Child sexual abuse

Child sexual abuse is a subtype of child abuse that occurs when an adult or older child forces or coerces a child into sexual activity. In some definitions of the sexual abuse of children, the abuse hinges on the motivations of the abuser rather than on the specifics of the activity with a child; in this view the sexual abuse of a child occurs in any activity "before the age of legal consent, that is for the sexual gratification of an adult or a significantly older child". There are also legal definitions of child sexual abuse, which, worldwide, is ordinarily considered a crime and therefore is variously described by different statutes and laws. It is important to note that, along with overtly sexually explicit activities, child sexual abuse can also include indecent exposure, voyeurism, and exposing a child to pornography. Physical contact is not always required for the sexual abuse of a child to have occurred.

Terminology

There are currently two main views on how to use terminology in describing sexual interaction between minors and adults. On one hand, it is argued that minors are, due to their age, unable to consent to sex and that all sexual contacts with adults are harmful. In this perspective it is natural to use a negative terminology in describing all such behavior. This may include labeling a willing sexual relationship as child sexual abuse, the minor as victim and the adult as perpetrator.

In the other perspective, minors are viewed as being able to give simple consent and not all sexual experiences between adults and minors are assumed to be harmful. In this perspective it is natural to use a terminology that adapts to the type of experience that has occurred. A willing minor and adult in a non-harmful relationship may be labeled partners rather than victim and perpetrator, and instead of calling the experience 'child sexual abuse', terms like 'adult/non-adult sexual behavior' may be used.

At the moment, there is no consensus in the scientific community on which type of terminology that should be used.

Demographics: incidence and prevalence

Estimates of the number of children who endure sexual abuse vary worldwide. Some of these statistics are based on reporting by health care professionals in countries where central reporting of any suspected child abuse is mandatory by law. Because of the stigma associated with sex, and the extreme stigma associated with sexual activity in a child, not only are many cases not reported despite such laws, but there is a definite trend for adults to fail to recognize the fact that such abuse has occurred. As a result, child sexual abuse tends to go unreported even in municipalities where suspicion of sexual abuse demands a report to agencies devoted to child welfare. In many poor and subsistence regions of the world, there are no such agencies, or at least none that have the personnel and facilities to record and investigate such reports. Additionally, the criteria for acts that are considered sexual abuse change a bit regionally and culturally. For these reasons, the incidence and prevalence of the sexual abuse of children can only be estimated, and the differing rates reported in different areas may not represent actual differences in the magnitude of the problem.

USA and Canada

According to a 2004 report by the U.S. Department of Health and Human Services, 2.2% of under 4 year olds, 9.1% of 4-7 year olds, 11.4% of 8-11 year olds, and 16.5% of 12-15 year olds reported being sexually abused. It has been suggested by many health care professionals that girls are abused far more often than boys. However due to sexism, and the social connotation that abuse of boys by women is enjoyable, the sexual abuse of boys may be underreported. Therefore, it may be possible that boys are victims of sexual abuse just as frequently as girls. Unfortunately, this is difficult to determine, as it is estimated that up to 90% of sexual abuse cases are never reported to the proper authorities. Doctors, pediatricians, and other professionals in the medical field are left with the legal and moral burden of reporting any suspicious abuse. Unfortunately, according to a 2006 literature review of more than 15 studies, there is much inconsistency as to what constitutes reasonable suspicion for sexual abuse. According to one study on the Pennsylvania American Academy of Pediatrics, approximately 85% of the individuals surveyed were inconsistent in applying their standard for determining reasonable suspicion. Furthermore, there is a lack of knowledge among medical professionals with regard to child maltreatment. Of the 139 pediatricians included in a study by Giardino Dubow, 29% could not accurately label the hymen; a membrane typically examined in cases involving sexual abuse or rape. Furthermore, only half of the pediatricians in the study felt that they had been adequately educated in the area of child sexual abuse. Whether or not the medical community is doing enough to detect and prevent child sexual abuse is still controversial.

