| Introduction
Child sexual abuse is a significant public
health problem in the United States and across
the world. In the United States one out of three
females and one out of five males have been
victims of sexual abuse before the age of 18
years. Sexual abuse occurs across all ethnic/racial,
socioeconomic, and religious groups. Unfortunately,
sexual abuse is considered a relatively common
experience in the lives of children. A report
released by the National Institute of Justice
in 1997 revealed that of the 22.3 million children
between the ages of 12 and 17 years in the United
States, 1.8 million were victims of a serious
sexual assault/abuse. There are gender differences
with regard to sexual abuse incidents; specifically,
girls are at twice the risk than boys for sexual
victimization throughout childhood and at eight
times the risk during adolescence. Because significant
physical, emotional, social, cognitive and behavioral
problems are related to childhood trauma, the
need to more effectively address the issue has
become paramount.
There are a number of commonly held misconceptions
regarding child sexual abuse in the United States.
These include the following: sexual abuse is
limited to sexual intercourse between an adult
and a child; the perpetrator of the sexual abuse
is always a stranger; and rape occurs with adult
women, not children. However, these beliefs
are false. Sexual abuse involves a range of
activities including non-contact and contact
offenses (see Table1); stranger abuse comprises
only a small percentage of total victimizations;
and children are approximately three times more
likely than adults to be victims of rape. In
fact, among females, almost 30% of all forcible
rapes occur before the age of 11 years, and
another 32% occur between the ages of 11 and
17.
Researchers in this area use somewhat different
criteria
for sexual abuse; the
most common definition of sexual abuse, however,
is any sexual activity involving a child where
consent is not or cannot be given. Sexual contact
between an adult and a minor child, as well
as an older teen and a younger child, are both
examples of sexual abuse. Depending upon the
age at which a state deems a child capable of
giving consent, sexual abuse between two minors
can also occur. For example, the law in Texas
dictates that there be greater than a three-year
age differential between children in order to
be considered sexual abuse. The types of sexual
abuse vary widely and include both physical
contact as well as non-contact offenses. Despite
the choices made by laws and research criterion,
the impact of a forced or coerced sexual activity
can be devastating on a child even if the action
cannot be legally or academically described
as sexual abuse.
All states require some kind of mandated child
abuse reporting. Child abuse reporting laws
most often require specified professionals (e.g.,
physicians, teachers) who have contact with
children to report to law enforcement, the department
of social services, or children protection agencies
incidents in which abuse is suspected. These
laws were developed in order to better protect
children. From state to state, it varies as
to who is mandated to report and what abuse
acts require reporting. For example, according
to California Penal Code there are two categories
of sexual abuse that are reportable: sexual
assault and sexual exploitation. According to
the code, sexual assault includes rape and rape
in concert, oral copulation and sodomy, lewd
and lascivious acts upon a child under the age
of 14, penetration of a genital and/or anal
opening by a foreign object, and child molestation.
Sexual exploitation includes conduct involving
matter depicting minors engaged in obscene acts;
promoting, aiding, or assisting a minor to engage
in prostitution; a live performance involving
obscene sexual conduct, or posing for a pictorial
depiction involving obscene conduct for commercial
purposes; and depicting a child in or knowingly
developing a pictorial depiction in which a
child engages in obscene sexual conduct.
Effects of Sexual Abuse
There are a significant number of negative
short-term effects of sexual abuse that impact
a child’s functioning. The most commonly
experienced effect of sexual abuse is posttraumatic
stress disorder (PTSD). Posttraumatic stress
disorder is a clinical syndrome whose symptoms
fall into three clusters: reenactment of the
traumatic event; avoidance of cues associated
with the event or general withdrawal; and physiological
hyper-reactivity. A recent review article suggested
over 50% of sexually abused children meet at
least partial criteria of PTSD and another study
suggested a third of all sexually abused children
develop full diagnostic criteria. If not effectively
addressed, PTSD can become a chronic problem
affecting the child well into adulthood. The
development of sexualized behavior, also called
sexually reactive behavior, is another common
negative short-term effect of sexual abuse.
