The M+G+R Foundation


S_e_x_ual Abuse of Children


Notes:

(1) We have had to change the spelling of  the "S" word and its derivatives because many internet server and security filters are filtering out this document as if it were of pornographic nature. Whereas this document was being accessed 600 to 1,000 times a month, now it is seldom reached because of the filters.

(2) The underscoring throughout the report was done by The M+G+R Foundation to highlight the areas which are particularly pertinent to the s_e_x_ual abuse scandal unleashed within the Roman Catholic Church.

A Report By:

Renee Z. Dominguez, Ph.D.*
Connie F. Nelke, Ph.D.**
Bruce D. Perry, M.D., Ph.D.***


For:

Encyclopedia of Crime & Punishment
Berkshire Publishing Group
Great Barrington, MA
In Press: 2001


This is a Child Trauma Academy version of a chapter to be published in Encyclopedia of Crime & Punishment, 2001



*      Child Trauma Academy, Houston, TX and La Rabida Children's Hospital, Chicago, IL
* *  Child Trauma Academy, Houston, TX and Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX
*** Child Trauma Academy, Houston, TX and Children's Mental Health Programs, Alberta Mental Health Board, Calgary, CA



 

Introduction

Child s_e_x_ual 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 s_e_x_ual abuse before the age of 18 years. s_e_x_ual abuse occurs across all ethnic/racial, socioeconomic, and religious groups. Unfortunately, s_e_x_ual 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 s_e_x_ual assault/abuse. There are gender differences with regard to s_e_x_ual abuse incidents; specifically, girls are at twice the risk than boys for s_e_x_ual 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 s_e_x_ual abuse in the United States. These include the following: s_e_x_ual abuse is limited to s_e_x_ual intercourse between an adult and a child; the perpetrator of the s_e_x_ual abuse is always a stranger; and rape occurs with adult women, not children. However, these beliefs are false. s_e_x_ual abuse involves a range of activities including non-contact and contact offenses (seeTable1); stranger abuse comprises only a small percentage of total victimization; 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 s_e_x_ual abuse; the most common definition of s_e_x_ual abuse, however, is any s_e_x_ual activity involving a child where consent is not or cannot be given. s_e_x_ual contact between an adult and a minor child, as well as an older teen and a younger child, are both examples of s_e_x_ual abuse. Depending upon the age at which a state deems a child capable of giving consent, s_e_x_ual 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 s_e_x_ual abuse. The types of s_e_x_ual 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 s_e_x_ual activity can be devastating on a child even if the action cannot be legally or academically described as s_e_x_ual 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 s_e_x_ual abuse that are reportable: s_e_x_ual assault and s_e_x_ual exploitation. According to the code, s_e_x_ual 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. s_e_x_ual 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 s_e_x_ual 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 s_e_x_ual conduct.



Effects of s_e_x_ual Abuse

There are a significant number of negative short-term effects of s_e_x_ual abuse that impact a child's functioning. The most commonly experienced effect of s_e_x_ual abuse is post traumatic stress disorder (PTSD). Post traumatic 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 s_e_x_ually abused children meet at least partial criteria of PTSD and another study suggested a third of all s_e_x_ually 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 s_e_x_ualized behavior, also called s_e_x_ually reactive behavior, is another common negative short-term effect of s_e_x_ual abuse. Children who have been s_e_x_ually abused engage in more s_e_x_ualized behavior when compared to children who are not victims of s_e_x_ual 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 s_e_x_ually abused subsequently manifest this symptom. Additionally, a third or more of child victims of s_e_x_ual 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 s_e_x_ual abuse.

It is estimated that somewhere between 21-49% of child s_e_x_ual 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-s_e_x_ual 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 s_e_x_ual abuse and include characteristics of the crime itself, characteristics of the individual child, and characteristics of the environment. Regarding the crime itself, s_e_x_ual 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 s_e_x_ual 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 s_e_x_ual abuse persists over time, often into adulthood. Potential long-term effects of child s_e_x_ual abuse include depression, anxiety, post traumatic stress disorder, s_e_x_ual dysfunction, and substance abuse. Further, among the female adult outpatient population, individuals with s_e_x_ual abuse histories as children were twice as likely to attempt suicide than their non-abused counterparts. Across the life span, individuals who were s_e_x_ually 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 s_e_x_ual 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 s_e_x_ual Abuse

    It is rare for a child to speak directly about s_e_x_ual abuse. Evidence of physical trauma to the genitals or mouth, genital or rectal bleeding, s_e_x_ually 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 s_e_x_ual 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 s_e_x_ual abuse. Most often, children who are victims of s_e_x_ual 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 s_e_x_ually 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 s_e_x_ual 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 s_e_x_ual 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, s_e_x_ual 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 s_e_x_ual 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 s_e_x_ual 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 s_e_x_ual abuse. Different techniques may be used to process the s_e_x_ual 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 s_e_x_ual abuse. Group-based psychotherapy can be particularly powerful for s_e_x_ual 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 s_e_x_ual 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 s_e_x_ual abuse. While highly controversial and with questionable documentation of efficacy, s_e_x_ual molestation of children is a treatable, but not curable behavior problem. The primary goal of the treatment of s_e_x_ual 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 s_e_x_ual 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 s_e_x_ual offender about this process of s_e_x_ual offending and facilitating an understanding of his particular pattern of offending. Within this conceptualization, it is important to teach s_e_x_ual 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 likelihood that he will re-offend. Other important areas of treatment include accepting responsiblity 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 s_e_x_ual 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 s_e_x_ual 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 s_e_x_ual 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 s_e_x_ual 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 s_e_x_ual abuse and how to respond, and may even facilitate subsequent disclosures, which ultimately may reduce child s_e_x_ual abuse from occurring. Tertiary prevention targets services to victims of child s_e_x_ual 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 s_e_x_ual 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 s_e_x_ual 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 s_e_x_ual abuse. Adequate resources are needed, both for treatment of victims of child s_e_x_ual 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 s_e_x_ual 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 s_e_x_ual abuse have been well documented and highlight the need for effective psychological interventions. Evidence also suggests that participation in legal proceedings following s_e_x_ual abuse can be further distressing for the child s_e_x_ual 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). s_e_x_ual offender treatment efficacy revisited. s_e_x_ual Abuse: A Journal of Research and Treatment, 11 (2), 101-116.

Briere, J., Berliner, L., Bulkley, J.A., Jenny, C., & Reid, T., (1996). The APSACHandbook 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 s_e_x_ual 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). s_e_x_ual Abuse of Young Children. New York, New York: Guilford Press.

Perry. B.P., & Azad, I. (1999). Post traumatic 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 Child Physical and s_e_x_ual Abuse (Draft Report: April 6, 2001). Charleston, SC

Tables in Original Document

TABLE 1: TYPES OF S_e_x_uAL ABUSE (OF CHILDREN)
TABLE  2: RANGE OF SYMPTOMS THAT MAY BE PRESENT IN S_E_X_UALLY ABUSED CHILDREN
S_e_x_ual/Physical Symptoms ·
Emotional Symptoms· 
Behavioral Symptoms· 


Published in this Domain on May 2, 2002. Texas, U.S.A.
Edited for accessibility on September 9, 2010. European Union

Format Copyright 2002-2010 by The M+G+R Foundation. All rights reserved.


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