Underreporting and statistical inaccuracies

Due to social taboo and the negative stigma associated with child sexual abuse, many children do not disclose the abuse. Reasons for lack of disclosure may include fear of getting the abuser in trouble, feelings of guilt or shame, not wanting to disrupt the family structure, and fear of not being believed. Additionally, threats (physical or otherwise) may be used by the abuser to keep the child from breaking the silence. Because of this, a significant number of child sexual abuse cases are never disclosed to anyone; and of the ones that are disclosed, there is no guarantee that the child's parents will press charges or take legal action. In turn, this makes it very difficult to gather accurate statistics, as the percentages of abused children may be much higher than what is recorded. Furthermore, if certain children are more likely to report the abuse than other children, many studies on child sexual abuse may be guilty of sampling bias; that is, certain children are either systematically or accidentally not included in the study. This is also true of many studies on child sex offenders, as many do not account for predators that have not yet been reported or have yet to go through the legal system. Lastly, studies that use questionnaires or surveys as a means of alleviating sampling bias may also be guilty of response bias. In studies such as these, the subjects may fail to answer the questions accurately due to the stigma attached to the subject; or in some cases, may fail to answer the survey at all. All of these problems combined make it very difficult to gather accurate, neutral statistics on child sexual abuse using a representative sample.

Children at high risk

Any child can be a victim of child sexual abuse. However in the U.S., most recent studies show that Caucasian children account for the highest percentage of child sexual abuse, second being Hispanics, and third being African Americans. The average age group for child sexual abuse is 8-11, with an average age of 9.9 for boys, and 9.6 for girls. Additionally, children who are on the brink of puberty are at a high risk for abuse, as many child sex offenders will take advantage of their developing sexual curiosity. Furthermore, children who lack confidence or do not have strong social support (i.e. friends, family, etc) are at a much higher risk for sexual abuse, as many fixated offenders (see below) tend to seek out such children. Lastly, children with special needs (i.e. lacking a father figure, living in poverty) are also at a higher risk for abuse because many offenders will shower such children with attention and gifts only to abuse their relationship at a more opportune time. Despite this however, it should be noted that sexual abuse occurs in both lower and upper class families, and is not limited to any specific ethnic group or any other social group.

Children with communication disorders, mentally retarded children

Children who cannot report abuse because they cannot speak or use manual language are at very high risk for abuse, including sexual abuse.

Child sex offenders

Child sexual abuse can be perpetrated by anyone regardless of age, race, lifestyle, or any other individual factors. However, men account for the majority (96%) of child sexual abuse cases, though females can abuse as well. Furthermore, it is very common (and most probable) that the offender is either related to the child or knows the child by other means. This means adults who have a trusting relationship with the child are most likely to be abusers; which includes aunts, uncles, cousins, teachers, coaches, etc. Additionally, child sex offenders can usually be categorized as regressed or fixated, based on the motive for their crime.

Regressed offenders

Regressed offenders are primarily attracted to adults their own age, but may be passively aroused by minors. Typically, with regressed offenders, any sexual activity in their adolescent years has been exclusively with peers their own age; not with younger children. Additionally, regressed offenders tend only to offend when under times of stress, or under the influence of drugs or alcohol. Furthermore, the main criteria used by regressed offenders appears to be availability, as the child is only used as a substitute and is not the primary preference. As a result, regressed offenders tend to have a higher rate of incestuous relationships, and may abuse their own children. While regressed offenders prefer an adult partner over that of a child, they may seek out a child partner when they encounter problems in their adult relationship. Due to this, it would be inaccurate to refer to a regressed offender as a pedophile, as he or she is not primarily or exclusively attracted to children.

Fixated offenders

Fixated offenders are much different in that their primary sexual interest is with children instead of adults. Most fixated offenders meet the American Psychological Association's diagnostic criteria for pedophilia, and are either primarily or exclusively aroused by prepubescent children. Fixated offenders are either not interested in or incapable of holding adult relationships, hence why they pursue relationships with children. Most sexual acts perpetrated by fixated offenders are not related to drugs or alcohol. Lastly, it should be noted that fixated offenders are not only attached to children physically, but also emotionally.

Older children and teens

Older children and teenagers are also capable of sexually abusing younger children. In the U.S., about 25% of all sexual offenses are perpetrated by minors. As long as the abuser is older, has a mental advantage, and has greater sexual knowledge than the child engaging in the act, the act can also be considered child sexual abuse. Many studies have shown that most fixated offenders recognized their attraction to children well before adulthood. Teens or older children who take younger children to secret places, excessively hug or kiss younger children who don't want such attention, or make frequent comments about the physical development of others may be exhibiting warning signs that indicate possible abuse of the younger child. It should also be noted that many children begin abusing younger children before the age of 18, and such instances are not uncommon. In many cases, children who sexually abuse younger children may have learned the behavior from being sexually abused themselves.

