Child Sexual Abuse: A Very Real Public Health Concern

Written By Mahrin Rahman


Definition of the Problem

\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0 Child sexual abuse includes a range of illicit, sexual behaviors that take place between an older person and a child (less than 18 years of age). These sexual activities are intended to erotically arouse the older person, without consideration for the reactions or choices of the child. Behaviors that are sexually abusive often involve bodily contact, such as sexual kissing, touching, fondling of genitals, and oral, anal and vaginal intercourse. Behaviors may also be sexually abusive despite a lack of contact, such as genital exposure (\x93flashing\x94), verbal pressure for sex, and sexual exploitation for pornography or prostitution.

\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0 While some statistical data is available on the prevalence of child sexual abuse, it is at best limited and flawed due to underreporting and low disclosure rates. In the year 2000, US figures approximate that 879,000[1] children were victims of maltreatment, and about 10% of those children, or 87,900, had suffered through sexual abuse. These figures also showed that as age increased, the rates of victimization decreased; from birth to three years old there were 15.71 victims per 1,000 children, and from 16 to 17 years old there were 5.7 victims per 1,000 children. Furthermore, child sexual abuse occurs across all ethnic, racial, socioeconomic and religious backgrounds, affecting 1 in 4 girls and 1 in 7 boys.[2] The perpetrators are most often known by their victims, as they are likely to be caregivers, parents, step-parents, relatives, or family friends. Fewer than 10% of children are abused by complete strangers.2 \xA0Over 90% of offenders are males engaging in nonconsensual intercourse with underage females[3], however female perpetrators are becoming an increasingly common problem as well.

\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0 While these figures indicate that child sexual abuse is a prevalent problem, prevention education is regarded as highly inadequate. Children are warned to stay away from dangerous strangers from an early age, however statistics prove that strangers are not where primary suspicions should lie. Additionally, while public health officials have designated counseling and community outreach programs to help deal with children after the trauma has occurred, more emphasis needs to be placed upon promoting early disclosure as well as education in the home between parents and children.


Disclosure: The Biggest Barrier

\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0 Children often fail to report because of the fear that disclosure of the crime will bring consequences even worse than being victimized again. The survivor may fear being penalized by the family, feel guilty for consequences to the perpetrator, and may fear subsequent retaliatory actions from the perpetrator.[4] Among victims of sexual abuse, the inability to trust is pronounced, which also contributes to secrecy and non-disclosure. Victims may also have a feeling that "something is wrong with me," and that the abuse is their fault, an easy belief for children to succumb to. They may also feel different from peers, harbor vengeful and angry feelings toward both parents, feel guilty about reporting the abuse, and fear bringing disloyalty and disruption to the family. Any of these feelings of guilt could outweigh the decision of the victim to report, the result of which is that the secret may remain intact and undisclosed.

A child's initial denial of sexual abuse should not be the sole basis of reassurance that abuse did not occur. Virtually all investigative protocols are designed to respond to only those children who have disclosed. Policies and procedures that are geared only to those children who have disclosed fail to recognize the needs of the majority of victims, and this is an arena where more education efforts need to be made.

In a study of 630 cases of alleged sexual abuse of children from 1985 through 1989, by using a subset of 116 confirmed cases, findings indicated that 79 percent of the children of the study initially denied abuse or were tentative in disclosing. Of those who did disclose, approximately three-quarters disclosed accidentally. Additionally, of those who did disclose, 22 percent eventually recanted their statements.[5] This study demonstrates the vulnerability of children, and how easily their thoughts can be distorted or manipulated. Since most children seek approval from adults, they are very vulnerable to abuse. They will do what is asked of them without question. In fact, the use of physical force is rarely necessary to draw a child into sexual activity because children are so trusting and dependent. They want to please others and gain approval. Children are taught not to question authority and they believe that adults are always right. Offenders know this and take advantage of children in this way. Additionally, early identification of sexual abuse victims appears to be crucial in reducing the suffering of abused youth, establishing support systems for assistance, and pursuing appropriate psychological development.[6] However, as long as disclosure continues to be a problem for young victims, then fear, suffering, and psychological distress will, like the secret, remain with the victim.


Recognizing the Signs of Child Sexual Abuse:

\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0 Children rarely show visible signs of physical abuse, therefore it is up to adults to recognize when there is something wrong if the child does not immediately disclose. Unfortunately, there is no one definite behavioral indicator that demonstrates that a child is being abused, however the following signs seen over a period of time repeatedly may indicate abuse: physical complaints (i.e. headaches); fear or dislike of certain people or places; extreme changes in behavior; depression and withdrawal; frequent nightmares; regression to infantile behavior (i.e. bedwetting); age inappropriate interest in sexual matters; frequent genital infections; excessive masturbation; and self mutilation[7]. In older adolescents, suicide attempts, eating disorders and disciplinary problems may become evident[8].


