Assessing the emotional damage sustained by children who have been sexually abused is extraordinarily difficult. Although not all children sustain damage,1*' emotional problems are extremely common among the sexually abused children who are examined by Child Protective Services or in outpatient psychiatric clinics.3 Many of these molested children have been living in socially and psychologically disordered families so that the damage noted may be related ?? non-sexual factors such as deprivation, physical cruelty, and emotional abuse. Postdiscovery events, such as family disruption with foster home placement, confer further insult. When sexually molested children are evaluated, the damage is multi-determined,4-5 and may be affected by a variety of family, community, law-enforcement, and placement variables.
In this article, that damage found in prepubescent, sexually molested children that is directly related to the sex.ua! aspects oí their experience is addressed. Through a prolonged sexual relationship, these children become sexually experienced and, as a consequence, are highly eroticized.6 On evaluation, the extent of the children's sexual interest, activity, and rcsponsiveness is directly related to the intensity and the duration of the sexual experience. This means, in effect, that the child has had the opportunity to learn sexual behavior and rcsponsiveness. In our clinical experience, the heightened eroticization occurs whether or not there has been coercion and whether or not the child initially perceived the experience as frightening or painful.
Some degree of erolicization is an expectable occurrence for all children. In fact, if a child does not become somewhat eroticized in the course of development, he or she is at risk for sexual dysfunction or sexual problems in adult life.7 Expectable eroticization in lhis culture is dependent upon events such as diapering. dressing, skin to skin contact, naming the genitals, bathroom play. experimentation with siblings and peers, games such as "mommy and daddy" or "doctor" and ihe observation of other people's sexual interest and activity: especially that of the parenls as they enjoy touching and kissing one another. States of heightened (but not abnormal) eroticization occur when there is extensive skin to skin contact between the child and other family members. This might occur via holistic health practices, in liberal homes in which nudity and sleeping together are common, in sexually permissive communes,8,9 including [he Kibbutz,10 and when the child is involved in a good deal of sex play with peers. Through these circumstances, the child also learns to be quite sexual; however, the eroticism of these youngsters is rarely as intense as that of children who have been involved in a long-term molestation.
With many cases of alleged sexual abuse in litigation, the question often arises as to whether children could have been eroticized through viewing explicit television, films, or magazines. Based on clinical experience, the observation oí' scatological materials produces a qualitatively and quantitatively different elìce t on children than docs children's direct involvement with another person. Children who observe erotic materials will fantasize more and their fantasies will become more elaborate, but they are unlikely to act oui sexually unless they have had a tangible sexual experienec. However, children who frequently observe humans or animals having intercourse do become eroticized, especially if they are closely identified wilh one or both participants. Children easily identify with animals and think of them as human beings.
Characteristics of Young, Eroticized Children
Eroticized children follow the specifie format that they have learned, which has become highly cathected. Therefore, when a 4-year-old boy, suspected of an incestuous involvement with his mother, French-kisses his teacher, repetitively pokes his finger inside the vagina of the anatomically correct doll, and attempts oral sex with the girl who baby sils, this behavior is a clear indication of past or present sexual experience. As the youngster is attracted to older females and as he employs oral and manual methods, his sexual experience was most likely with an older woman, involving oral and manual practices.
As sexual responsiveness is learned behavior that does not require a great deal of cogniti ve skill. children of any age can be eroticized.0 However, the younger the child, the more profound the effect of the eroticization is likely to be. Characteristics of young, eroticized children are given in the Figure.
DAMAGE ASSOCIATED WITH THE HIGHLY EROTICIZED STATE
A heightened state of eroticization during (he early years inevitably affects character development. However, the particulars depend on other aspects of the child's early relationships. For instance, heightened eroticization has a very different impact on the character formation of a well-nurtured child who lives in a stable family with concerned, consistent, and variously affectionate parents than it would on a deprived and abused youngster whose only meaningful contact is through a sexualized relationship with an unpredictable, angry caretaker. The well-nurtured child has the necessary substrate to contain and diversify the heightened eroticization. He or she may develop sufficient internal elaboration to be able to understand and adapt to a variety of situations. The deprived and abused child has little else other than the pathological, sexualized relationship on which to foster internal elaboration and, therefore, is likely to maintain a simplistic, sexualized approach to complex situations.
In addition, the anxiety from events such as sudden separations, random physical punishment, or abrupt rejection, intensifies the importance of the sexual mode. There are no alternatives: the sexual self becomes exclusive and central; the character is impoverished. The sexual behavior is more resistant to change and is more likely to become self-hurtful, learned, as it was, in the context of a painful relationship.