Homosexuals

Contrary to many popular myths, there is no conclusive evidence to prove homosexuals are at a higher risk for sexually abusing children. In the U.S., many religious and conservative organizations claim that a third of sexual abuse cases involve men abusing boys, thus proving that homosexuals abuse disproportionately compared to heterosexuals. Unfortunately, many of these claims fail to address the fact that not every man who abuses a boy is a homosexual, as that is very rarely the case. Homosexual men are sexually attracted to adult men and their masculine characteristics. However of the studies done on fixated offenders, those who abuse boys are actually attracted to their lack of maturity, prepubescence, and feminine characteristics (i.e. underdeveloped muscles, lack of pubic hair, etc). Therefore, men who are primarily attracted to children (regardless of gender) are by definition, a pedophile; not a homosexual.

Intrafamilial child sexual abuse (incest)

Intrafamilial child sexual abuse refers to the sexual abuse of a minor where the offender is related by blood or marriage. It has been suggested that incestuous abuse is more often perpetrated by regressed offenders due to the motive of their crime. For example, a father may turn to his younger daughter for sexual gratification while experiencing difficulties with his sex life, even if he as little erotic attraction towards her. In cases like this, it is much easier for an offender to abuse a child he/she is related to, than to seek out someone else's children. Furthermore, it has been suggested that children who are abused by a close family member or relative may be less inclined to disclose the abuse. According to Incest: Origins of the Taboo (2005), the most serious damage results from mother-son incest, compared to other incestuous relationships. Additionally, according to large-sample studies, approximately 11-46% of child sexual abuse cases involve incest. Typically, incest carries a much deeper social stigma/taboo than sexual abuse alone; hence why some children may delay longer in disclosing the abuse, or may not disclose it at all.

Child grooming

In most cases, before any sexual abuse actually occurs, the abuser will usually groom the child before initiating any sexual activity. Child grooming refers to any deliberate actions taken by an adult to form a trusting relationship with a child, for the purpose of later having sexual contact. The act of grooming a child sexually may include (and usually does include) activities that are legal in and of themselves. Typically, this is done to gain the child's trust as well as the trust of other adults in the child's life. Furthermore, research has shown children are less likely to report the crime if it involves someone that the he or she knows, trusts, and cares about. Additionally, a trusting relationship with the family means the child's parents will be less likely to believe any potential accusations, or suspect the abuse. Some examples of child grooming may include:

• Taking an undue interest in someone's child.
• Giving gifts or money for no apparent reason.
• Hugging, kissing, tickling, or other physical contact even when the child does not want this attention.
• Showing pornography to the child.
• Taking the child on special outings, away from other adults.

It is important to note that many abusers will go out of their way to be charming, nice, and helpful to divert attention away from their deeper motive. By assimilating themselves into a child's family life, the child's parents will feel more comfortable leaving their child unattended with the potential abuser. The period between assimilating one's self into the family, to actual sexual contact is when the grooming process takes place.

Effects of child sexual abuse

Child sexual abuse can cause permanent physical and mental damage depending on the age of the child and the force used by the abuser. Physical damage can result from penetration, which can cause lacerations or infections in the vagina or anus. Typically, any attempted penetration with a child under 11 or who is still underdeveloped will usually result in pain and bleeding. In extreme cases, child sexual abuse involving penetration may even cause damage to the child's internal organs. In addition to physical damage, child sexual abuse can also have significant mental effects on the child, that may carry into adulthood. Child sexual abuse has been linked as a possible cause for psychopathology. Additionally, other emotional damage can also result from the abuse such as depression, post-traumatic stress disorder, anxiety, poor self-esteem, Somatoform disorders, and self destructive behavior. One study conducted by Widom, which controlled for possible confounding variables, found that 37.5% of the study's sexually abused subjects met the criteria for post traumatic stress disorder. However it was also noted that other family/lifestyle variables can also contribute to the symptoms.

Additionally, children who do not exhibit any symptoms at all may develop psychological problems later on in life. Such problems are usually referred to as sleeper effects, as they do not fully manifest until adulthood. Furthermore, it has been found that a small percentage of sexually abused children may go on to abuse others. Although there has been some speculation about the accuracy of statements made by sex offenders who claim they had been sexually abused. Such statements are usually made in a group setting, where the offender may be trying to receive sympathy or rationalize his/her behavior. Some studies that make use of a polygraph test show that many sex offenders fabricate such accounts of abuse. Accepted validity of the abused-abuser phenomena in the psychiatric community is still very controversial.