Progression of Abuse:

\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0 There are five major stages of progression in the \x93courtship\x94 of a perpetrator and a child. They include the engagement phase, sexual interaction phase, secrecy phase, disclosure phase, and lastly, the suppression phase.[9] The engagement phase is when the perpetrator will use his position of power to exploit and dominate the child. This will consist of manipulating \x93games\x94 or activities that misrepresent common moral standards. For example, the perpetrator will encourage the child to take off her clothes to \x93play,\x94 and since the child is easily influenced and willing to please, she will do exactly as the perpetrator wants without any guilt or suspicion.

\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0 The next stage is the sexual interaction phase, and this is when the perpetrator has crossed the line of what that child considers \x93affectionate\x94. Hugs, kisses, lap sitting and tickling now turn into sexualized activities. The perpetrator will now begin to undress the child or lift up her shirt simply to look at features on her body without \x93playing,\x94 and begin masturbating or stimulating himself in her presence. This will progress to bodily contact of the child, which includes kissing, fondling or stroking different parts of her body and genitals. Eventually oral or digital penetration may occur, followed by anal or vaginal penetration. This phase may take months or years, as the longer the perpetrator spends with the child the stronger the relationship will be.

\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0 The secrecy phase is what follows the sexual interaction phase, and it is here that the perpetrator subtly coerces the child into keeping their \x93games\x94 secret. She may be rewarded with attention, pleasure, love, and materials goods, however she may also be threatened with bodily harm and threats. This secrecy allows the abuse to continue, and the perpetrator is made to feel important, powerful, dominant and in control of their non threatening relationship.

\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0 The next phase is the disclosure phase, and as the name describes, disclosure may happen purposefully or on accident. A third party may observe the abuse taking place, or clinical symptoms may manifest. In the case disclosure does happen, the entire family is affected, as siblings and other relatives begin to feel self-protective, modeling defense mechanisms to keep themselves out of the situation. However, without a comforting environment and social disconnect from the family, the child will feel like she brought it upon herself, or she is the only one this has ever happened to.

\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0 The last stage is the suppression phase, in which the victim may deny the occurrence of any events. She may suppress crisis intervention, supplying information to law enforcement, or deny the significance of any events. Now, while these five stages of progression are not seen in every child, something similar or along the same lines may become apparent. It is then in the hands of adults to recognize that something is wrong with the particular child in question and take the appropriate actions to stop the progression.


Immediate Effects on the Child Once Disclosure Occurs

\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0 There are certain issues that are likely to have an effect on the child regardless of whether the perpetrator was a stranger or acquaintance. The child may feel something entitled \x93Damaged Good Syndrome\x94[10], in which they feel their body has been forever tainted, thus resulting in a negative self body image and all accompanying compulsions to \x93fix\x94 what has been broken. Children will also suffer pain and anxiety, not knowing how to properly deal with their emotions, or their new forced sexual maturity. \xA0

\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0 Guilt is another major issue that the child will have to grapple with following disclosure. This comes about as the child feels responsible for participating in the sexual act, as well as revealing an important secret that they may have promised not to divulge. Since the family may also be disrupted, feelings of guilt may surround this particularly sensitive subject. Feelings of fear will also be an issue; fear of any consequences as well as fear of subsequent episodes, physical reprisals and being separated, from either the perpetrator of the family. Signs of depression may also be unconcealed in the child, as behavior drastically changes from cheerful to sad and tired. Depression may also be masked behind self mutilation, fatigue or illness, especially in older child abuse cases.

\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0 Low esteem can be another hurdle the child might have to overcome after the abuse. This may result in poor social interaction skills, feelings of inferiority, and initiating sexual relationships with others to prove their own worth. Additionally, anger and hostility may manifest, as the child may be angry with the perpetrator who committed the crime, or with the family for not protecting them from the beginning.

\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0 All of these feelings may lead to an increased inability to trust others, depending on the degree of the damage. As disclosure can accentuate feelings of rejection, betrayal and alienation, these can all lead to an emotional shutdown in which the child raises their guard in response to the sexual abuse. However, children behave in their own ways and expecting someone to struggle with all the above issues is unrealistic; the issues are simply a clinical range of symptoms experienced by children across the board. Furthermore, if these issues are not treated in the present, then the child will feel the residue effects throughout the course of the rest of their life.



