Sexual Abuse of
Children
Its Very
Serious Consequences
A Guest
Report by
Renee Z. Dominguez, Ph.D. (1)
Connie F. Nelke, Ph.D. (2)
Bruce D. Perry, M.D., Ph.D. (3)
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 (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 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 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 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,
post traumatic 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 life span, 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
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 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.
___________________________
(1) Child Trauma
Academy,
Houston,
TX and La Rabida Children's Hospital, Chicago, IL
(2) Child Trauma Academy, Houston, TX and Department
of
Psychiatry
and Behavioral Sciences, Baylor College of Medicine, Houston, TX
(3) Child Trauma Academy, Houston, TX and Children's Mental
Health
Programs, Alberta Mental Health Board, Calgary, CA
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 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 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). 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 sexual
Abuse (Draft Report: April 6, 2001). Charleston, SC
Tables in Original Document
TABLE 1: TYPES OF sexual ABUSE (OF CHILDREN)
TABLE 2: RANGE OF SYMPTOMS THAT MAY BE PRESENT IN sexualLY ABUSED CHILDREN
sexual/Physical Symptoms ·
Emotional Symptoms·
Behavioral Symptoms·
Published in this Domain on May
2, 2002. Texas, U.S.A.
Format Copyright 2002-2017 by The M+G+R Foundation. All rights reserved. However, you may freely reproduce and distribute this document as long as: (1) Appropriate credit is given as to its source; (2) No changes are made in the text without prior written consent; and (3) No charge is made for it.
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