pedophilia is often
a consequence of injuries of the right or both cerebral hemispheres
(Braun, Dumont, Duval, Hamel, & Godbout, 2003). The right orbi-
tofrontal syndrome, of which hypersexuality may be a core symp-
tom (de Oliveira-souza & Moll, 2019) but which only rarely causes
pedophilia (de Oliveira-souza, Paranhos, Moll, & Grafman, 2019),
provides a conspicuous example of this association.
In the four patients with pedophilia who were not hypersex-
ual the lesions were localized to the temporal lobes (Case 3,
Mendez & Shapira, 2011), the caudate and putamen (Case 6,
Mendez & Shapira, 2011), and the upper brainstem and poster-
ior hypothalamus (Sartori, Scarpazza, Codognotto, & Pietrini,
2016). The frontal lobes were undamaged in all, thus support-
ing the tenet that acquired pedophilia is primarily related to an
injury of the temporal lobes and associated neural systems
(e.g., Starkstein & Robinson, 1997).
Acquired pedophilia was caused by an irritative focus in
two cases (Devinsky et al., 2010; Poeppl et al., 2015).
Although the patient of Poeppl et al. did not meet our inclu-
sion criteria, the case is worthy of note because he developed
absence-like episodes and pedophilic behavior in adult life.
His scalp EEG showed bilateral frontotemporal theta waves
that normalized in parallel with the remission of the absence
seizures and pedophilic behavior following treatment with
valproate. Discontinuation of the medication resulted in the
recurrence of symptoms, while the subsequent introduction
of the medication led to prompt relief again. There is no
evidence that valproate acts in the remission of pedophilic
behavior in the absence of mania (Thibaut, De La Barra,
Gordon, Cosyns, & Bradford, 2010); it seems more probable
that valproate acted indirectly through the suppression of
seizure activity. Regardless of the mechanism of action of
valproate, this indicates that pedophilic behavior may be
produced by nonconvulsive epileptic activity in the absence
of gross structural lesions, a well-known phenomenon in the
clinical (Mitchell et al., 1954) and experimental (Goldensohn,
1984) literature.
The preceding observations concur with the implication of
the temporal lobes in a variety of deviant sexual behaviors,
especially, but not necessarily, when the cerebral injury is
acquired in early childhood (Kolářský, Freund, Matchek, &
Polak, 1967; Walker, 1972). An injury of the frontal lobes
abolishes or weakens the modulation that they normally exert
upon the “libidinous” temporal lobes in the fine-tuning of sexual
behavior to social context. Frontal lesions thus add the symp-
toms of social inadequacy and disinhibition to the clinical man-
ifestations (Ibáñez & Manes, 2012). Medical treatment, whether
hormonal, serotonergic, antiepileptic, or stereotactic, aims to
reduce hypersexuality and pathologic urges by a direct action
on the MFB reward system. Cognitive-behavioral therapy addi-
tionally aims to modify the paraphilic fantasies and urges.
Pathological hypersexuality and acquired pedophilia have
most often been documented in right hemisphere lesions.
Therefore, it might be thought that they share a common sub-
strate in the right hemisphere. However, only very few cases of
right hemisphere damage with hypersexuality develop
acquired pedophilia. This asymmetric double dissociation sug-
gests that pathological hypersexuality and acquired pedophilia
are independent symptoms of right hemisphere damage (see
supplementary Table and supplementary Figure 2).
Given the complex interactions that are known to exist
between handedness, hemispheric dominance for different cog-
nitive domains, and gender, it is remarkable that the only case with
a lesion of the left hemisphere was a right-handed man (Gilbert &
Vranič, 2015). This case might represent a new pattern of atypical
hemispheric asymmetry for emotions, empathy, and social beha-
vior akin to those described in left-handers with asymmetric tem-
poral lobe atrophy (Perry et al., 2001). Similar asymmetries of
gender and laterality in acquired sociopathy stress these intriguing
associations (de Oliveira-souza et al., 2019).
4.3. Acquired pedophilia: true and apparent
The first intriguing question that springs from the cases herein
surveyed is the possibility that the brain lesions may have
converted a theretofore occult pedophilia (that is, pedophilic
ideation without translation into actual behavior) into a true
pedophilic disorder. This phenomenon would support current
phenomenological and behavioral distinctions (American
Psychiatric Association, 2013; Berlin, 2002). However, this pos-
sibility cannot be generalized because information on possible
premorbid sexual misconduct is lacking or has been concealed
by the patient over the years, sometimes with the acquiescence
of his closest relatives. Nonetheless, at least in a few cases, there
is evidence that a pedophilic disorder had unobtrusively
existed for years up to the advent of the brain lesion that
ultimately exposed it (e.g., case 1 of Mendez et al., 2000).