Children who have been sexually abused engage
in more sexualized behavior when compared to
children who are not victims of sexual abuse,
and when compared to clinical samples of children
with other mental health issues. A recent report
suggested that about a third of children who
have been sexually abused subsequently manifest
this symptom. Additionally, a third or more
of child victims of sexual abuse report depression
and anxiety. Other frequently occurring symptoms
include promiscuity (38%), general behavior
problems (30%), poor self-esteem (35%), and
disruptive behavior disorders (23%). In some
important recent research conducted, in part,
by the Centers for Disease Control, risk for
health problems in adult life including heart
disease were increased by adverse childhood
events, including sexual abuse.
It is estimated that somewhere between 21-49%
of child sexual abuse victims appear asymptomatic
post-victimization. Potential explanations for
this include: difficulties with the methods
used to detect problems in children, delays
in symptom development post-sexual abuse, underreporting
of symptoms, resiliency, and mitigating factors
that may make the impact of the abuse less severe
for some children.
Mitigating factors can increase or decrease
distress related to sexual abuse and include
characteristics of the crime itself, characteristics
of the individual child, and characteristics
of the environment. Regarding the crime itself,
sexual abuse involving force and penetration
are associated with increased distress as are
multiple victimizations. If the perpetrator
of the crime is a parent rather than an adult
stranger or older child, the child is also more
likely to experience distress. Child characteristics
include age and developmental level. With advanced
cognitive development, a child’s perspective
regarding the victimization may include more
or less distress. Children with lower self-esteem
experience increased levels of distress. Children
whose coping methods include avoidance are also
more apt to develop distress symptoms. Characteristics
of the environment include children who have
a supportive relationship with an adult, parent,
or sibling. These individuals generally have
better adjustment than children who experience
little support. Similarly, family cohesiveness
is also a positive buffer for child victims
of sexual abuse. Parental distress is associated
with child distress, i.e., the more the parent
is negatively affected by the crime, the more
the child is negatively affected.
Evidence suggests that the negative psychological
impact of child sexual abuse persists over time,
often into adulthood. Potential long-term effects
of child sexual abuse include depression, anxiety,
posttraumatic stress disorder, sexual dysfunction,
and substance abuse. Further, among the female
adult outpatient population, individuals with
sexual abuse histories as children were twice
as likely to attempt suicide than their non-abused
counterparts. Across the lifespan, individuals
who were sexually abused as children are four
times more likely to be at risk for developing
a psychiatric disorder and are about three times
more likely to abuse substances than their non-abused
counterparts. It is estimated that approximately
one third of child sexual abuse victims experience
PTSD as adult survivors. Among women whose abuse
involved penetration, an increased risk associated
for the development of PTSD is experienced,
resulting in about two thirds of this population
developing PTSD at some point during their lifetime.
Identification of Sexual Abuse
It is rare for a child to speak directly about
sexual abuse. Evidence of physical trauma to
the genitals or mouth, genital or rectal bleeding,
sexually transmitted disease, pregnancy, unusual
and offensive odors, and complaints of pain
or discomfort of the genital area can all be
indicators. An aware medical practitioner may
notice these symptoms during a physical examination.
However, in most cases of sexual abuse, there
are no physical indicators of the crime. It
is rare to actually have positive medical findings
upon medical examination, although such findings
can provide powerful corroboration of a child’s
account of sexual abuse. Most often, children
who are victims of sexual abuse exhibit emotional
or behavioral characteristics that may indicate
distress. These neuropsychiatric symptoms (see
Table 2) indicate a distressed child. The presence
of any one of these indicators does not necessarily
mean that the child is or has been sexually
abused. Children with several of these symptoms,
however, are often referred for mental health
evaluations. Most disclosures from children
are to trusted friends or adults in their life
– the teacher, coach, pastor, grandparent
or therapist.
The reaction of the adult to whom a child discloses
sexual abuse can significantly impact the child’s
subsequent adjustment. It is important for the
adult to be respectful, caring, and believing.
