Child sexual abuse or 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 asking or pressuring a child to engage in sexual activities (regardless of the outcome), indecent exposure (of the genitals, female nipples, etc.) to a child with intent 
to gratify their own sexual desires or to intimidate or groom the child, physical sexual contact with a child, or using a child to produce child pornography.
The effects of child sexual abuse can include depression,[5] post-traumatic stress disorder,[6] anxiety,[7] complex post-traumatic stress disorder,[8] propensity to further victimization in adulthood,[9] and physical injury to the child, among other problems.[10] 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.
The global prevalence of child sexual abuse has been estimated at 19.7% for females and 7.9% for males, according to a 2009 study published in Clinical Psychology Review that examined 65 studies from 22 countries.
Using the available data, the highest prevalence rate of child sexual abuse geographically was found in Africa (34.4%), primarily because of high rates in South Africa; Europe showed the lowest prevalence rate (9.2%); America and Asia had prevalence rates between 10.1% and 23.9%.[12]
In the past, other research has concluded similarly that in North America, for example, approximately 15% to 25% of women and 5% to 15% of men were sexually abused when they were children.
Most sexual abuse offenders are acquainted with their victims; approximately 30% are relatives of the child, most often brothers, fathers, uncles or cousins; 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.[13]
Most child sexual abuse is committed by men; studies show that women commit 14% to 40% of offenses reported against boys and 6% of offenses reported against girls.[13][14][16] Some sources report that most offenders who sexually abuse prepubescent children are pedophiles,[17] but some offenders do not meet the clinical diagnosis standards for pedophilia.[18][19]
Under the law, "child sexual abuse" is 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.[4][20]
The American Psychiatric 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."
While children may exhibit regressive behaviours such as a return to thumb-sucking or bed-wetting, the strongest indicator of sexual abuse is sexual acting out and inappropriate sexual knowledge and interest.[29][30]
Victims may withdraw from school and social activities[29] and exhibit various learning and behavioural problems including cruelty to animals,[31][32][33] attention deficit/hyperactivity disorder (ADHD), conduct disorder, and oppositional defiant disorder (ODD).[25] Teenage pregnancy and risky sexual behaviors may appear in adolescence.[34] Child sexual abuse victims report almost four times as many incidences of self-inflicted harm.[35]
A study funded by the USA National Institute of Drug Abuse found that
"Among more than 1,400 adult females, childhood sexual abuse was
associated with increased likelihood of drug dependence, alcohol
dependence, and psychiatric disorders.
A well documented long term negative effect is repeated or additional victimization in adolescence and adulthood.[9][37] A causal relationship has been found between childhood sexual abuse and various adult psychopathologies, including crime and suicide,[13][38][39][40][41][42] in addition to alcoholism and drug abuse.[36][37][43]
Males who were sexually abused as children more frequently appear in the criminal justice system than in a clinical mental health setting.[29]
A study comparing middle-aged women who were abused as children with non-abused counterparts found significantly higher health care costs for the former.[24][44]
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.[45]
A specific characteristic pattern of symptoms has not been identified[46] and there are several hypotheses about the causality of these associations.[5][47][48]
Studies have found that 51% to 79% of sexually abused children exhibit psychological symptoms.[40][49][50][51][52] 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.[53]
The level of harm may also be affected by various factors such as penetration, duration and frequency of abuse, and use of force.[10][22][54][55] The social stigma of child sexual abuse may compound the psychological harm to children,[55][56] and adverse outcomes are less likely for abused children who have supportive family environments.[57][58]
Besides dissociative identity disorder (DID) and posttraumatic stress disorder (PTSD), child sexual abuse survivors may present borderline personality disorder (BPD) and eating disorders auch as bulimia nervosa.[61]
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."[65] Other studies have found an independent association of child sexual abuse with adverse psychological outcomes.[7][22][47]
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.[47]
A 1998 meta-analysis by Bruce Rind et al. generated controversy by suggesting that child sexual abuse does not always cause pervasive harm, 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."[66]
The study was criticized for flawed methodology and conclusions.[67][68] The US Congress condemned the study for its conclusions and for providing material used by pedophile organizations to justify their activities.[69]
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;"[75] Teicher et al. (1993) found that an increased likelihood of "ictal temporal lobe epilepsy-like symptoms" in abused subjects;[76] Anderson et al. (2002) recorded abnormal transverse relaxation time in the cerebellar vermis of adults sexually abused in childhood;[77] 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;[78] and Ito et al. (1993) found increased electrophysiological abnormalities in sexually abused children.[79]
Some studies indicate that sexual or physical abuse in children can lead to the overexcitation of an undeveloped limbic system.[78] Teicher et al. (1993)[76] 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.[76][80]
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.[81]
The most-often reported form of incest is father–daughter and stepfather–daughter incest, with most of the remaining reports consisting of mother/stepmother–daughter/son incest.[84] 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.[85][86] Similarly, some argue that sibling incest may be as common, or more common, than other types of incest: Goldman and Goldman[87] reported that 57% of incest involved siblings; Finkelhor reported that over 90% of nuclear family incest involved siblings;[88] while Cawson et al. show that sibling incest was reported twice as often as incest perpetrated by fathers/stepfathers.[89]
