Child sexual abuse is most commonly used in reference lo sexual activity involving a child that has at least une ?G two characteristics:
* It occurs within a relationship where it is deemed exploitative by virtue of an age difference or caretaking relationship thai exists with the child;
* It occurs as a result of threat or force.
There is broad professional agreement in using the term sexual abuse to apply to sexual contact between a child and his/her father, stepfather, mother, stepmother, another older relative, teacher, or baby sitter, as well as sexual contact at the hands of any adult, known or unknown.
The number of cases of sexual abuse reported to child protection agencies has grown dramatically in the last decade. The American Humane Association, which servos as a clearinghouse for state statistics, estimated that 123, UUO cases were officially reported in 1985, up from an estimate of only 7,559 in 1976.' However, it is well recognized that officially reported cases constitute only a small proportion of all occurring cases and even of all cases known to professionals.2
The bust sense of the full scope of the sexual abuse problem, both reported and unreported. is obtained from the community surveys of normal adults revealing their childhood experiences. Although all the studies have found at least 5° ? of adults reporting some sexual abuse in their childhood, the variation among the studies is great, ranging troni 6% to 62% for women and from 3% to 31% for men. For example, in one of the largest and most meticulous studies. Russell surveyed a random sample of ^35 women in San Francisco and found 38% had been sexually abused before the age of 18; 16% had been abused by a family members The one national study, conducted with 2000 adults by the Los Angeles Times Poll, uncovered sexual abuse among 27% of the women and 16% of the men.4 A number of other studies of normal populations have been done with varying degrees of sophistication.5-8
These community studies, beside being sources of prevalence estimates.5,5,7,-10 are also the best sources of information about the distribution of different types of sexual abuse. They show that abuse by fathers and stepfathers, even though it dominates reports from the child welfare system, actually constitutes no more than 7% to 8% of all abuse cases. Abuse by other family members (most frequently uncles and older brothers) constitutes an additional 16% to 42%. Other non-relatives known to the child (including neighbors, family friends, child care workers, and other authorities) make up 32% to 60% of offenders. Stranger abusers (the traditional stereotype of the child molester), who make up the remainder, are in almost all studies substantially less common than either family members or persons known to the child.
In terms of the types of sexual activities, the studies show that only 16% to 29% of the abuse involves intercourse or attempted intercourse. Another 3% to 11% of the activities involve attempted or completed oral or anal intercourse, and 13% to 33% manual touching of lhe genitals. The largest category of abuse in virtually all studies involves fondling of children's bodies and genitals without penetration.
In terms of the age at which abuse begins, the community studies show that vulnerability seems to peak between ages 9 and 12. and then declines somewhat during later adolescent years. (This distribution changes somewhat, however, depending on how much of adolescent date and acquaintance rape is included as sexual abuse.) Nonetheless, most studies show that a quarter of the victimizations occur before age eight, and some clinicians insist that (his percentage would be even greater if it were not for the occlusion of memories from these early years (Herman, |, personal communication, 1985), Approximately 42% to 75% of experiences reported in the surveys are single events, which do not reoccur. Longer lasting experiences are associated with abuse within the family.
These findings from general population surveys do vary somewhat from findings based solely on reported cases and agency caseloads. In tbe data culled from reported cases there appears to be an overrepresentation of:
* Abuse involving fathers and stepfathers;
* Abuse involving intercourse and other more intrusive acts;
* Abuse that goes on over an extended period.
The ages of the children also lend to be higher, because these reported cases record the age at the time of the disclosure rather than the age at onset. There also seems to be an underreporting of the sexual abuse of boys compared to the community studies.7
In spite of the very dramatic growth in numbers of reported cases in the U.S. over the last decade,1 it is not at all clear that this reflects any real rìse in true incidence. Most of the growth is probably accounted for by the intensification, through media exposure and professional education, of efforts at case detection. Il should be noted several of the community studies do show somewhat higher rates of sexual abuse among younger cohorts.3,1-6 Such an effect might be the sign of a historical increase, or it might be due to memory decay among older cohorts.
In addition to prevalence estímales, lhe community surveys have also provided information about the distribution of sexual abuse within various sociodemographic subgroups in the communities studii >. 7.8,10. n Interestingly, the studies are lairly uniform in failing to find differences in rates according to social class or racial subdivision. The findings about urban-rural differences are inconsistent at the moment.
However, several other factors have emerged from the community studies as being consistently associated with higher risk for abuse (Figure D." Although few studies have examined why lhe factors summarized in Figure I increase risk, the cluster suggests that the underlying dynamics may be poor supervision, emotional turmoil, neglect, and rejection (hat make a child vulnerable to the ploys of child molesters. In other words, as a result of conflicts and emotional deficits, the children are easier to manipulate with offers of affection, attention, and rewards in exchange for sex and secrecy. If these children are also unable to count on help and support from parents, il may make il harder for them lo stop or terminate lhe abuse once it begins.