 NEUROCASE 9

A no less enticing alternative is the possibility that certain
patterns of brain injury do create pedophilic urges in previously
euphilic individuals. True acquired pedophilia, that is, pedophilia
arising for the first time in genuinely euphilic individuals, may have
occurred in at least a few cases (e.g., Ortego et al., 1993). In such
cases, the patient’s sexuality would change not only in amount
(pathologic hypersexuality) but mainly in quality. Miller,
Cummings, McIntyre, Ebers, and Grode (1986) argued that fronto-
temporal lesions without the involvement of the hypothalamus
and basal forebrain give rise to heightened sexual impulses with-
out a change in sexual orientation, whereas injuries of the basal
forebrain or its direct connections with the frontotemporoinsular
(FTI) cortices may entail a change in sexual orientation. We elabo-
rate on this inventive hypothesis further on.
A recent cluster analysis of acquired pedophilia provided six
“red flags” that suggest a structural cause for pedophilia (Ciani,
Scarpazza, Covelli, & Bataglia, 2019). Part of their work included
the same cases that we collected in the present review. However,
the authors do not detail the neural correlates of their cases,
making their work and ours complementary to each other.
4.4. A provisional working hypothesis: acquired
pedophilia as a product of injury of a right
frontotemporoinsular network
As a testable hypothesis, we suggest that the emergence of
pedophilia from brain damage depends on the lesion or dys-
function of certain sectors of the FTI cortices, their subcortical
connections, or both. Injuries that fall within the boundaries of
this region appear to entail two consequences that ultimately
make up the clinical presentation of acquired pedophilia. The
first is to determine the pattern of the deviant sexual interests
and behaviors in individual cases as well as the co-occurrence
of other paraphilias and impulse control disorders. The second
consequence is to release the dopaminergic fibers that course
in the MFB from the modulation of the injured FTI cortices
themselves. The relative hyperfunction of the mesocortical
system thus created provides the appetitive-hedonic back-
ground of the behavioral manifestations, such as the heigh-
tened sexual drive that makes up the core of pathological
hypersexuality (Bracht, Doidge, Keedwell, & Jones, 2015). This
simple account is a particular case of a classical rule of neurol-
ogy, which states that the symptoms of a non-epileptic lesion
are the product of a capricious interaction between what is
impaired with what is spared (Brazzelli, Colombo, Della Sala, &
Spinnler, 1994). Future research should pinpoint the minimal
regions that must be injured and spared for pedophilia to
emerge. The present cases indicate that these regions should
be sought within the boundaries of the region outlined in the
preceding paragraphs as well as in the spared regions (Suffren
et al., 2011).
4.4.1. The importance of sparing the perifornical-anterior
commissural area
In most cases of acquired pedophilia, a small region that lies at
the crossroads of the fornix and the anterior commissure seems
to have been spared (Figure 2). Bilateral damage to this region
destroys a large part of the preoptic area and anterior hypotha-
lamus, leading to permanent loss of libido, impotence, and
anorgasmia (Meyers, 1962; Plum & van Uitert, 1978). This is
the richest region in the human brain of receptors of the
affiliative peptides oxytocin and vasopressin (Loup, Tribollet,
Dubois-Dauphin, & Dreifuss, 1991), being strongly engaged by
affiliative experiences (Moll et al., 2012) and sexual arousal in
both sexes (Stoléru, 2014). This perifornical-anterior commis-
sural region has been spared in virtually all cases of pathologi-
cal hypersexuality whether associated with pedophilia or not
(e.g., Gorman & Cummings, 1992; Poeck & Pilleri, 1965);

Figure 2. (modified from Meyers, 1962). Schematic rendering of the critical perifornical-anterior commissural region (circled in red) damage to which leads to
permanent loss of libido, impotence, and anorgasmia. The insert depicts the descending columns of the fornix, which split into pre- and postcommissural as they near
the anterior commissure. The ventral tegmental area is colored green. Am: amygdala; CC: corpus callosum; CG: cingulate gyrus; CS: cingulate sulcus; FP: frontal pole; H:
hypothalamus; IC: internal capsule; IFS: inferior frontal sulcus; L: lenticular nucleus; Post: postcommissural column of the fornix; Pre: precommissural column of the
fornix; SFS: superior frontal sulcus; Th: thalamus; TP: temporal pole. Artwork: RO-S on MRIcron: http://people.cas.sc.edu/rorden/mricron/index.html.