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.[84]
The American Academy of Child and Adolescent Psychiatry provides guidelines for what to say to the victim and what to do following the disclosure.[102] 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."[103]
The three major modalities for therapy with children and teenagers are family therapy, group therapy, and individual therapy. Which course is used depends on a variety of factors that must be assessed on a case by case basis. For instance, treatment of young children generally requires strong parental involvement, and can benefit from family therapy. Adolescents tend to be more independent, and can benefit from individual or group therapy. The modality also shifts during the course of treatment, for example group therapy is rarely used in the initial stages, as the subject matter is very personal and/or embarrassing.[104]
Major factors that affect both the pathology and response to treatment include the type and severity of the sexual act, its frequency, the age at which it occurred, and the child’s family of origin. Roland C. Summit, a medical doctor had defined the different stages the victims of child sexual abuse go through, Child Sexual Abuse Accommodation Syndrome. He suggested that children who are victims of sexual abuse depict a range of symptoms that include secrecy, helplessness, entrapment, accommodation, delayed and conflicted disclosure and recantation.[105]
Generally the approach is to the present problem, rather than the abuse itself. Treatment is highly varied and depends on the person’s specific issues. For instance, a person with a history of sexual abuse suffering from severe depression would be treated for depression. However, there is often an emphasis on cognitive restructuring due to the deep-seated nature of the trauma. Some newer techniques such as Eye Movement Desensitization and Reprocessing (EMDR) have been shown to be effective.[107]
Sexual abuse is associated with many sub-clinical behavioral issues as well, including re-victimization in the teenage years, a bipolar-like switching between sexual compulsion and shut-down, and distorted thinking on the subject of sexual abuse (for instance, that it is common and happens to everyone). When first presenting for treatment, the patient can be fully aware of their abuse as an event, but their appraisal of it is often distorted, such as believing that the event was unremarkable (a form of isolation). Frequently, victims do not make the connection between their abuse and their present pathology.
More offenders are male than female, though the percentage varies between studies. The percentage of incidents of sexual abuse by female perpetrators that come to the attention of the legal system is usually reported to be between 1% and 4%.[111] Studies of sexual misconduct in US schools with female offenders have shown mixed results with rates between 4% to 43% of female offenders.[112] Maletzky (1993) found that, of his sample of 4,402 convicted pedophilic offenders, 0.4% were female.[113] Another study of a non-clinical population found that, among those in the their sample that had been molested, as much as a third were molested by women.[114]
In U.S. schools, educators who offend range in age from "21 to 75 years old, with an average age of 28" with teachers, coaches, substitute teachers, bus drivers and teacher's aides (in that order) totaling 69% of the offenders.[115]
Later work (Holmes and Holmes, 2002) expanded on the types of offenders and their psychological profiles. They are divided thus:[117]
Offenses may be facilitated by cognitive distortions of the offender, such as minimization of the abuse, victim blaming, and excuses.[120]
Unlike research on adult offenders, a strong causal relationship has been established between child and adolescent offenders and these offenders' own prior victimization, by either adults or other children.[135][136][137][138]
The prevalence of child sexual abuse in Africa is compounded by the virgin cleansing myth that sexual intercourse with a virgin will cure a man of HIV or AIDS. The myth is prevalent in South Africa, Zimbabwe,[140] Zambia and Nigeria and is being blamed for the high rate of sexual abuse against young children.[141]
A number of high-profile baby rapes appeared since 2001 (including the fact that they required extensive reconstructive surgery to rebuild urinary, genital, abdominal, or tracheal systems). In 2001, a 9-month-old was raped and likely lost consciousness as the pain was too much to bear.[145] In February 2002, an 8-month-old infant was reportedly gang raped by four men. One has been charged. The infant has required extensive reconstructive surgery. The 8-month-old infant's injuries were so extensive, increased attention on prosecution has occurred.[146]
In the UK, a 2010 study estimated prevalence at about 5% for boys and 18% for girls[153] (not dissimilar to a 1985 study that estimated about 8% for boys and 12% for girls[154]). More than 23,000 incidents were recorded by the UK police between 2009 and 2010. Girls were six times more likely to be assaulted than boys with 86% of attacks taking place against them.[155][156] The estimates for the United States vary widely. A literature review of 23 studies found rates of 3% to 37% for males and 8% to 71% for females, which produced an average of 17% for boys and 28% for girls,[157] while a statistical analysis based on 16 cross-sectional studies estimated the rate to be 7.2% for males and 14.5% for females.[15] The US Department of Health and Human Services reported 83,600 substantiated reports of sexually abused children in 2005.[158][159] Including incidents which were not reported would make the total number even larger.[160] According to Emily M. Douglas and David Finkelhor, "Several national studies have found that black and white children experienced near-equal levels of sexual abuse. Other studies, however, have found that both blacks and Latinos have an increased risk for sexual victimization".[161][162]