Furthermore, it has been suggested that young boys may experience double the trauma when sexually abused by an adult female, due to the widespread belief that boys either cannot be abused by women, or that they enjoyed the experience. However one study found differing results, showing that most men who had sexual relations with a woman as a boy regarded their experience as positive. Additionally, other studies found that the definition of child sexual abuse can greatly effect the outcome of the results. One study conducted on male college students found 22% were abused when age differential or coercion was involved, 14% when only age differential was required, and 10% when both were necessary. Additionally, the percentage dropped to 8% when physical contact was also required. Despite differing results in the effects of male sexual abuse by women, Colin Crawford, author of Forbidden Femininity: Child Sexual Abuse and Female Sexuality claims that current societal views underestimate the reality and damage done by female sexual abusers.

Positive and negative reactions to child sexual abuse

Several studies have shown that some children may regard their experience as positive. However in many cases, those who are sexually abused as a child will view it as positive at the time, but reflect on it negatively as they enter adulthood. One such study by Urquiza (1987) found that 38% of 53 adult males regarded their sexual abuse as positive at the time, while only 15% retained this attitude. According to Coffey et al. (1996), this may be due in part to the stigma attached to child sexual abuse. However in some cases, victims will view their event as positive, even as they enter adulthood. Russell (1986) speculated that the perception of a sexually abusive event as 'positive' could stem from a mechanism for coping with traumatic experiences. In many abuse cases, such as the rape of women, the victim will attempt to minimize the trauma of the event or pretend that nothing abnormal has happened, due to their desire to return to a normal (pre-abuse) state. Due to this, studies that use questionnaires to assess the trauma of child sexual abuse can fall victim to inaccurate responses, and thus produce unreliable results. Other findings suggest that some children and adolescents may view the relationship as positive if they had a friendship with the older person.

Some researchers such as John Money, David Finkelhor, and Gabriel Holguin, have suggested that the presumption of trauma or damage can itself cause iatrogenic harm to child victims. Or in other words, automatically assuming harm can actually create harm that would never have existed.

Prevention

Educating children

Prevention programs for child sexual abuse have been controversial as it has been questioned whether children are mentally or physically capable of thwarting off sexual advances. According to one literature review by the American Psychological Association, in order for prevention programs to be successful, a child must:

1. Recognize the situation as abusive.
2. Believe that he or she can take action.
3. Use the protective skills he or she has been taught.

Furthermore, in order to ensure success, prevention programs must provide age appropriate information as well as detailed instructions for how to react in such situations. Some programs aimed at preventing sexual abuse have been designed for and implemented in elementary schools. Such programs are usually broken up into two sections:

1. Primary prevention (preventing the abuse)
2. Detection (recognizing/disclosing the abuse)

These programs usually provide children with a brief overview of sexual abuse, and inform them of the following topics:

• Definition of sexual abuse
• Who can be sexual abusers (i.e. making clear it can be people they know)
• Having control over one's body
• Good touch, bad touch
• Emphasizing actions that must be taken in abusive situations
• How to say "no" to adults
• Difference between good secrets and bad secrets
• Telling a trusted adult about inappropriate behavior, and to keep telling until someone listens.

Additionally, school programs tend to be very light-spirited with the occasional use of humor. This is done to increase its use in public schools, eliminate controversy, and to reduce the chances of frightening the children. Sexual abuse prevention programs come in many forms, including slide-show presentations, movies, discussions, and even role-play.

Educating parents and caregivers

Furthermore, while it is important for children to be educated about sexual abuse, it is equally important for the parents to be educated as well. According to a 1984 random sample of 521 parents, only 29% talked to their children (aged 6-14) about sexual abuse. More importantly, only 22% of those that did talk about it ever mentioned that the abuser might be a family member. In other words, only 34 of the 521 parents mentioned to their children that family members/acquaintances can be sexual abusers. Furthermore, more recent findings show a similar percentage of 30%, indicating that more effort must be made to increase parental awareness as well as their willingness to discuss sexual abuse with their children.

The two-adult rule

Many organizations that work specifically with children have implemented what is known as the two-adult rule. In essence, this rule requires at least two adults to be present for every single child; or in other words, no child can ever be left alone with one adult for any period of time. Furthermore, if a child needs help going to the bathroom and/or getting dressed, it is common for one adult to help the child with the door open, while another adult stands close by and listens to what is going on. Many day care centers and youth programs have implemented this rule. This policy is helpful in that, if implemented properly, provides a witness for every possible sexual abuse accusation. Furthermore, it significantly reduces the chances of sexual abuse, as no adult volunteer will ever be able to create an opportunity to be alone with a child.