10 P. M. G. LOPES ET AL.
conversely, it has been injured in cases in which the opposite
occurred (Meyers, 1962; Plum & van Uitert, 1978). The integrity
of this perifornical-anterior commissural region may be
a requisite for the manifestation of pathologic sexuality in
general, including pedophilic behavior.
4.5. Neuroanatomical affinities between developmental
and acquired pedophilia
The prevalence of developmental pedophilia in the general
population is unknown. The best available estimates indicate
that the paraphilias are disorders of men; except for sadism
and masochism, paraphilias are almost never diagnosed in
women (Sorrentino, 2017). From a qualitative point of view,
this gender ratio is comparable to what we found in acquired
pedophilia. The chief difference between developmental and
acquired pedophilia is the age at onset. This has been con-
firmed in a recent cluster analysis, in which six additional “red
flags were found out, namely, absence of previous psychiatric
diagnoses, criminal sex offenses, premeditation, and masking,
and presence of guilt feelings and spontaneous confession
(Ciani et al., 2019). Acquired pedophilia is first noted in middle
and late adulthood, reflecting the age of incidence of the
pathologic processes that we found in this review. In several
other respects, the neuroanatomical gaps between develop-
mental and acquired pedophilia may be narrower than might
appear at first sight (Tost et al., 2004). Demographic studies
indicate that pedophiles differ from normal men in a number
of cognitive and physical characteristics, such as lower IQs,
shorter stature due to a small leg-to-torso length, and non-
right handedness. Like developmental pedophilia, acquired
pedophilia is a disorder of men, is often accompanied by
other acquired paraphilias, and the abnormal sexual attraction
is rarely confined to the age ranges that are implied by the
concept of pedophilia; both developmental and acquired
pedophilia are often associated with hypersexuality and
other paraphilias as well as with disorders of impulse control
(Abel et al., 1988). These abnormalities suggest that some kind
of neural organization laid down before birth may predispose
to pedophilia later in life (Fazio, 2018). They also concur with
recent findings of volumetric reductions of the right temporal
pole (Poeppl et al., 2013), the right amygdala and related basal
forebrain structures, especially the bed nucleus of the stria
terminalis, the anterior hypothalamus-preoptic area, and the
septal nuclei in pedophiles (Schiltz et al., 2007). These struc-
tures are critical for normal sexual differentiation and main-
tenance of adult sexual orientation and behavior (Bauer,
1959). Most of them are included in the cortical and subcor-
tical regions which were injured in acquired pedophilia. The
present survey may provide a framework against which
upcoming studies on the brains of developmental pedophiles
may be contrasted.
4.6. Legal implications
Before the neuroscientific revolution of the last quarter of the
twentieth century, criminal responsibility was judged based
solely on a guilty (or intentional) state of mind (mens rea),
which was supposed to determine behavior at the moment in
which the criminal act (actus reus) was perpetrated. In practice,
this is an admittedly huge task, to say the least (Green & Groff,
2003; Pardo & Patterson, 2013). In the medicolegal vernacular,
the traditional method for ascribing criminal responsibility must
simultaneously be phenomenological (criminal intent) and beha-
vioral (criminal act). The growth of neurological knowledge has
contributed new ways of viewing criminal liability that rely on the
brain, as opposed to the mind, of the defendant (Markowitsch,
2008). This novel paradigm was not originally intended to sweep
away the phenomenological-behavioral tradition. It has been
hailed instead as a complement to it, an ongoing program that
is still far from meeting its early expectations. For some scholars
and researchers, it may never be, due to the irreconcilable nature
of their respective objects of study: the mind and the brain
(Aharoni, Funk, Sinnott-Armstrong, and Gazzaniga, 2008).