Surveys have shown that one fifth to one third of all women reported some sort of childhood sexual experience with a male adult.[163] A 1992 survey studying father-daughter incest in Finland reported that of the 9,000 15-year old high school girls who filled out the questionnaires, of the girls living with their biological fathers, 0.2% reported father-daughter incest experiences; of the girls living with a stepfather, 3.7% reported sexual experiences with him. The reported counts included only father-daughter incest and did not include prevalence of other forms of child sexual abuse. The survey summary stated, "the feelings of the girls about their incestual experiences are overwhelmingly negative."[164] Others argue that prevalence rates are much higher, and that many cases of child abuse are never reported. One study found that professionals failed to report approximately 40% of the child sexual abuse cases they encountered.[165] A study by Lawson & Chaffin indicated that many children who were sexually abused were "identified solely by a physical complaint that was later diagnosed as a venereal disease...Only 43% of the children who were diagnosed with venereal disease made a verbal disclosure of sexual abuse during the initial interview."[166] It has been found in the epidemiological literature on CSA that there is no identifiable demographic or family characteristic of a child that can be used to bar the prospect that a child has been sexually abused.[150]
In 2007 the Ministry of Women and Child Development published the "Study on Child Abuse: India 2007."[175] It sampled 12447 children, 2324 young adults and 2449 stakeholders across 13 states. It looked at different forms of child abuse: physical abuse, sexual abuse and emotional abuse and girl child neglect in five evidence groups, namely, children in a family environment, children in school, children at work, children on the street and children in institutions.
The study's[175] main findings included: 53.22% of children reported having faced sexual abuse. Among them 52.94% were boys and 47.06% girls. Andhra Pradesh, Assam, Bihar and Delhi reported the highest percentage of sexual abuse among both boys and girls, as well as the highest incidence of sexual assaults. 21.90% of child respondents faced severe forms of sexual abuse, 5.69% had been sexually assaulted and 50.76% reported other forms of sexual abuse. Children on the street, at work and in institutional care reported the highest incidence of sexual assault. The study also reported that 50% of abusers are known to the child or are in a position of trust and responsibility and most children had not reported the matter to anyone. Despite years of lack of any specific child sexual abuse laws in India, which treated them separately from adults in case of sexual offense, the 'Protection of Children Against Sexual Offences Bill, 2011' was passed the Indian parliament on May 22, 2012.[178]
The United Nations Convention on the Rights of the Child (CRC) is an international treaty that legally obliges states to protect children's rights. Articles 34 and 35 of the CRC require states to protect children from all forms of sexual exploitation and sexual abuse. This includes outlawing the coercion of a child to perform sexual activity, the prostitution of children, and the exploitation of children in creating pornography. States are also required to prevent the abduction, sale, or trafficking of children.[182] As of November 2008, 193 countries are bound by the CRC,[183] including every member of the United Nations except the United States and Somalia.[184][185]
Second wave feminism brought greater awareness of child sexual abuse and violence against women, and made them public, political issues.[187][188] Judith Lewis Herman, Harvard professor of psychiatry, wrote the first book ever on father-daughter incest when she discovered during her medical residency that a large number of the women she was seeing had been victims of father-daughter incest. Herman notes that her approach to her clinical experience grew out of her involvement in the civil rights movement.[189] Her second book Trauma and Recovery coined the term complex post-traumatic stress disorder and included child sexual abuse as a possible cause.[190]
In 1986, Congress passed the Child Abuse Victims' Rights Act, giving children a civil claim in sexual abuse cases. The number of laws created in the 1980s and 1990s began to create greater prosecution and detection of child sexual abusers. During the 1970s a large transition began in the legislature related to child sexual abuse. Megan's Law which was enacted in 2004 gives the public access to knowledge of sex offenders nationwide.[191]
Anne Hastings described these changes in attitudes towards child sexual abuse as "the beginning of one of history's largest social revolutions."[192]
According to John Jay College of Criminal Justice professor B.J. Cling,
In June 2008 in Zambia the issue of teacher-student sexual abuse and sexual assault was brought to the attention of the High Court of Zambia where a landmark case decision, with presiding Judge Philip Musonda, awarded $45million Zambian Kwacha ($13,000 USD) to the plaintiff, a 13-year-old girl for sexual abuse and rape by her school teacher. This claim was brought against her teacher as a "person of authority" who, as Judge Musonda stated, "had a moral superiority (responsibility) over his students" at the time.[195]
A 2000 World Health Organization – Geneva report, “World Report on Violence and Health (Chap 6 – Sexual Violence)” states, “Action in schools is vital for reducing sexual and other forms of violence. In many countries a sexual relation between a teacher and a pupil is not a serious disciplinary offence and policies on sexual harassment in schools either do not exist or are not implemented. In recent years, though, some countries have introduced laws prohibiting sexual relations between teachers and pupils. Such measures are important in helping eradicate sexual harassment in schools. At the same time, a wider range of actions is also needed, including changes to teacher training and recruitment and reforms of curricula, so as to transform gender relations in schools.”[196]
In March 2011 Europol, the European Police, in a mission called Operation Rescue, arrested 184 alleged members out of 670 identified, of an online paedophile ring and rescued 230 children which is considered as the biggest case of its kind.[197]
to gratify their own sexual desires or to intimidate or groom the child, physical sexual contact with a child, or using a child to produce child pornography.
