S@xual 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 were filtering out this document as if it were of pornographic
nature.
(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@xual 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
CONTENTS
Introduction
Child s@xual 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@xual
abuse before the age of 18 years. S@xual abuse occurs across all
ethnic/racial, socioeconomic, and religious groups. Unfortunately,
s@xual 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@xual assault/abuse. There are gender differences with
regard to s@xual abuse incidents; specifically, girls are at twice
the risk than boys for s@xual 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@xual abuse in the United States. These include the following:
s@xual abuse is limited to s@xual intercourse between an adult
and a child; the perpetrator of the s@xual abuse is always a
stranger; and rape occurs with adult women, not children. However,
these beliefs are false. S@xual 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@xual abuse; the most common definition of s@xual abuse,
however, is any s@xual activity involving a child where consent is
not or cannot be given. S@xual contact between an adult and a minor
child, as well as an older teen and a younger child, are both examples
of s@xual abuse. Depending upon the age at which a state deems a
child capable of giving consent, s@xual 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@xual abuse. The types of s@xual 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@xual activity can be devastating on a child
even if the action cannot be legally or academically described as
s@xual 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@xual abuse that are reportable: s@xual
assault and s@xual exploitation. According to the code, s@xual
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@xual 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@xual 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@xual conduct.
Effects of
S@xual
Abuse
There are a significant number of negative short-term effects of
s@xual abuse that impact a child's functioning. The most commonly
experienced effect of s@xual 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@xually abused children meet at least partial criteria of
PTSD and another study suggested a third of all s@xually 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@xualized behavior, also
called
s@xually reactive behavior, is another common negative short-term
effect of s@xual abuse. Children who
have been s@xually abused
engage in more s@xualized behavior when compared to children who are
not victims of s@xual 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@xually abused
subsequently manifest this symptom. Additionally,
a third or more of
child victims of s@xual 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@xual abuse.
It is estimated that somewhere between 21-49% of child s@xual 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@xual 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@xual abuse and include characteristics of the crime itself,
characteristics of the individual child, and characteristics of the
environment. Regarding the crime itself, s@xual 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@xual 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@xual abuse persists over time, often into adulthood. Potential
long-term effects of child s@xual abuse include depression, anxiety,
post traumatic stress disorder, s@xual dysfunction, and substance
abuse. Further, among the female adult outpatient population,
individuals with s@xual abuse histories as children were twice as
likely to attempt suicide than their non-abused counterparts. Across
the life span, individuals who were s@xually 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@xual 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@xual Abuse
It is rare for a child to speak
directly about s@xual abuse.
Evidence of physical trauma to the genitals or mouth, genital or rectal
bleeding, s@xually 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@xual 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@xual abuse. Most
often, children who are
victims of s@xual 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@xually 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@xual 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@xual 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@xual 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@xual 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@xual 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@xual abuse. Different techniques may
be used to process the s@xual 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@xual abuse. Group-based psychotherapy can be particularly powerful
for s@xual 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@xual 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@xual abuse. While
highly controversial and with questionable documentation of efficacy,
s@xual molestation of children is a treatable, but not curable
behavior problem. The primary goal of the treatment of s@xual
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@xual 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@xual offender about this process of
s@xual offending and facilitating an understanding of his particular
pattern of offending. Within this conceptualization, it is important to
teach s@xual 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@xual 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@xual 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@xual 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@xual
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@xual abuse and how to respond, and may even facilitate subsequent
disclosures, which ultimately may reduce child s@xual abuse from
occurring. Tertiary prevention targets services to victims of child
s@xual 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@xual 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@xual 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@xual abuse. Adequate
resources are needed, both for treatment of victims of child s@xual
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@xual 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@xual abuse have been well
documented and highlight the need for effective psychological
interventions. Evidence also suggests that participation in
legal
proceedings following s@xual abuse can be further distressing for
the child s@xual 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@xual offender treatment efficacy
revisited. S@xual 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@xual 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@xual 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@xual Abuse (Draft Report: April 6, 2001). Charleston, SC
Tables in Original Document
TABLE 1: TYPES OF S@XUAL ABUSE (OF CHILDREN)
TABLE 2: RANGE OF SYMPTOMS THAT MAY BE PRESENT IN S@XUALLY ABUSED
CHILDREN
S@xual/Physical Symptoms
Emotional Symptoms
Behavioral Symptoms
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Published in this Domain on May
2, 2002. Texas, U.S.A.
Edited for accessibility on September
9, 2010. European Union
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