Underage sexual abuse

Child sexual abuse (CSA), also called child molestation, is a form of child abuse in which an adult or older adolescent uses a child for sexual stimulation.^[1]^[2] Forms of child sexual abuse include engaging in sexual activities with a child (whether by asking or pressuring, or by other means), indecent exposure, child grooming, and child sexual exploitation,^[3]^[4]^[5] such as using a child to produce child pornography.^[1]^[6]

CSA is not confined to specific settings; it permeates various institutions and communities. CSA affects children in all socioeconomic levels, across all racial, ethnic, and cultural groups, and in both rural and urban areas. Schools, homes, and online spaces are just a few contexts where minors are vulnerable to abuse and exploitation.(in places where child labor is common). Child marriage is one of the main forms of child sexual abuse; UNICEF has stated that child marriage "represents perhaps the most prevalent form of sexual abuse and exploitation of girls".^[7] The effects of child sexual abuse can include depression,^[8] post-traumatic stress disorder,^[9] anxiety,^[10] complex post-traumatic stress disorder,^[11]^{[not verified in body]} and physical injury to the child, among other problems.^[12] Sexual abuse by a family member is a form of incest and can result in more serious and long-term psychological trauma, especially in the case of parental incest.^[13]

Before the age of 18, 1 in 5 children are sexually abused, this equates to more than 1 million children will be sexually abused this year.^[14]^[15] Reports by the Centers for Disease Control and Prevention, reveal that about 1 in 4 girls and 1 in 20 boys in the United States experience child sexual abuse.^[14] One study found an estimated 19.7% of females and 7.9% of males experienced some form of child sexual abuse prior to the age of 18.^[16] Most sexual abuse offenders are acquainted with their victims; approximately 30% are relatives of the child, most often brothers, fathers, uncles, or cousins;^[17]^{[not verified in body]} around 60% are other acquaintances, such as "friends" of the family, babysitters, or neighbors; strangers are the offenders in approximately 10% of child sexual abuse cases.^[18] Most child sexual abuse is committed by men; studies on female child molesters show that women commit 14% to 40% of offenses reported against boys and 6% of offenses reported against girls.^[18]^[19]^[20]^{[not verified in body]}

The word pedophile is commonly applied indiscriminately to anyone who sexually abuses a child,^[21] but child sexual offenders are not pedophiles unless they have a strong sexual interest in prepubescent children.^[22]^[23]^{[not verified in body]} Under the law, child sexual abuse is often used as an umbrella term describing criminal and civil offenses in which an adult engages in sexual activity with a minor or exploits a minor for the purpose of sexual gratification.^[6]^[24]^{[not verified in body]} The American Psychological Association states that "children cannot consent to sexual activity with adults", and condemns any such action by an adult: "An adult who engages in sexual activity with a child is performing a criminal and immoral act which never can be considered normal or socially acceptable behavior."^[25]^{[not verified in body]}

Effects

Psychological

Child sexual abuse can result in both short-term and long-term harm, including psychopathology in later life.^[12]^[26] Indicators and effects include depression,^[8]^[27]^[28] anxiety,^[10] eating disorders,^[29] poor self-esteem,^[29] somatization,^[28] sleep disturbances,^[30]^[31] and dissociative and anxiety disorders including post-traumatic stress disorder.^[9]^[32] While children may exhibit regressive behaviours such as thumb sucking or bedwetting, the strongest indicator of sexual abuse is sexual acting out and inappropriate sexual knowledge and interest.^[33]^[34] Victims may withdraw from school and social activities^[33] and exhibit various learning and behavioural problems including cruelty to animals,^[35]^[36]^[37]^[38] attention deficit/hyperactivity disorder (ADHD), conduct disorder, and oppositional defiant disorder (ODD).^[29] Teenage pregnancy and risky sexual behaviors may appear in adolescence.^[39] Child sexual abuse victims report almost four times as many incidences of self-inflicted harm.^[40] Sexual assault among teenagers has been shown to lead to an increase in mental health problems, social exclusion and worse school performance.^[41]^[42]