The effects of child sexual abuse can include depression,[5] post-traumatic stress disorder,[6] anxiety,[7] complex post-traumatic stress disorder,[8] propensity to further victimization in adulthood,[9] and physical injury to the child, among other problems.[10] 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.
The global prevalence of child sexual abuse has been estimated at 19.7% for females and 7.9% for males, according to a 2009 study published in Clinical Psychology Review that examined 65 studies from 22 countries.
Using the available data, the highest prevalence rate of child sexual abuse geographically was found in Africa (34.4%), primarily because of high rates in South Africa; Europe showed the lowest prevalence rate (9.2%); America and Asia had prevalence rates between 10.1% and 23.9%.[12]
In the past, other research has concluded similarly that in North America, for example, approximately 15% to 25% of women and 5% to 15% of men were sexually abused when they were children.
Most sexual abuse offenders are acquainted with their victims; approximately 30% are relatives of the child, most often brothers, fathers, uncles or cousins; 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.[13]
Most child sexual abuse is committed by men; studies show that women commit 14% to 40% of offenses reported against boys and 6% of offenses reported against girls.[13][14][16] Some sources report that most offenders who sexually abuse prepubescent children are pedophiles,[17] but some offenders do not meet the clinical diagnosis standards for pedophilia.[18][19]
Under the law, "child sexual abuse" is 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.[4][20]
The American Psychiatric 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."
Effects
Psychological effects
Child sexual abuse can result in both short-term and long-term harm, including psychopathology in later life.[10][22] Indicators and effects include depression,[5][23][24] anxiety,[7] eating disorders,[25] poor self-esteem,[25] somatization,[24] sleep disturbances,[26][27] and dissociative and anxiety disorders including post-traumatic stress disorder.[6][28]While children may exhibit regressive behaviours such as a return to thumb-sucking or bed-wetting, the strongest indicator of sexual abuse is sexual acting out and inappropriate sexual knowledge and interest.[29][30]
Victims may withdraw from school and social activities[29] and exhibit various learning and behavioural problems including cruelty to animals,[31][32][33] attention deficit/hyperactivity disorder (ADHD), conduct disorder, and oppositional defiant disorder (ODD).[25] Teenage pregnancy and risky sexual behaviors may appear in adolescence.[34] Child sexual abuse victims report almost four times as many incidences of self-inflicted harm.[35]
The associations are expressed as
odds ratios: for example, women who experienced nongenital sexual abuse
in childhood were 2.83 times more likely to suffer drug dependence as
adults than were women who were not abused."[36]
A well documented long term negative effect is repeated or additional victimization in adolescence and adulthood.[9][37] A causal relationship has been found between childhood sexual abuse and various adult psychopathologies, including crime and suicide,[13][38][39][40][41][42] in addition to alcoholism and drug abuse.[36][37][43]
Males who were sexually abused as children more frequently appear in the criminal justice system than in a clinical mental health setting.[29]
A study comparing middle-aged women who were abused as children with non-abused counterparts found significantly higher health care costs for the former.[24][44]
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.[45]
A specific characteristic pattern of symptoms has not been identified[46] and there are several hypotheses about the causality of these associations.[5][47][48]
Studies have found that 51% to 79% of sexually abused children exhibit psychological symptoms.[40][49][50][51][52] 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.[53]
The level of harm may also be affected by various factors such as penetration, duration and frequency of abuse, and use of force.[10][22][54][55] The social stigma of child sexual abuse may compound the psychological harm to children,[55][56] and adverse outcomes are less likely for abused children who have supportive family environments.[57][58]
Dissociation and posttraumatic stress disorder (PTSD)
Main articles: Dissociation (psychology) and 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.[59]
When severe sexual abuse (penetration, several perpetrators, lasting
more than one year) had occurred, dissociative symptoms were even more
prominent.[60]Besides dissociative identity disorder (DID) and posttraumatic stress disorder (PTSD), child sexual abuse survivors may present borderline personality disorder (BPD) and eating disorders auch as bulimia nervosa.[61]
Research factors
Because child sexual abuse often occurs alongside other possibly confounding variables, such as poor family environment and physical abuse,[62] some scholars argue it is important to control for those variables in studies which measure the effects of sexual abuse.[22][47][63][64]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."[65] Other studies have found an independent association of child sexual abuse with adverse psychological outcomes.[7][22][47]
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.[47]
A 1998 meta-analysis by Bruce Rind et al. generated controversy by suggesting that child sexual abuse does not always cause pervasive harm, 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."[66]
The study was criticized for flawed methodology and conclusions.[67][68] The US Congress condemned the study for its conclusions and for providing material used by pedophile organizations to justify their activities.[69]
Physical effects
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.[70] Herman-Giddens et al. found six certain and six probable cases of death due to child sexual abuse in North Carolina between 1985 and 1994. The victims ranged in age from 2 months to 10 years. Causes of death included trauma to the genitalia or rectum and sexual mutilation.Infections
Child sexual abuse may cause infections and sexually transmitted diseases.[72] Depending on the age of the child, due to a lack of sufficient vaginal fluid, chances of infections are higher. Vaginitis has also been reported.[72]Neurological damage
