Addressing insanity in paedophilic disorder: The need for a cognitive approach for forensic assessment to correctly identify idiopathic, acquired and iatrogenic forms.

Assessing insanity in individuals with paedophilic disorder presents unique challenges, particularly due to the diverse aetiologies of the condition, which lead to varying symptomatology and behavioural manifestations. To address this complexity, in this article we overview the characteristics of three variants of paedophilic disorder - idiopathic, acquired, and iatrogenic - and highlight the key obstacles in differentiating these forms, resulting in inconsistent and, at times, biased judicial outcomes. Through the analysis of three real-life case studies, we illustrate how forensic evaluations must go beyond a one-size-fits-all approach, integrating neuropsychological and neuroimaging assessment to provide more precise determinations of criminal responsibility. We therefore propose a cognitive model for the forensic assessment of insanity that emphasises the role of scientific evidence in distinguishing cases in which neurological conditions or medical treatments significantly impair volitional and cognitive capacities. In such cases, incarceration may be inappropriate, as incarceration hinders rehabilitation, while treatment in specialised non-custodial facilities could better address the underlying condition and reduce the risk of recidivism. In our analysis, we argue for the inclusion of a criterion in the DSM to ensure that the symptoms of paedophilic disorders are not due to substance effects or other medical conditions. Finally, we propose guidelines for forensic assessments of insanity in child sexual offences that support a multidisciplinary approach based on the cognitive model. In this framework, behavioural analysis, neuropsychological assessment, and (if necessary) neuroimaging techniques are combined to assess how the condition affects self-determination, ultimately leading to more accurate and scientifically informed legal decisions.