Programs targeted at potential abusers

Some programs have been launched in the U.S. and the U.K. to help potential abusers before they commit a crime. Such programs are aimed at helping people the minute they feel they might be at risk for abusing a child, this way the offense can be prevented. Stop In Now! is one popular program implemented in both countries, that effectively provides a hotline for would-be child sexual abusers. The program was launched in 2002 as a public service campaign, urging adults to seek help before they act on their urges, as well as encouraging friends and family to recognize and report anyone who exhibits unusual warning signs. Within its first year, it received hundreds of phone calls from both worried men, as well as people who were concerned about a certain individual. The program provides social services to men and women who feel they may be at risk for abusing children. Although the program has received its fair share of criticism by those who feel such individuals cannot be cured, it is one of the few programs that are taking a new approach at sexual abuse prevention. The main goal of the program is to encourage people (child sex offenders) to be responsible for their actions, thus taking the burden off of parents, children, and medical professionals.

Effectiveness of school programs

The effectiveness of child sexual abuse prevention in schools has been disputed, as many feel that children should not be left with the burden of protecting themselves from abusers. Additionally, although some studies have shown that elementary school teachers who participated in a training program were more knowledgeable on the topic, they were still not any more likely to actually report the abuse. On the bright side however, some studies have shown that children who participate in such programs are likely to retain and understand the information. According to one evaluation of a sexual abuse prevention program, children were far more knowledgeable after the three one-hour sessions, and a post-test showed a 25% increase in the accuracy of their responses. Unfortunately, it is not clear whether knowledge will make children any more likely to prevent the abuse from happening. A majority of the research suggests that follow-up or review sessions may be necessary for children to retain and understand the curriculum presented.

Treatment for sex offenders

Treatment for sex offenders has been controversial, as there has yet to be consensus in the psychiatric community as to whether treatment is effective. Many studies that evaluate the treatment of sex offenders are poor in design, as they fail to have a control group, do not evaluate the offender for a long period of time, or fail to account for subsequent sexual offenses (both reported and unreported). Only a few of the 20+ studies conducted on adolescent offenders made use of both a treatment and a control group. Furthermore, the follow-up duration for those two studies was less than three years. It is unfortunate that most studies conducted on treatment effectiveness have serious flaws in design, and tend to be unreliable or unrepresentative of the population of sex offenders.

Some pharmeceutical treatments for sex offenders includes estrogen, cyproterone acetate, medroxyprogesterone acetate, and selective serotonin reuptake inhibitors (SSRIs). Some studies have shown that SSRIs can reduce an offender's "sexual arousal and sexual preoccupations." However the use of such drugs for adolescent offenders has been criticized due to the lack of studies proving them to be safe for use by minors.

Furthermore, other forms of treatment may involve a series of visits with a social worker or psychiatrist. Such visits are designed to teach the offender how to control and channel his or her sexual urges in an effective and safe manner. For example, encouraging the offender to exercise and go for a walk as opposed to looking at child pornography may be a recommendation made during his or her visits. The offender may also be given recommendations on what to do when sexual fantasies involving children begin to enter his/her mind. In very rare instances will the treatment involve therapy designed to change the offender's sexual attraction away from children, as such efforts have been proven unsuccessful, and are not well accepted in the psychiatric community.

Recidivism

Just as the actual rates of child sexual abuse are unknown, so are the rates of recidivism. Recidivism refers to repeated offenses made by already convicted child sex offenders. Studies that analyze recidivism tend to vary greatly, as some will only measure the number of related convictions, only rely on self tests, or will only track the offender while he or she is still in treatment. Despite this however, estimates of recidivism fall into the range of 10-50% for fixated/pedophilic offenders. Other more conservative estimates fall into the range of 12-20%. Furthermore, research has shown that certain types of offenders (i.e. extrafamilial) may have a higher likelihood of re-offending. For example, some studies have shown that sex offenders who abuse their same gender may have a higher rate of recidivism than those exclusively attracted to opposite sex children. Furthermore, according to one literature review of sexual abuse studies, those who are convicted for incestuous abuse have been shown to have the lowest rate of recidivism. However some reports contradict this theory, as one showed that 59% of 329 convicted sex offenders abused both biological and unrelated children. This suggests quite the opposite, as the authors stated incestuous offenders should not be considered at a lower risk for recidivism, concluding the categorization of incestuous vs. nonincestuous is irrelevant. Additionally, the deviancy of the offender can play a great role in his or her likelihood of re-offending. For example, some studies have shown the younger the child, and the more antisocial personality traits the offender has, the more likely he or she is to abuse other children. Unfortunately, based on the reports above, lack of self-reporting and underreported offenses causes unreliability and lack of consistency in most of the statistics that are collected. Law enforcement agencies have yet to develop a reliable method for detecting someone's likelihood of re-offending upon release.