Research has shown that traumatic stress, including stress caused by sexual abuse, causes notable changes in brain functioning and development.[73][74]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;"[75] Teicher et al. (1993) found that an increased likelihood of "ictal temporal lobe epilepsy-like symptoms" in abused subjects;[76] Anderson et al. (2002) recorded abnormal transverse relaxation time in the cerebellar vermis of adults sexually abused in childhood;[77] 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;[78] and Ito et al. (1993) found increased electrophysiological abnormalities in sexually abused children.[79]
Some studies indicate that sexual or physical abuse in children can lead to the overexcitation of an undeveloped limbic system.[78] Teicher et al. (1993)[76] 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.[76][80]
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.[81]
Incest
Incest between a child or adolescent and a related adult has been identified as the most widespread form of child sexual abuse with a huge capacity for damage to a child.[11] One researcher stated that more than 70% of abusers are immediate family members or someone very close to the family.[82] 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.[13] 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.[83]The most-often reported form of incest is father–daughter and stepfather–daughter incest, with most of the remaining reports consisting of mother/stepmother–daughter/son incest.[84] 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.[85][86] Similarly, some argue that sibling incest may be as common, or more common, than other types of incest: Goldman and Goldman[87] reported that 57% of incest involved siblings; Finkelhor reported that over 90% of nuclear family incest involved siblings;[88] while Cawson et al. show that sibling incest was reported twice as often as incest perpetrated by fathers/stepfathers.[89]
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.[84]
Types
Child sexual abuse includes a variety of sexual offenses, including:- sexual assault – a term defining offenses in which an adult touches a minor for the purpose of sexual gratification; for example, rape (including sodomy), and sexual penetration with an object.[90] 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.[91]
- sexual exploitation – a term defining offenses in which an adult victimizes a minor for advancement, sexual gratification, or profit; for example, prostituting a child,[92] and creating or trafficking in child pornography.[93]
- sexual grooming – defines 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.
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.[95][96] In general, studies have found that children need support and stress-reducing resources after disclosure of sexual abuse.[97][98] Negative social reactions to disclosure have been found to be harmful to the survivor’s well being.[99] 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.[100] 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.[98] 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.[101]The American Academy of Child and Adolescent Psychiatry provides guidelines for what to say to the victim and what to do following the disclosure.[102] 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."[103]
Treatment
The initial approach to treating a person who has been a victim of sexual abuse is dependant upon several important factors:- Age at the time of presentation
- Circumstances of presentation for treatment
- Co-morbid conditions
Children and adolescents
Children often present for treatment in one of several circumstances, including criminal investigations, custody battles, problematic behaviors, and referrals from child welfare agencies.[104]The three major modalities for therapy with children and teenagers are family therapy, group therapy, and individual therapy. Which course is used depends on a variety of factors that must be assessed on a case by case basis. For instance, treatment of young children generally requires strong parental involvement, and can benefit from family therapy. Adolescents tend to be more independent, and can benefit from individual or group therapy. The modality also shifts during the course of treatment, for example group therapy is rarely used in the initial stages, as the subject matter is very personal and/or embarrassing.[104]
Major factors that affect both the pathology and response to treatment include the type and severity of the sexual act, its frequency, the age at which it occurred, and the child’s family of origin. Roland C. Summit, a medical doctor had defined the different stages the victims of child sexual abuse go through, Child Sexual Abuse Accommodation Syndrome. He suggested that children who are victims of sexual abuse depict a range of symptoms that include secrecy, helplessness, entrapment, accommodation, delayed and conflicted disclosure and recantation.[105]
Adults
Adults with a history of sexual abuse often present for treatment with a secondary mental health issue, which can include substance abuse, eating disorders, personality disorders, depression, and conflict in romantic or interpersonal relationships.[106]Generally the approach is to the present problem, rather than the abuse itself. Treatment is highly varied and depends on the person’s specific issues. For instance, a person with a history of sexual abuse suffering from severe depression would be treated for depression. However, there is often an emphasis on cognitive restructuring due to the deep-seated nature of the trauma. Some newer techniques such as Eye Movement Desensitization and Reprocessing (EMDR) have been shown to be effective.[107]
Sexual abuse is associated with many sub-clinical behavioral issues as well, including re-victimization in the teenage years, a bipolar-like switching between sexual compulsion and shut-down, and distorted thinking on the subject of sexual abuse (for instance, that it is common and happens to everyone). When first presenting for treatment, the patient can be fully aware of their abuse as an event, but their appraisal of it is often distorted, such as believing that the event was unremarkable (a form of isolation). Frequently, victims do not make the connection between their abuse and their present pathology.