RESEARCH ON OFFENDERS
The single most clearly established fact about offenders is that they are predominantly males. This is confirmed in non-clinical studies as well as surveys of general sexual histories unrelated to abuse, so it is noi simply an artifacl of what gets reported or what gets labeled as abuse. A comprehensive review found thai women are perpetrators in no more than 5% of the abuse involving girls and 20% of the abuse involving boys, and that these proportions are not the result of reporting or labeling biases.12 This disproportionate perpetration by men clearly distinguishes sexual abuse from other forms of child abuse and neglect.
A wide variety of theories have been proposed Io account for abusers, rnoslly on the basis of clinical experience with incarcerated offenders.13-15 These theories can be organized info four categories, as summarized in Figure 2.
Although good research is sparse, there is some reasonable empirical support for propositions that are consistent with some of these theories:
* Some groups of abusers do have unusual needs for power and domination which may be related to their offender bchaviorlb;
* Most groups of offenders, who have been tested using physiological monitors, do show unusual levels of deviant sexual arousal to children17-20;
* Many offenders have histories of being victims of sexual abuse themselves (Bard L, Carter D, Ceree D, et al, unpublished data, 198321-23;
* Many offenders do have conflicts over adult heterosexual relationships or are experiencing disruption in normal adult heterosexual partnerships at the time of offense,22, 24,25;
* Alcohol is connected to the commission of lhe acts in a large number ol the offenses, ranging in studies from 19% to 70%, 26,27 although no causative role for alcohol has been established.
One interesting recent .study in regard to incestuous abuse found that incest fathers had participated less actively in early care of their victim children than had a comparison group oi normal fathers, suggesting that early interaction with a young and dependent child may create some inhibitions against seeing this child as a sex object later on.28 Another recent study suggests that sexual abusers have histories of sexual deviance and deviant fantasies that generally go back to adolescence. 2q This study also found a much greater extent and variety of deviarli sexual acts among child molesters than had been previously reported. However, in spite of promising leads, the field of research on child s e ? LI a 1 abusers is in an extremely primitive state.
RESEARCH ON THE IMPACT OF SEXUAL ABUSE
There are a long list of symptoms that clinicians in the U.S. and Canada have noted in children who have been sexually abused. These include fear, eompulsivity, hypcractivity, phobias, withdrawal, guilt, depression, mood swings, suicidal ideation, fatigue, loss of appetite, somatic complaints, changes in sleeping and eating patterns, hostility, mistrust, sexual acting out, compulsive masturbation, and school problems.™-32 However, there have been very few systematic evaluations of large samples ol sexually abused children (o assess the prevalence and seriousness ol these various symptoms. One exception was the Tufts Family Crisis Program study, which evaluated ?? sexually abused children within a year alter disclosure using standardized psychological measures." Tufts researchers found that 17% of 4- to 6-year-olds met criteria for clinically significan! pathology on the Louisville Behavior Checklist, as did 40% of the 7- to 13-year-olds. The most commonly observed symptomatic behaviors among the school aged abused children were aggrcssion (50%), antisocial behavior (45%), fear (45%), sexual behavior (16%). neurotic behavior (38%). and immaturity (40%). Fearfulness followed by anger and hostility are lhe most common observations in other such studies. These behaviors are very possibly results of (he sexual abuse; however, no study has ruled out the possibility that these behaviors may have preceded the abuse or stemmed from some common antecedent.
5 High Risk Factors for Child Sexual Abuse
In contrast to these initial effects, the long-term impact of sexual abuse has been the subject of more sophisticated studies. There are at least seven surveys of sexually abused women in the general population, all ol which have found significant, identifiable mental health impairment compared to non-victims in lhe same sample.3,5,7,7, 34-57 One of the best to date was a survey of 344 women in Calgary using such epidemiological measures as the Middlesex Hospital Health Survey and CES-D depression scale. ^ The study found sexually abused women to be at generally twice the risk for depression, psychoneurosis. somatic anxiety, psychiatric hospitalizaron, and suicidal gestures. Moreover, sexual abuse was demonstrated to be a major risk for such outcomes even when controlling for other negative developmental and family background factors. However, severe levels of psychopathology were apparent in less than 25% of the sexual abuse victims.
Other studies have similar findings. In a random sample of 250 Los Angeles women, Peters found that a history of sexual abuse was associated with an increased risk for depression, as well as lor drug and alcohol abuse, even when background factors were controlled.'7 Two other outcomes that have been uncovered by several studies in the general population are sexual problems - including frigidity, vaginismus, flashbacks, and emotional problems related to sex - and a much higher risk of subsequent sexual victimization.9,35 38"40
Studies that have compared sexual abuse victims to other help-seekers in various clinical populations have also found sexual abuse victims ?? be more impaired on a number of dimensions*0·41'45: victims were more isolated, had lower self-esteem, were more fearful of men, had more anxiety attacks, sleeping difficulties and nightmares, alcohol and drug abuse, and were more prone to suicide and soH'-muiilation. There is some addilional research suggesting connections between sexual abuse and prostitution,15·44 multiple personality disorder, and eating disorders.40 In short, very rapidly mounting evidence suggests that sexual abuse is a serious risk factor for a wide variety of negative mental health outcomes. None of the studies by themselves are definitive on this point, but the weight of the growing number of studies is impressive.