\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0 The typical offender is more likely to be a family member or relative to the child rather than a complete stranger. Most reported offenders are male, although studies estimate the number of female perpetrators to be between 5%-20%[11] Offenders are typically classified by their motivation, which is assessed by reviewing the characteristics of their offense. In 1982, a system was proposed in which pedophiles (persons attracted to minor, prepubescent children), were either classified as \x93fixated\x94 or \x93regressed\x94.[12] There is a third category, however most perpetrators fall under the first two. Regressed offenders are primarily attracted to their own age group but are passively aroused by minors (pseudo-pedophiles). This attraction usually does not manifest itself until adulthood, and their sexual conduct until adulthood is aligned with their own age group. Their interest in minors is either not cognitively realized until well into adulthood or it was recognized early on and simply suppressed due to social taboo[13].

\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0 Fixated perpetrators, on the other hand, are most often adult pedophiles who are cannot accept social norms. They develop compatibility and self-esteem issues, stunting their social growth, which manifests into the sexually deviant behavior[14]. Such offenders often resort to collecting personal articles related to minors (clothing, children's books) as an outlet for their repressed desires. Most fixated offenders prefer members of the same sex. There is a difference of opinion as to whether this may be classified as homosexual behavior due to the nature of the individual's attractions. The sexual acts are typically preconceived and are not alcohol or drug related. The third category includes the sadistic offenders. They are very rare and innately violent criminals. They primarily use sexuality as a tool of sadistic suppression and not for sexual satisfaction.

\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0 Most offenders fit into the regressed pedophile category[15]. Only between 2-10% of all perpetrators are considered fixated. These categories, (primarily the first two), are based on the assumption that the offender suffers from an irreversible mental illness. A few have noted that the primary division between "regressed" or "fixated" offenders seems to rest on two criteria: the offending person's ability to successfully live a socially acceptable lifestyle before committing the crime and the person's primary sexual preference. However, these terms do not encompass the full range of possible scenarios and merely attempt to label easily identifiable situations. A growing number of minor-attracted adults feel that the two main classifications are a direct result from the lack of understanding and/or bias in the mainstream regarding intergenerational sexual attraction in western society and thus are categorically flawed[16]. As more research being done on this type of categorization, perhaps we can move to a more educated view of how to classify pedophilic sexually deviant behavior.


Ethical Issues and Cultural Relativism

\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0 There is no consensus between the cultural relativists about whether different cultural practices in Western or non-Western societies can be defined as definite sexual abuse. In different cultures throughout the world, practices sanctioned by cultural norms include: both male and female circumcision (cutting and bleeding of the genitals), castration, and infibulation. Furthermore, sexual relationships between adolescent boys and adult men are sanctioned by the state in some places, and were sanctified by religion in both ancient Greece and feudal Japan. Child prostitution is still tolerated in some societies as a way for children to support their families, and the purposeful groping of schoolgirls in Japanese trains is seen as normal. Furthermore, sexual interactions between adults and children were commonplace and accepted in a variety of archaic cultures, including that of the Aranda aborigines, Hawaiians, and Polynesians[17]. Lastly, remedies against masturbation (once named 'self-abuse') are still found in Japan, as well as ritual fellation by youths which is seen in some Oceanic cultures.

\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0 While there is great debate surrounding the above examples, the issue of granting cognitive consent is what is at the heart of it. The mainstream opinion in countries such as the U.S. and U.K. is that any minor under the legal age of consent is deemed mentally incapable of consenting to sexual activity with people older than they are, thus any and all contact is automatically considered abuse. Also, in cases of multi-generational relationships where both parties are legal adults, such relationships are still often widely considered immoral and taboo, even though legal. In most cases involving minors, it has resulted in the passing of laws which prohibit them from giving legal informed consent, even if they are indeed a willing partner to the best of their own knowledge. Thus, if such acts are discovered, the adult may be charged with a criminal offense.


Public Health Prevention Efforts

\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0 While research has been done to decrease the incidence of child sexual abuse, rates are still climbing higher. This is a problem that is going to require researchers from the social sciences, medical, and criminal justice fields to join together and gather better information on the prevalence, causes, consequences, prevention, and treatment of child sexual abuse. A 1996[18] report from the Department of Justice estimated rape and sexual abuse of children to cost $1.5 billion in medical expenses and $23 billion total annually to U.S. victims. Whereas $2 is spent on research for every $100 dollars in cost for cancer, only $.05 is spent for every $100 dollars in cost for child maltreatment[19]. The National Child Traumatic Stress Network is a federally funded network of 54 sites providing community-based treatment to children and their families exposed to a wide range of trauma. The network should be expanded to address the enormous public health consequences of child trauma, and support to develop new forms of treatment. Even creation of a new Institute of Child Abuse and Interpersonal Violence within the NIH would be justified on the basis of the emotional and economic cost of these problems.