Offenders
Offenders are more likely to be relatives or acquaintances of their victim than strangers.[108] A 2006–2007 Idaho study of 430 cases found that 82% of juvenile sex offenders were known to the victims (acquaintances 46% or relatives 36%).[109][110]More offenders are male than female, though the percentage varies between studies. The percentage of incidents of sexual abuse by female perpetrators that come to the attention of the legal system is usually reported to be between 1% and 4%.[111] Studies of sexual misconduct in US schools with female offenders have shown mixed results with rates between 4% to 43% of female offenders.[112] Maletzky (1993) found that, of his sample of 4,402 convicted pedophilic offenders, 0.4% were female.[113] Another study of a non-clinical population found that, among those in the their sample that had been molested, as much as a third were molested by women.[114]
In U.S. schools, educators who offend range in age from "21 to 75 years old, with an average age of 28" with teachers, coaches, substitute teachers, bus drivers and teacher's aides (in that order) totaling 69% of the offenders.[115]
Typology
Early research in the 1970s and 1980s began to classify offenders based on their motivations and traits. Groth and Birnbaum (1978) categorized child sexual offenders into two groups, "fixated" and "regressed."[116] Fixated were described as having a primary attraction to children, whereas regressed had largely maintained relationships with other adults, and were even married. This study also showed that adult sexual orientation was not related to the sex of the victim targeted, e.g. men who molested boys often had adult relationships with women.[116]Later work (Holmes and Holmes, 2002) expanded on the types of offenders and their psychological profiles. They are divided thus:[117]
- Situational – does not prefer children, but offend under certain conditions.
- Regressed – Typically has relationships with adults, but a stressor causes them to seek children as a substitute.
- Morally Indiscriminate – All-around sexual deviant, who may commit other sexual offenses unrelated to children.
- Naive/Inadequate – Often mentally disabled in some way, finds children less threatening.
- Preferential – has true sexual interest in children.
- Mysoped – Sadistic and violent, target strangers more often than acquaintances.
- Fixated – Little or no activity with own age, described as an "overgrown child."
Causal factors
Causal factors of child sex offenders are not known conclusively.[118] The experience of sexual abuse as a child was previously thought to be a strong risk factor, but research does not show a causal relationship, as the vast majority of sexually abused children do not grow up to be adult offenders, nor do the majority of adult offenders report childhood sexual abuse. The US Government Accountability Office concluded, "the existence of a cycle of sexual abuse was not established." Prior to 1996, there was greater belief in the theory of a "cycle of violence," because most of the research done was retrospective—abusers were asked if they had experienced past abuse. Even the majority of studies found that most adult sex offenders said they had not been sexually abused during childhood, but studies varied in terms of their estimates of the percentage of such offenders who had been abused, from 0 to 79 percent. More recent prospective longitudinal research—studying children with documented cases of sexual abuse over time to determine what percentage become adult offenders—has demonstrated that the cycle of violence theory is not an adequate explanation for why people molest children.[119]Offenses may be facilitated by cognitive distortions of the offender, such as minimization of the abuse, victim blaming, and excuses.[120]
Recidivism
Recidivism rates for sex offenders are lower than for the general criminal population.[130] Estimated rates among child sex offenders vary. One study found that 42% of offenders re-offended (either a sex crime, violent crime, or both) after they were released. Risk for re-offense was highest in the first 6 years after release, but continued to be significant even 10–31 years later, with 23% offending during this time.[131] A study done in California in 1965 found an 18.2% recidivism rate for offenders targeting the opposite sex and a 34.5% recidivism rate for same-sex offenders after 5 years.[132]Child and young adolescent offenders
When a prepubescent child is sexually abused by one or more other children or adolescent youths, and no adult is directly involved, it is defined as child-on-child sexual abuse. The definition includes any sexual activity between children that occurs without consent, without equality, or due to coercion,[133] whether the offender uses physical force, threats, trickery or emotional manipulation to compel cooperation. When sexual abuse is perpetrated by one sibling upon another, it is known as "intersibling abuse", a form of incest.[134]Unlike research on adult offenders, a strong causal relationship has been established between child and adolescent offenders and these offenders' own prior victimization, by either adults or other children.[135][136][137][138]
Prevalence
Africa
A ten-country school-based study in southern Africa in 2007 found 19.6% of female students and 21.1% of male students aged 11-16 years reported they had experienced forced or coerced sex. Rates among 16-year-olds were 28.8% in females and 25.4% in males. Comparing the same schools in eight countries between 2003 and 2007, age-standardised on the 2007 Botswana male sample, there was no significant decrease between 2003 and 2007 among females in any country and inconsistent changes among males.[139]The prevalence of child sexual abuse in Africa is compounded by the virgin cleansing myth that sexual intercourse with a virgin will cure a man of HIV or AIDS. The myth is prevalent in South Africa, Zimbabwe,[140] Zambia and Nigeria and is being blamed for the high rate of sexual abuse against young children.[141]
South Africa