A well-documented, long-term negative effect is repeated or additional victimization in adolescence and adulthood.^[44]^[45] A causal relationship has been found between childhood sexual abuse and various adult psychopathologies, including crime and suicide,^[18]^[46]^[47]^[48]^[49]^[50] in addition to alcoholism and drug abuse.^[43]^[45]^[51] Males who were sexually abused as children more frequently appear in the criminal justice system than in a clinical mental health setting.^[33] A study comparing middle-aged women who were abused as children with non-abused counterparts found significantly higher health care costs for the former.^[28]^[52] Intergenerational effects have been noted, with the children of victims of child sexual abuse exhibiting more conduct problems, peer problems, and emotional problems than their peers.^[53]

A specific characteristic pattern of symptoms has not been identified,^[54] and there are several hypotheses about the causality of these associations.^[8]^[55]^[56]

Studies have found that 51% to 79% of sexually abused children exhibit psychological symptoms.^[48]^[57]^[58]^[59]^[60] The risk of harm is greater if the abuser is a relative, if the abuse involves intercourse or attempted intercourse, or if threats or force are used.^[61] The level of harm may also be affected by various factors such as penetration, duration and frequency of abuse, and use of force.^[12]^[26]^[62]^[63] The social stigma of child sexual abuse may compound the psychological harm to children,^[63]^[64] and adverse outcomes are less likely for abused children who have supportive family environments.^[65]^[66]

Posttraumatic stress disorder

Child abuse, including sexual abuse, especially chronic abuse starting at early ages, has been found to be related to the development of high levels of dissociative symptoms, which includes amnesia for abuse memories.^[67] When severe sexual abuse (penetration, several perpetrators, lasting more than one year) had occurred, dissociative symptoms were even more prominent.^[68] Recent research showed that females with high exposure to child sexual abuse (CSA) develop PTSD symptoms that are associated with poor social functioning, which is also supported by prior research studies.^[69] The feeling of being "cut-off" from peers and "emotional numbness" are both results of CSA and highly inhibit proper social functioning. Furthermore, PTSD is associated with higher risk of substance abuse as a result of the "self-medication hypothesis" and the "high-risk and susceptibility hypothesis".^[70]

Besides dissociative identity disorder (DID), posttraumatic stress disorder (PTSD), and complex post-traumatic stress disorder (C-PTSD), child sexual abuse survivors may present borderline personality disorder (BPD) and eating disorders such as bulimia nervosa.^[71]

Research factors

Because child sexual abuse often occurs alongside other possibly confounding variables, such as poor family environment and physical abuse,^[72] some scholars argue it is important to control for those variables in studies which measure the effects of sexual abuse.^[26]^[55]^[73]^[74] In a 1998 review of related literature, Martin and Fleming state "The hypothesis advanced in this paper is that, in most cases, the fundamental damage inflicted by child sexual abuse is due to the child's developing capacities for trust, intimacy, agency and sexuality, and that many of the mental health problems of adult life associated with histories of child sexual abuse are second-order effects."^[75] Other studies have found an independent association of child sexual abuse with adverse psychological outcomes.^[10]^[26]^[55]

Kendler et al. (2000) found that most of the relationship between severe forms of child sexual abuse and adult psychopathology in their sample could not be explained by family discord, because the effect size of this association decreased only slightly after they controlled for possible confounding variables. Their examination of a small sample of CSA-discordant twins also supported a causal link between child sexual abuse and adult psychopathology; the CSA-exposed subjects had a consistently higher risk for psychopathologic disorders than their CSA non-exposed twins.^[55]

A 1998 meta-analysis by Bruce Rind et al. generated controversy by suggesting that child sexual abuse does not always cause pervasive harm, that girls were more likely to be psychologically harmed than boys, that some college students reported such encounters as positive experiences and that the extent of psychological damage depends on whether or not the child described the encounter as "consensual".^[76] The study was criticized for flawed methodology and conclusions.^[77]^[78] The US Congress condemned the study for its conclusions and for providing material used by pedophile organizations to justify their activities.^[79]

Physical

Injury

Depending on the age and size of the child, and the degree of force used, child sexual abuse may cause internal lacerations and bleeding. In severe cases, damage to internal organs may occur, which, in some cases, may cause death.^[80]