Why Child Sexual Abusers Abuse
Given evidence of apparently serious effect on some individuals. researchers have now begun to look at whether certain aspects is of the experience or context of the experience explain the degree of trauma. However the research here is still very tentative.31 The weight of current evidence is that victims show more/ symptoms in the long-term when the abuse involves fathers and stepfathers,5,14,47 events that continue over time,'-47 and force.5-34-35,47 On lhe other hand. studies have not been able to demonstrate consistently that abuse at any particular age is more traumatic. The single best study of initial effects in children'"1 shows that the factors predict! ve of greater disturbance arc: * Violence and physical injury in the abusive episode;
* A mother's hostile attitude toward the child upon revelation of the abuse;
* When the child is removed from his or her home subsequent to the abuse.
Unfortunately the literature does not yet justify many well articulated propositions about what types of abuse should receive priority for professional attention.
Professional efforts to respond tu the problem oí sexual abuse can be grouped into five categories:
* Broad campaigns of public and professional education designed to increase the detection and disclosure ot sexual abuse;
* An enormous variety of educational programs, particularly within school systems, aimed at making children better able to protect themselves against victimization48;
* Mental health and social service professionals setting up treatment programs for victims and their families in many localities4"';
* Treatment programs established for offenders both within and outside of criminal justice settings su;
* Efforts to reform the criminal justice system, both to reduce additional lrauma tu victims and to insure more effective sanctions against offenders.5
These last two efforts have not been nearly so widespread as the first three.
Among those engaged in these interventions, there are a set of assumptions that are widely accepted, even though most have not been subjected to empirical test. Among these assumptions are:
* That detection and reporting arc preferable to lhe experience remaining secret; that they improve the chances for positive outcome for a child.
* That the majority of reports of sexual abuse made by children are truthful.52
* That when children recant previous allegations ol abuse as they sometimes do. these deniais are not generally sincere, but are due to pressure, fear, and stress.53
* That it is preferable to remove offenders from the home than to remove the children.
* That to assure the cooperation of offenders in terminating the abuse, staying away from the victims, and participating in treatment, the threat or reality of criminal sanctions must be brought to bear in most cases.
* That effective intervention in child sexual abuse requires substantial inleragency cooperation.
* That children who know a) what sexual abuse is, b) that they have a right tu refuse such activity, and c) that they have permission to tell someone about it. are less likely to become victims.
There is an urgent need to evaluate these and other assumptions, especially as controversies havebegun to develop surrounding some of them. l;or instance, although it is clear that public campaigns have been successful in stimulating more detection and reporting, the benefits of this for victims have not been demonstrated. Disclosure may terminate the abuse, but it can also result in retaliation, stigmatization, and disappointment, whieh may outweigh any benefits. Studies are needed of the conditions, under which disclosure has beneficial versus detrimental effects.
Similarly, there is an acrimonious public policy debate over whether it should be a goal of treatment to try to reunite children with parents who sexually abused them. Nobody has proven that there are benefits to reunification and that these outweigh risks of further abuse.
Although ? here are many research reports of successful treatment of child molcsters24,54 - in particular, using behavior modification - there is a great deal of warranted skepticism about the state of the art. Few sufficiently long-term follow-up studies have been done, especially given the evidence thai recidivism olten occurs many years subsequent to release."'5 Moreover, it is generally acknowledged that some offenders are not amenable to treatment, and no reliable techniques exist for determining who these offenders are.
In spile of great public enthusiasm for the idea of making the criminal justice process less traumatic for children in sex abuse cases, there is no research to suggest either how olten children are traumatized by this process, or what aspects of the process create trauma.
Also, although a lew prevention education programs have been evaluated to lind out if children learn the concepts involved,^'1,"17 there is no research to date that indicates that such programs actually reduce the amount of victimization. Nor is there research about whether such programs have any unintended negative consequences, such as increasing fear about adults or aboui sexuality.
Research on sexual abuse is still in ils infancy, tind few facts about it can be regarded as indisputably established. However, from available data it seems that sexual abuse is a serious public health problem. More children probably suffer some form of sexual abuse than suffer from lead poisoning or some of the infectious diseases. And the consensus of studies (backed up by clinical opinion) is that such victimization creates a significant risk for immediate and longterm mental health impairments.
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5 High Risk Factors for Child Sexual Abuse
Why Child Sexual Abusers Abuse