South Africa has some of the highest incidences of child and baby rape in the world.[142] A survey by CIET found around 11% of boys and 4% of girls admitted to forcing someone else to have sex with them.[142] In a related survey conducted among 1,500 schoolchildren, a quarter of all the boys interviewed said that "jackrolling", a term for gang rape, was fun.[143] More than 67,000 cases of rape and sexual assaults against children were reported in 2000 in South Africa, compared to 37,500 in 1998. Child welfare groups believe that the number of unreported incidents could be up to 10 times that number. The largest increase in attacks was against children under seven. The virgin cleansing myth is especially common in South Africa, which has the highest number of HIV-positive citizens in the world. Eastern Cape social worker Edith Kriel notes that "child abusers are often relatives of their victims – even their fathers and providers."[144][144]A number of high-profile baby rapes appeared since 2001 (including the fact that they required extensive reconstructive surgery to rebuild urinary, genital, abdominal, or tracheal systems). In 2001, a 9-month-old was raped and likely lost consciousness as the pain was too much to bear.[145] In February 2002, an 8-month-old infant was reportedly gang raped by four men. One has been charged. The infant has required extensive reconstructive surgery. The 8-month-old infant's injuries were so extensive, increased attention on prosecution has occurred.[146]
Democratic Republic of the Congo
Child rape is on the rise in the war ravaged eastern Democratic Republic of the Congo.[147] Aid workers blame combatants on all sides for a culture of sexual violence, who operate with much impunity.[148]United States and Europe
Child sexual abuse occurs frequently in Western society.[149] The rate of prevalence can be difficult to determine.[150][151][152]In the UK, a 2010 study estimated prevalence at about 5% for boys and 18% for girls[153] (not dissimilar to a 1985 study that estimated about 8% for boys and 12% for girls[154]). More than 23,000 incidents were recorded by the UK police between 2009 and 2010. Girls were six times more likely to be assaulted than boys with 86% of attacks taking place against them.[155][156] The estimates for the United States vary widely. A literature review of 23 studies found rates of 3% to 37% for males and 8% to 71% for females, which produced an average of 17% for boys and 28% for girls,[157] while a statistical analysis based on 16 cross-sectional studies estimated the rate to be 7.2% for males and 14.5% for females.[15] The US Department of Health and Human Services reported 83,600 substantiated reports of sexually abused children in 2005.[158][159] Including incidents which were not reported would make the total number even larger.[160] According to Emily M. Douglas and David Finkelhor, "Several national studies have found that black and white children experienced near-equal levels of sexual abuse. Other studies, however, have found that both blacks and Latinos have an increased risk for sexual victimization".[161][162]
Surveys have shown that one fifth to one third of all women reported some sort of childhood sexual experience with a male adult.[163] A 1992 survey studying father-daughter incest in Finland reported that of the 9,000 15-year old high school girls who filled out the questionnaires, of the girls living with their biological fathers, 0.2% reported father-daughter incest experiences; of the girls living with a stepfather, 3.7% reported sexual experiences with him. The reported counts included only father-daughter incest and did not include prevalence of other forms of child sexual abuse. The survey summary stated, "the feelings of the girls about their incestual experiences are overwhelmingly negative."[164] Others argue that prevalence rates are much higher, and that many cases of child abuse are never reported. One study found that professionals failed to report approximately 40% of the child sexual abuse cases they encountered.[165] A study by Lawson & Chaffin indicated that many children who were sexually abused were "identified solely by a physical complaint that was later diagnosed as a venereal disease...Only 43% of the children who were diagnosed with venereal disease made a verbal disclosure of sexual abuse during the initial interview."[166] It has been found in the epidemiological literature on CSA that there is no identifiable demographic or family characteristic of a child that can be used to bar the prospect that a child has been sexually abused.[150]
In schools
In US schools, according to the United States Department of Education,[167] "nearly 9.6% of students are targets of educator sexual misconduct sometime during their school career." In studies of student sex abuse by male and female educators, male students were reported as targets in ranges from 23% to 44%.[167] In U.S. school settings same-sex (female and male) sexual misconduct against students by educators "ranges from 18–28% of reported cases, depending on the study"[168]Underreported forms
Significant underreporting of sexual abuse of boys by both women and men is believed to occur due to sex stereotyping, social denial, the minimization of male victimization, and the relative lack of research on sexual abuse of boys.[169] Sexual victimization of boys by their mothers or other female relatives is especially rarely researched or reported. Sexual abuse of girls by their mothers, and other related and/or unrelated adult females is beginning to be researched and reported despite the highly taboo nature of female–female child sex abuse. In studies where students are asked about sex offenses, they report higher levels of female sex offenders than found in adult reports.[170] This underreporting has been attributed to cultural denial of female-perpetrated child sex abuse,[171] because "males have been socialized to believe they should be flattered or appreciative of sexual interest from a female."[112] Journalist Cathy Young writes that under-reporting is contributed to by the difficulty of people, including jurors, in seeing a male as a "true victim".[172]India
Nineteen percent of the world's children live in India,[175][176] which constitutes 42 percent of India’s total population.[177]In 2007 the Ministry of Women and Child Development published the "Study on Child Abuse: India 2007."[175] It sampled 12447 children, 2324 young adults and 2449 stakeholders across 13 states. It looked at different forms of child abuse: physical abuse, sexual abuse and emotional abuse and girl child neglect in five evidence groups, namely, children in a family environment, children in school, children at work, children on the street and children in institutions.