Infections

Child sexual abuse may cause sexually transmitted infections.^[81] Due to a lack of sufficient vaginal fluid, chances of infections can heighten depending on the age and size of the child. Vaginitis has also been reported.^[81]

Neurological damage

Research has shown that traumatic stress, including stress caused by sexual abuse, may cause notable changes in brain functioning and development.^[82]^[83] Various studies have suggested that severe child sexual abuse may have a deleterious effect on brain development. Ito et al. (1998) found "reversed hemispheric asymmetry and greater left hemisphere coherence in abused subjects;"^[84] Teicher et al. (1993) found that an increased likelihood of "ictal temporal lobe epilepsy-like symptoms" in abused subjects;^[85] Anderson et al. (2002) recorded abnormal transverse relaxation time in the cerebellar vermis of adults sexually abused in childhood;^[86] Teicher et al. (1993) found that child sexual abuse was associated with a reduced corpus callosum area; various studies have found an association of reduced volume of the left hippocampus with child sexual abuse;^[87] and Ito et al. (1993) found increased electrophysiological abnormalities in sexually abused children.^[88]

Some studies indicate that sexual or physical abuse in children can lead to the overexcitation of an undeveloped limbic system.^[87] Teicher et al. (1993)^[85] used the "Limbic System Checklist-33" to measure ictal temporal lobe epilepsy-like symptoms in 253 adults. Reports of child sexual abuse were associated with a 49% increase to LSCL-33 scores, 11% higher than the associated increase of self-reported physical abuse. Reports of both physical and sexual abuse were associated with a 113% increase. Male and female victims were similarly affected.^[85]^[89]

Navalta et al. (2006) found that the self-reported math Scholastic Aptitude Test scores of their sample of women with a history of repeated child sexual abuse were significantly lower than the self-reported math SAT scores of their non-abused sample. Because the abused subjects' verbal SAT scores were high, they hypothesized that the low math SAT scores could "stem from a defect in hemispheric integration." They also found a strong association between short-term memory impairments for all categories tested (verbal, visual, and global) and the duration of the abuse.^[90]

Incest

Incest between a child or adolescent and a related adult is known as child incestuous abuse,^[91] and has been identified as the most widespread form of child sexual abuse with a highly significant capacity to damage the young person.^[13] One researcher stated that more than 70% of abusers are immediate family members or someone very close to the family.^[92] Another researcher stated that about 30% of all perpetrators of sexual abuse are related to their victim, 60% of the perpetrators are family acquaintances, like a neighbor, babysitter or friend and 10% of the perpetrators in child sexual abuse cases are strangers.^[18] A child sexual abuse offense where the perpetrator is related to the child, either by blood or marriage, is a form of incest described as intrafamilial child sexual abuse.^[93]

The most-often reported form of incest is father–daughter and stepfather–stepdaughter incest, with most of the remaining reports consisting of mother/stepmother–daughter/son incest.^[94] Father–son incest is reported less often; however, it is not known if the actual prevalence is less or it is under-reported by a greater margin.^[95]^[96]^[97]^[98] Similarly, some argue that sibling incest may be as common, or more common, than other types of incest: Goldman and Goldman^[99] reported that 57% of incest involved siblings; Finkelhor reported that over 90% of nuclear family incest involved siblings;^[100] while Cawson et al. show that sibling incest was reported twice as often as incest perpetrated by fathers/stepfathers.^[101]

Prevalence of parental child sexual abuse is difficult to assess due to secrecy and privacy; some estimates state that 20 million Americans have been victimized by parental incest as children.^[94]

Types

Child sexual abuse includes a variety of sexual offenses, including:

sexual assault – a term defining offenses in which an adult uses a minor for the purpose of sexual gratification; for example, rape (including sodomy), and sexual penetration with an object.^[102] Most U.S. states include, in their definitions of sexual assault, any penetrative contact of a minor's body, however slight, if the contact is performed for the purpose of sexual gratification.^[103]
sexual exploitation – a term defining offenses in which an adult victimizes a minor for advancement, sexual gratification, or profit; for example, prostituting a child,^[104] live streaming sexual abuse,^[105] and creating or trafficking in child pornography.^[106]
sexual grooming – a term defining the social conduct of a potential child sex offender who seeks to make a minor more accepting of their advances, for example in an online chat room.^[107]
sextortion - a term defining where children are threatened or blackmailed, most often with the possibility of sharing with the public a nude or sexual images of them, by a person who demands additional sexual content, sexual activity or money from the child.