A response involving panic, shock, or disbelief,
or an overly emotional response can negatively
impact the child. Children often feel badly
and blame themselves for the sexual abuse. Therefore,
a response in which the adult communicates that
the abuse was not the child’s fault and
that disclosing the information was the right
thing to do is recommended. Preparing the child
for the potential aftermath of the disclosure
is also important. For example, if the adult
to whom the child disclosed is a mandated reporter,
the local child protection agency or law enforcement
will have to be notified. If the adult to whom
the child disclosed is a non-offending parent,
the parent must take steps to protect the child
from further abuse, including reporting the
abuse to the proper authorities. In some states
(e.g., Texas), if a non-offending parent fails
to report, sexual abuse charges can be filed
against them as well.
The legal process can be especially intimidating,
confusing, and frightening for children. Many
aspects of the process (such as providing testimony
and multiple interviews) can be overwhelming
for children. It is estimated that the average
number of interviews a child victim whose case
is going through the court system undergoes
is eleven. It is often said that during this
time, a child can potentially be “re-traumatized.”
The pre-trial phase can be more distressful
for the child than the disclosure phase because
the pre-trial phase often involves ongoing investigation,
multiple interviews, and protracted fear of
perpetrator retaliation. Children report a number
of courtroom related fears. Approximately 95%
report being frightened to testify and many
children report that the day they testified
was the worst day of their lives. Other reported
fears include retaliation by the perpetrator,
being sent to jail, being punished for making
a mistake, having to prove their innocence,
crying on the witness stand, describing the
details of the offense(s) in front of strangers,
and not understanding the questions which are
being asked.
Intervention
There are several modalities of psychological
treatment that have demonstrated positive benefits
for child victims of sexual abuse. These include
individual psychotherapy, group-based psychotherapy,
and treatments that involve the entire family.
When treatment for this population is trauma-focused,
structured, and targets the specific symptoms
of sexual abuse, it can be effective at reducing
short-term and long-term effects. Individual
treatment usually involves the child and a therapist
meeting together for an hour a week. The therapist
may be a master’s level clinician, social
worker, psychologist, or psychiatrist. Despite
varied professional backgrounds, it is important
that the treating therapist have specific training
and expertise in working with child victims
of sexual abuse. Different techniques may be
used to process the sexual abuse experience,
normalize reactions, and develop adaptive coping
strategies to address symptoms of depression,
anxiety, and PTSD. Trauma-focused play therapy,
trauma-focused cognitive-behavioral therapy,
and eye movement desensitization and reprocessing
therapy are all specific individual child-focused
interventions that may be appropriate treatment
for child sexual abuse. Group-based psychotherapy
can be particularly powerful for sexual abuse
victims; they are exposed to other victims and
subsequently do not feel alone. Moreover, this
modality is useful in helping child victims
understand that people cannot simply look at
them and identify them as a sexual abuse victim.
Treatment interventions that involve the entire
family include family preservation services,
attachment-trauma therapy, and Parents United
programs. The focus of these interventions is
to strengthen the parent-child relationship
in order to help process the trauma and to ultimately
increase the level of family functioning.
Treatment is also available to the offender
of sexual abuse. While highly controversial
and with questionable documentation of efficacy,
sexual molestation of children is a treatable,
but not curable behavior problem. The primary
goal of the treatment of sexual offenders is
to minimize the likelihood that the individual
will re-offend. This is best achieved by modifying
emotional, cognitive, behavioral, environmental,
and psychological factors, which support the
desire, capacity, and opportunity to offend.
Cognitive-behavioral therapies, including Relapse
Prevention, have proven to be the most successful
at reducing recidivism rates. The recidivism
rate for individuals who undergo cognitive behavioral
treatment and/or Relapse Prevention is estimated
to be 8.1% compared to 25.6% who are untreated
(Alexander, 1999). Treatment often occurs in
a group therapy context and involves approximately
100-150 weekly sessions. When offenders have
particular needs that cannot be addressed within
this therapeutic context, adjunct treatments
are often utilized as a supplement (e.g., substance
abuse treatment, individual psychotherapy, anger
management training).
Central to cognitive-behavioral therapies and
Relapse Prevention is the belief that sexual
abuse is something that does not “just
happen.” The overwhelming majority of
the time there are identifiable behaviors in
which offenders engage prior to offending. Successful
treatment involves educating the sexual offender
about this process of sexual offending and facilitating
an understanding of his particular pattern of
offending. Within this conceptualization, it
is important to teach sexual offenders how to
identify circumstances that place them at greater
risk for re-offending. Based on the offender’s
understanding of his behavior, he can then learn
to identify problematic behaviors early in this
cycle, modify his behavior, and consequently
reduce the liklihood that he will re-offend.