The more intense and central the child's erotic needs and interests, the more likely other elements of the character structure are to form in alignment with, or contradiction to, the eroticizatiion. Relationships, identity, and goals are formed in order to enhance or suppress sexuality. Without treatment the child may be unable to form gratifying relationships that are not overtly sexual because non-sexual, close relationships remain highly frustrating.
After discovery, many eroticized children arc removed from their homes and placed with foster families, where they soon become acutely aware of the culture's view of childhood sexuality. Our culture attempts to delay ihc psychosexual development of children12; it expects that children should not be sexual.0 In most families, sexual interests or games among peers are forbidden. The genitals of children are covered, children are ashamed if they are accidentally exposed, and parents chastise children for their sexual interests and activities.1,14 Parents, who have not addressed their own early sexual conflicts, avoid most sexual topics in educating their offspring.15 They deem themselves fortunate if they do not have to contend with their children's sexual questions or experiments.0 Eroticized children must divest themselves of sexual interests and activities if they are to be accepted. Their predicament can be viewed as a form of culture shock.
Most eroticized children do wish to please and to be accepted by adults. They may try to please the foster parents by not responding sexually, but this is an extraordinarily difficult task when there may be nothing else in the child's life as highly valued or as gratifying. Unless the placement is in a family that is comfortable in discussing sexual issues and will allow some form of sexual expression, such as masturbation, the child is likely to fail. At first the foster parents may assume that the sexual behavior is a symptom of the abuse that will disappear in a suitable environment with proper guidance. When the eroticized behavior continues in spite of their efforts, the foster parents are understandably upset and may begin to view the child as intrinsically evil. The youngster may have eroticized other children living in the home, seduced a neighbor, or attempted a Maison with a foster parent. When the foster parents are utterly exasperated, their final recourse is to have the child removed from their home.
When the child is rejected by the foster parents, insult is added to the original injury. In the next foster placement the child predicts that it will not last, and may bring about the self-fulfilling prophecy. The child may be placed in one foster home after another, may be expelled from school, ridiculed by peers, isolated within the neighborhood, teased and shunned in community groups. The repeated rejection and placement disruption compound the damaged sense of self and the inability to trust. It is then that a number of selfdefeating patterns are likely to emerge. The child may act out sexually at times when he or she is certain to be discovered, rejected, or punished. TIi e child may be attracted to peers or adults who are cruel, demeaning, or exploitative. When these children become adults, they often view post-discovery events as more damaging than the molestation itself.
Very few eroticized children are referred for intensive, long-term therapy; the culture views them as behaviorally rather than emotionally disturbed. Foster parents are shown behavioral programs or told to ignore the undesirable activity. Yet multimodal therapy, spearheaded by a therapist trained in child development and human sexuality clearly is indicated. This person must coordinate the efforts of the foster parents, agencies, and the school to support these children m the\r eîVuïts. to adapt to cultural expectations. Above all else, the therapist must attempt to insure the appropriateness and stability of the child placements. The children need to develop intense, non-sexual relationships that will serve as alternatives to the original, intensely sexual relationship. The therapist needs to help foster parents to actively teaeh these children the difference between sexual and non-sexual touch so that the children can respond appropriately to affection.6 Therapist and foster parents must become comfortable in establishing closeness in spite of a child's arousal. Close, accepting, non-sexual relationships with adults are essential for the development of trust and further internal elaboration.
Foster parents need to implement a behavioral approach to support the child's ego functions during the transition. The program should be positively based to enhance the child's self-esteem. As the sexual activity is self-reinforcing, inappropriale sexual expression must be controlled before the program is instituted. Allowable sexual activity needs to be clearly defined and, in some selected cases, may be used as a reinforcement. Eroticized children should not be placed in homes in which there is no acceptable sexual activity, such as masturbation. Foster parents benefit from courses in human sexuality with the goal of objectively understanding their own early sexual contlicts.
Foster parents are understandably reluctant about hugging or touching these children. Foster parents who engage eroticized children are in a dangerous posilion as the children may misinterpret and report erotic behavior within the home to the authorities. In that case, the foster family's license may be revoked and the parents could be indicted for child molestation, Foster parents need education, support, ongoing guidance, and legal safeguards to be able to collaborate comfortably in the treatment of these difficult children.
Eroticized children need to be considered for placement in classes for the educationally handicapped. Although may of these children present themselves as bright and socially adept, they need the positive role modeling derived from the close relationship to the teacher in a small. clearly structured classroom. The teacher can monitor the child's behavior and can assist in discussing the child's frustrations.