Commercial sexual exploitation

Commercial sexual exploitation of children (CSEC) is defined by the Declaration of the First World Congress against Commercial Sexual Exploitation of Children, held in Stockholm in 1996, as "sexual abuse by an adult accompanied by remuneration in cash or in kind to the child or third person(s)."^[108] CSEC usually takes the form of child prostitution or child pornography, and is often facilitated by child sex tourism. CSEC is particularly a problem in developing countries of Asia.^[109]^[110] In recent years, new innovations in technology have facilitated the trade of Internet child pornography.^[111]

In the United Kingdom, the term child sexual exploitation covers any form of sexual abuse which includes an exchange of a resource for sexual activity with a child.^[3]^[112] Prior to 2009, the term commonly used to describe child sexual exploitation was child prostitution.^[113]^[114] The term child sexual exploitation first appeared in government guidance in 2009 as part of an attempt to promote an understanding that children involved in exploitation were victims of abuse rather than criminals.^[115]^[116] Because early definitions of child sexual exploitation were created to foster a move away from use of the term child prostitution, the concept of exchange, which made child sexual exploitation different from child sexual abuse, referred to financial gain only. However, in the years since the birth of the concept of child sexual exploitation, the notion of exchange has been widened to include other types of gain, including love, acquisition of status and protection from harm.^[116]

Disclosure

Children who received supportive responses following disclosure had less traumatic symptoms and were abused for a shorter period of time than children who did not receive support.^[117]^[118] In general, studies have found that children need support and stress-reducing resources after disclosure of sexual abuse.^[119]^[120] Negative social reactions to disclosure have been found to be harmful to the survivor's well-being.^[121] One study reported that children who received a bad reaction from the first person they told, especially if the person was a close family member, had worse scores as adults on general trauma symptoms, post traumatic stress disorder symptoms, and dissociation.^[122] Another study found that in most cases when children did disclose abuse, the person they talked to did not respond effectively, blamed or rejected the child, and took little or no action to stop the abuse.^[120] Non-validating and otherwise non-supportive responses to disclosure by the child's primary attachment figure may indicate a relational disturbance predating the sexual abuse that may have been a risk factor for the abuse, and which can remain a risk factor for its psychological consequences.^[123]

The American Academy of Child and Adolescent Psychiatry provides guidelines for what to say to the victim and what to do following the disclosure.^[124] Asa Don Brown has indicated: "A minimization of the trauma and its effects is commonly injected into the picture by parental caregivers to shelter and calm the child. It has been commonly assumed that focusing on children's issues too long will negatively impact their recovery. Therefore, the parental caregiver teaches the child to mask his or her issues."^[125]

In many jurisdictions, abuse that is suspected, not necessarily proven, requires reporting to child protection agencies, such as the Child Protection Services in the United States. Recommendations for healthcare workers, such as primary care providers and nurses, who are often suited to encounter suspected abuse are advised to firstly determine the child's immediate need for safety. A private environment away from suspected abusers is desired for interviewing and examining. Leading statements that can distort the story are avoided. As disclosing abuse can be distressing and sometimes even shameful, reassuring the child that he or she has done the right thing by telling and that they are not bad and that the abuse was not their fault helps in disclosing more information. Anatomically correct dolls are sometimes used to help explain what happened, although some researchers consider the dolls too explicit and overstimulating, which might contribute to non-abused children behaving with the dolls in one or more ways that suggest they were sexually abused.^[126] For the suspected abusers, it is also recommended to use a nonjudgmental, nonthreatening attitude towards them and to withhold expressing shock, in order to help disclose information.^[127]

Treatment

The initial approach to treating a person who has been a victim of sexual abuse is dependent upon several important factors:

Age at the time of presentation
Circumstances of presentation for treatment

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