Other important areas of treatment include accepting
responisiblity for offending, developing victim
empathy, and correcting faulty thinking patterns.
In the end, however, the most effective way
to prevent subsequent abusing is to decrease
or eliminate opportunity; offenders should not
have uncontrolled access to vulnerable children
or previous victims.
Prevention
Prevention of child sexual abuse occurs on
three levels: primary, secondary, and tertiary
prevention. Primary prevention targets services
to the general population in order to decrease
the frequency and occurrence of child sexual
abuse. Recently, public awareness campaigns
have emerged to address the issue. There is
some indication that in the last couple of years,
the incidence of sexual abuse may be decreasing
and some experts have attributed this to an
increase in public awareness at the primary
prevention level as a possible explanation.
Secondary prevention targets services to specific
groups that are considered at high risk in order
to avoid child sexual abuse from occurring.
Examples of secondary prevention programs include
child assault prevention programs and safety
education taught to children in schools. These
programs may increase a child’s knowledge
of sexual abuse and how to respond, and may
even facilitate subsequent disclosures, which
ultimately may reduce child sexual abuse from
occurring. Tertiary prevention targets services
to victims of child sexual abuse with the goal
of minimizing its negative effects and avoiding
reoccurrence. Examples of such programs were
described in the Intervention section above.
Although evidence suggests that trauma-focused
interventions are effective at reducing specific
sexual abuse related symptoms, more research
is needed to understand how this works.
There are two major deterrents to prevention
efforts in the area of child sexual abuse: lack
of efficacy for prevention services and lack
of adequate resources. It is imperative that
prevention services document that they do indeed
prevent child sexual abuse. Adequate resources
are needed, both for treatment of victims of
child sexual abuse and for prevention services
that reach the broader population. Once effective
primary prevention techniques are established,
adequate funding for tertiary programs may be
more easily attainable and this problem may
be more appropriately addressed.
Summary and Future Directions
Child sexual abuse is a pervasive problem in
the United States that affects individuals of
all racial and socioeconomic backgrounds. The
short-term and long-term effects of sexual abuse
have been well documented and highlight the
need for effective psychological interventions.
Evidence also suggests that participation in
legal proceedings following sexual abuse can
be further distressing for the child sexual
abuse victim. Future research efforts should
focus on prevention efforts and therapeutic
intervention for these child victims. Furthermore,
efforts should be focused towards making the
legal system more child-victim friendly in order
to minimize further helplessness, distress and
even trauma during this process.
References
Alexander, M.A. (1999). Sexual offender treatment
efficacy revisited. Sexual Abuse: A Journal
of Research and Treatment, 11 (2), 101-116.
Briere, J., Berliner, L., Bulkley, J.A., Jenny,
C., & Reid, T., (1996). The APSAC Handbook
on Child Maltreatment. Sage Publications: Thousand
Oaks, CA.
Finkelhor, D. (1979). What’s wrong with
sex between adults and children? Ethics and
the problem of sexual abuse. American Journal
of Orthopsychiatry, 49, 692-697.
Harris, G.E., Cross, J.C., Vincent, J.P., Mikalsen,
E., & Dominguez, R.Z. (2001). Giving kids
a chance: Helping victimized children and their
families. A Guide for professionals in educational
settings. Washington: DC: U.S. Department of
Justice, National Institute of Justice.
MacFarlane, K. & Waterman, J. et al.(1986).
Sexual Abuse of Young Children. New York, New
York: Guilford Press.
Perry. B.P., & Azad, I. (1999). Posttraumatic
stress disorder in children and adolescents.
Current Opinion in Pediatrics, 11, 310-316.
Saunders, B.E., Berliner, L., & Hanson,
R.F. (2001). Guidelines for the Psychosocial
Treatment of Intrafamilial hild Physical and
Sexual Abuse (Draft Report: April 6, 2001).
Charleston, SC
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