Eroticized children become aroused when they form close relationships. For therapy to be effective, the therapist must form a close relationship with the child. The eroticized child reacts to the therapist as if the therapist were soliciting sexual favors. When the therapist is consistent and kind, but firm, the child desists - but not until every strategy has been tried. If the therapist is of (he other sex from the original molesting partner, the child will display more aggressive and fewer sexual manifestations early in therapy. As the relationship deepens, sexual themes emerge regardless ol the gender match between the child and the therapist.16
Most eroticized children who have been identified are girls. When an eroticized little girlss is referred for long-term therapy, she is almost without exception referred to a female therapist. This is because there are more women who are interested in treating these children and because it is often assumed that only women arc appropriate, as a male presence might frighten and thereby injure the child further. In addition, it is difficult and dangerous for male therapists to treat these children. Male therapists must contend with intense counter-transference reactions and they must be constantly alert and able to handle constructively a child's seduction. When in a state of negative transference, a child may complain to others about the therapist's sexual advances. As child and therapist have been alone together, it is the child's word against the therapist's word in a culture that believes that children never lie about sexual molestation.17
Women therapists can accomplish many important treatment goals with girls who are eroticized. Issues of trust, ambivalence, dependency, role confusion, and anger can be resolved. With intensive, long-term therapy, the non-sexual therapeutic relationship can become as intense and invested as was the original, sexualized transference to the parent. However, the female therapist cannot restructure the girl's relationship with males. If this has not been accomplished prior to puberty, the eroticized adolescent will attempt to reconstitute the original sexualized relationship with a series of men who often share many of the characteristics of the original partner. These relationships tend to be evanescent, repetitive, and self-destructive. Therefore, eroticized children need an experience with a male therapist prior to adolescence. In order for this to occur, more males would need to be trained, supported, and protected.
Male and female therapists become sexually aroused when they treat eroticized youngsters, lb This is especially disturbing to male therapists. Therapists need to accept this response as a manifestation of the countertransfcrence: they can learn a great deal about the patient and about themselves through understanding the reaction rather than suppressing or denying it. However, if the therapist should act out the sexual leelings it would destroy the therapeutic process.
Eroticized children seldom receive the therapy and support they desperately need. When they reach adolescence the increase in hormones, together with the expectable regression, brings back into focus the original sexual mode. Behavioral controls diminish and the early patterns re-surface. Certain peers support the sexual behavior and the street culture seems exciting. Some eroticized children will enter prostitution when they grow up.18 In this case, early patterns are perpetuated through the sado-masochistic relationship with the pimp, the economic advantages, and the devalued, dependent role of the prosliiuie. Among this poor outcome group, there are many borderline, masochistic, hysterical, and schizotypal characteristics just as there arc among other groups or individuals whose childhoods were marked by disruption, rejection, deprivation, and violent abuse.
Some incestuous girls, when they mature, return to the original partner (usually the father) and continue to live with that person. The couple is unlikely to be apprehended and, in fact, are not outside the confines of the law when both are adults. The girls are willing to compromise their future because the original sexual pattern and the original partner remain highly cathected at a conscious and/or unconscious level. No other man seems as exciting or as attractive as the incestuous partner.
Other eroticized women will form stable but pathological relationships with partners who resemble the original consort. The most commonly sought after characteristics are the partner's buying of affection with gifts, or his need to control, devalue, or physically abuse. Although these relationships arc pathologically determined, they may persist over time.
There are relatively favorable outcomes, especially for individuals who have not been otherwise damaged. Eroticized adults with favorable adaptation often do experience lingering guilt over their earlier participation in the sexual congress. These women can suffer a specific sexual dysfunction in adulthood; they are easily orgasmic but avoid foreplay.19 This is most likely because it is during the arousal phase that they actively demonstrate their interest in and enjoyment of the sexual relationship, while they can experience the orgasm as something that is done to them, over which they have no control. Therefore it is the arousal phase that evokes guilt and is inhibited. In spite of this, these women may form gratifying relationships that endure over time.
Young, molested children may become highly erotic on the basis of their extensive sexual experience. Although not all of these children present with emotional problems. the hypererotic state carries a considerable risk of psychological damage. The damage is related to the children's acute erotic needs and to the intense cathexis of the genitals. Depending on other circumstances, this can lead to the impoverishment or distortion of the personality. Other forms of damage are related to the culture's inability to understand, tolerate, or interact lherapeutically with these children.
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Characteristics of Young, Eroticized Children