\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0 Furthermore, for many public health problems, one important prevention strategy is to increase public awareness about the issue[20], and this is seen to be very true for child sexual abuse. Prevention programs may be effective if the public views child sexual abuse as a problem that is relevant in their communities, not just something only seen on television in other parts of the world.[21] In Vermont, STOP IT NOW! is a non-profit organization that is intended to address child sexual abuse systematically as a public health issue by using social marketing and public education to emphasize the responsibility of adults for prevention. Specific goals of this innovative approach to prevention are to educate the public about perpetrators and to motivate adults to action to prevent child sexual abuse.

\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0 Another program like STOP IT NOW! that has achieved moderate success is Generation Five, a non-profit organization that brings together community leaders working to end child sexual abuse within five generations. Their programs provide leadership training to community members, activists and agency professionals and foster national strategy and information exchange on child sexual abuse. However, they are not a direct service organization; instead, they \x93work in collaboration with other service providers to ensure that affordable, culturally relevant support is available to survivors, offenders, and affected families\x94.[22]

\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0\xA0 While these organizations exist to promote further research and collaboration between disciplines, the goal of primary prevention outreach is to begin education in the home. By facilitating clear lines of communication between parents and their children, so much invaluable teaching can be done which will only help children in the future when it comes time to make critical decisions in regards to sex and consent. Parents need to specifically teach their children who is allowed to touch them and where, and more importantly, understand that a certain amount of sexual exploration during their child\x92s prepubescent years is not harmful or indicative of something wrong. By conveying this primary prevention method to parents, we can remain hopeful as a society that the prevalence of child sexual assault will decrease, allowing children the freedom of a carefree childhood.



[1] US Department of Health and Human Services. Administration for Children and Families, National Clearinghouse on Child Abuse and Neglect; 2000.

[2] National Resource Center on Child Sexual Abuse, 1993.

[3] Due to this statistic, all references to perpetrators in this chapter will be referred to as \x93him\x94 and all references to victims will be referred to as \x93her\x94.

[4] Berlinger & Barbieri, 1984; Groth, 1979; Swanson & Biaggio, 1985.

[5] Sorensen & Snow, 1991.

[6] Bagley, 1992; Bagley, 1991; Finkelhor et al. 1990; Whitlock & Gillman, 1989.

[7] Boney-McCoy, S. & Finkelhor, D. (1996). Is youth victimization related to trauma symptoms and depression after controlling for prior symptoms and family relationships? A longitudinal, prospective study. Journal of Consulting and Clinical Psychology, 64, 1406-1416.

[8] Neumann, D. A., Houskamp, B. M., Pollock, V. E., & Briere, J. (1996). The long-term sequelae of childhood sexual abuse in women: A meta-analytic review. Child Maltreatment, 1, 6-16



[11] Women Who Rape; National ClearingHouse on Child Abuse and Neglect; 2000.

[12] Groth, A.N., Hobson, W.F. and Gary, T.S. (1982). "The child molester: clinical observations." In Journal of Social Work and Child Sexual Abuse, 1(1/2), 129-144.

[13] Kisiel, C. L. and Lyons, J. S., "Dissociation as a Mediator of Psychopathology Among Sexually Abused Children and Adolescents" Am. J. of Psychiatry 158:1034-1039, July 2001.

[15] Fergusson, D. M., Lynskey, M. T., and Horwood L. J. (1996). "Childhood sexual abuse and psychiatric disorder in young adulthood: I. Prevalence of sexual abuse and factors associated with sexual abuse." In the Journal of the American Academy of Child and Adolescent Psychiatry, 35(10), 1355-64.

[16] Underwager, Ralph and Wakefield, Hollida, "Antisexuality and Child Sexual Abuse" IPT Volume 5 - 1993

[17] Green, Richard (2002). "Is pedophilia a mental disorder?", Archives of Sexual Behavior. 31 (6). 467-471.

[18] T. R. Miller, M. A. Cohen, B. Wiersema, Victim costs and consequences: A new look.  (US Department of Justice, Washington, DC., 1996) .

[19] F. W. Putnam.  In Franey K, Geffner R, Falconer R (eds). The cost of child maltreatment: who pays?  (San Diego, Family Violence & Sexual Assault Institute, pp. 185-198., 2001).

[20] Foege WH, Rosenberg ML, Mercy JA. Public health and violence prevention. Current Issues in Public Health 1995;1:2-9.\xA0

[21] Finkelhor D, Hotaling G, Lewis IA, Smith C. Sexual abuse in a national survey of adult men and women: prevalence, characteristics, and risk factors. Child Abuse Negl 1990;14:19-28.