Notwithstanding its critics, the entrance of neuroscience
into the science of criminology has come to stay, as shown by
the heated disputes held by scholars of different orientations
and fields of knowledge. The is obviously a complexity of this
subject is illustrated by two cases, one of which came to trial in
Italy a few years ago (Sartori et al., 2016). The details of one of
these cases and the controversies raised by the defense
(Scarpazza, Pellegrini, Pietrini, & Sartori, 2018; Scarpazza,
Pennati, & Sartori, 2018) and the prosecution (Farisco &
Petrini, 2013) have been widely publicized. Briefly, a 70-year-
old highly respected pediatrician was sentenced to house
arrest for sexually molesting a female child in his office’s kin-
dergarten. He had been married for 40 years and had two
children, never showing any evidence of abnormal sexual beha-
vior until two years before. By this time, his wife noticed the first
signs of unconcern for social conventions and increasing diffi-
culty in controlling his impulses, as shown by his interest in
pornography and by at least one episode of petty theft. Further
investigation revealed gross neurological signs that ultimately
led to a diagnosis of compression of the ventral pons and basal
forebrain by a clivus meningioma. The abnormal neurological
symptoms and the pedophilia remitted following the surgical
removal of the tumor.
The other case is that of a 40-year-old man who became
increasingly interested in child pornography and prostitution
over the previous two years (Burns & Swerdlow, 2003). His aware-
ness of the wrongness of his actions was shown by his attempts
to conceal his new preferences. This, however, was not sufficient
to prevent him from committing his lewd acts. For example, he
was unable to refrain from making sexual advances toward his
stepdaughter, who would soon denounce him to her mother. He
was eventually found guilty of pedophilia; in the meantime,
a neurologist was called to see him because he began to com-
plain of headache, incontinence, and titubation on walking. An
MRI revealed an expanding mass in the anterior cranial fossa,
where it destroyed a large part of the right frontal lobe. In the few
days that followed tumor resection, the behavioral and neurolo-
gical symptoms cleared. Nine months later, he furtively began
collecting pornography again. A follow-up MRI revealed that the
tumor was growing again. He was operated on, and the symp-
toms remitted one more time.
The critical issue in these cases is the demonstration of a causal
association between a deformation or destruction of a set of
cerebral structures and the development of pedophilia, which

were accompanied by antisocial changes of personality and other
impulse control disorders. Causality was demonstrated in both
cases by the remission of symptoms after tumor resection.
The dilemma may be illustrated by the following simple
questions (Gilbert & Focquaert, 2015): what difference, if any,
does a brain lesion make to the forensic conduction of a 65-
year-old socially adjusted and cognitively normal man who
has just been arrested for sexually molesting his 11-year-old
granddaughter? In other words, to what extent should a brain
lesion seated in the “right” place to produce pedophilia in
a theretofore euphilic man influence the jurors’ decision to
mitigate or exculpate the criminal charges?
These are difficult questions that do not lend themselves to
simple answers that might be generalized to apparently similar
cases. At our present stage of knowledge, prudence is advised.
Each case should be viewed as a single case in its own right
taking advantage of both the medical and forensic perspectives
(Buckholtz & Faigman, 2018).
5. Conclusion
Acquired pedophilia seems to result from three concomitant
changes in neural contingencies: first, the emergence (true
acquired pedophilia) or exposure (apparent acquired pedophilia)
of pedophilic urges and fantasies by an injury to the right FTI
cortices; second, a release from the modulation normally exerted
by the injured cortices on the ascending dopaminergic fibers
that run in the MFB (appetitive-hedonic background); and third,
the sparing of the perifornical-anterior commissural area (normal
or heightened sexuality). This hypothesis is based on incomplete
data and must be probed by new cases. Its chief merit possibly
lies in its parsimony and experimental falsifiability. At least, two
main points of contention remain, namely, (i) which injured and
spared cerebral areas are responsible for sexual attraction
toward children and adolescents, and (ii) the validity of the
concepts of true and apparent acquired pedophilia.
Acknowledgments
RO-S is indebted to Professor Omar da Rosa Santos (Gaffrée e Guinle
Hospital, The Federal University of the State of Rio de Janeiro) for his
unwavering institutional support, and to Mr. Jorge Baçal (in memoriam),
Mr. José Ricardo Pinheiro, Ms. Alessandra Pinheiro, and Ms. Monica Garcia
(The Oswaldo Cruz Foundation Library) for their invaluable help in the
retrieval of old texts and rare books. We are also indebted to Drs.
Giuseppe Sartori (University of Padua, Italy) and Andrej Vranič (Hôpital
Européen de Paris, France) for additional information on their patients via
personal communication.
Disclosure statement
No potential conflict of interest was reported by the authors.
ORCID
Pedro Maranhão Gomes Lopes http://orcid.org/0000-0002-9615-5837
Catarina Sodré de Castro Prado http://orcid.org/0000-0002-0248-653X
Ricardo de Oliveira-Souza http://orcid.org/0000-0001-7858-7217
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