| 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
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& Reid, T., (1996). The APSAC Handbook on
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Oaks, CA.
Finkelhor,
D. (1979). What’s wrong with sex between
adults and children? Ethics and the problem
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49, 692-697.
Harris,
G.E., Cross, J.C., Vincent, J.P., Mikalsen,
E., & Dominguez, R.Z. (2001). Giving kids
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MacFarlane,
K. & Waterman, J. et al.(1986). Sexual Abuse
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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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