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Sexual Abuse of Children
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 ChildTrauma Academy version of a chapter to be published in Encyclopedia of Crime & Punishment, 2001.
Official Citation:
Dominquez, R. Z., Nelke, C.F. and Perry, B.D. Child
Sexual Abuse in: Encyclopedia of Crime and Punishment
Vol 1.(David Levinson, Ed.) Sage Publications, Thousand
Oaks pp 202-207, 2002
* ChildTrauma Academy, Houston, TX and La Rabida Children’s Hospital, Chicago,
IL
* * ChildTrauma Academy, Houston, TX and Department of Psychiatry and Behavioral Sciences,
Baylor College of Medicine, Houston, TX
*** ChildTrauma Academy, Houston, TX and Children’s Mental Health Programs, Alberta
Mental Health Board, Calgary, CA
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 (see
Table1); stranger abuse comprises only a small percentage of total victimizations; 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
posttraumatic stress disorder (PTSD). Posttraumatic 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, posttraumatic 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 lifespan, 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 liklihood
that he will re-offend. Other important areas of treatment include accepting
responisiblity 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.
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 APSAC
Handbook 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). Posttraumatic 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
TABLE 1: TYPES OF SEXUAL ABUSE (OF CHILDREN)
Non-Contact
· Photographing the child for sexual purposes
· Showing the child pornographic materials
· Sexualized talk with the child
· Making fun of or ridiculing the child's sexual development, preferences, or organs
· Verbal and emotional abuse of a sexual nature
· Exposing genital area to child for sexual gratification
· "Peeping" in on child while dressing, showering, using the restroom
· Masturbating in front of the child
· Making the child witness others being sexually abused
Contact
· Touching the child sexually
· Invasive care of the child's genitals
· Stripping the child to hit/spank; obtaining sexual gratification out of hitting
· Making the child touch the adult sexually
· Making the child masturbate the adult
· Making the child engage in oral sex
· Making the child engage in vaginal or anal intercourse
· Making the child engage in prostitution
· Making the child engage in sexual activity with animals
TABLE 2: RANGE OF SYMPTOMS THAT MAY BE PRESENT IN SEXUALLY ABUSED CHILDREN
Sexual/Physical Symptoms
· Attempts to touch the genitals of others
· Sexualized play
· Detailed and age-inappropriate knowledge of sexual activity
· Excessive masturbatory behavior
· Reluctance to undress
· Avoidance of touch
· Increased startle response
· Hypervigilance
· Extreme fluctuations in heart rate (above 100 bpm or below 60 bpm)
· Sleep disturbance (bed wetting, nightmares)
· Drastic change in appetite somatic complaints
· Enuresis/encopresis
· Substance use
· Fatigue/exhaustion
Emotional Symptoms
· Regression to younger developmental stage
· Lack of affect
· Withdrawal/depression
· Anxiety/irritability/fear
· Phobias
· Excessive guilt
· Feelings of helplessness
· Low self-esteem
· Obsessive ideas
· Self-hate
· Hyperalertness
· Dissociation
Behavioral Symptoms
· Abrupt change in behavior or personality
· Aggression
· Excessive crying
· Over compliance
· School adjustment problems/sudden drop in school performance
· Temper tantrums
· Truancy or runaway behavior
· Self-mutilating/suicidal ideation/gestures/attempts
· Flashbacks/Avoidance
· Nightmares
· Lack of trust/social isolation/lack of friendships
· Hyperarousal
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