The study's[175] main findings included: 53.22% of children reported having faced sexual abuse. Among them 52.94% were boys and 47.06% girls. Andhra Pradesh, Assam, Bihar and Delhi reported the highest percentage of sexual abuse among both boys and girls, as well as the highest incidence of sexual assaults. 21.90% of child respondents faced severe forms of sexual abuse, 5.69% had been sexually assaulted and 50.76% reported other forms of sexual abuse. Children on the street, at work and in institutional care reported the highest incidence of sexual assault. The study also reported that 50% of abusers are known to the child or are in a position of trust and responsibility and most children had not reported the matter to anyone. Despite years of lack of any specific child sexual abuse laws in India, which treated them separately from adults in case of sexual offense, the 'Protection of Children Against Sexual Offences Bill, 2011' was passed the Indian parliament on May 22, 2012.[178]
International law
Child sexual abuse is outlawed nearly everywhere in the world, generally with severe criminal penalties, including in some jurisdictions, life imprisonment or capital punishment.[179][180] An adult's sexual intercourse with a child below the legal age of consent is defined as statutory rape,[181] based on the principle that a child is not capable of consent and that any apparent consent by a child is not considered to be legal consent.The United Nations Convention on the Rights of the Child (CRC) is an international treaty that legally obliges states to protect children's rights. Articles 34 and 35 of the CRC require states to protect children from all forms of sexual exploitation and sexual abuse. This includes outlawing the coercion of a child to perform sexual activity, the prostitution of children, and the exploitation of children in creating pornography. States are also required to prevent the abduction, sale, or trafficking of children.[182] As of November 2008, 193 countries are bound by the CRC,[183] including every member of the United Nations except the United States and Somalia.[184][185]
History
Child sexual abuse has gained public attention in the past few decades and has become one of the most high-profile crimes. Since the 1970s the sexual abuse of children and child molestation has increasingly been recognized as deeply damaging to children and thus unacceptable for society as a whole. While sexual use of children by adults has been present throughout history, it has only become the object of significant public attention in recent times.[citation needed]Early writings
The first published work dedicated specifically to child sexual abuse appeared in France in 1857: Medical-Legal Studies of Sexual Assault (Etude Médico-Légale sur les Attentats aux Mœurs), by Auguste Ambroise Tardieu, the noted French pathologist and pioneer of forensic medicine.[186]The rise of public concern
Child sexual abuse became a public issue in the 1970s and 1980s. Prior to this point in time, sexual abuse remained rather secretive and socially unspeakable.[citation needed] Studies on child molestation were nonexistent until the 1920s and the first national estimate of the number of child sexual abuse cases was published in 1948. By 1968 44 out of 50 U.S. states had enacted mandatory laws that required physicians to report cases of suspicious child abuse. Legal action began to become more prevalent in the 1970s with the enactment of the Child Abuse Prevention and Treatment Act in 1974 in conjunction with the creation of the National Center for Child Abuse and Neglect. Since the creation of the Child Abuse and Treatment Act, reported child abuse cases have increased dramatically. Finally, the National Abuse Coalition was created in 1979 to create pressure in congress to create more sexual abuse laws.Second wave feminism brought greater awareness of child sexual abuse and violence against women, and made them public, political issues.[187][188] Judith Lewis Herman, Harvard professor of psychiatry, wrote the first book ever on father-daughter incest when she discovered during her medical residency that a large number of the women she was seeing had been victims of father-daughter incest. Herman notes that her approach to her clinical experience grew out of her involvement in the civil rights movement.[189] Her second book Trauma and Recovery coined the term complex post-traumatic stress disorder and included child sexual abuse as a possible cause.[190]
In 1986, Congress passed the Child Abuse Victims' Rights Act, giving children a civil claim in sexual abuse cases. The number of laws created in the 1980s and 1990s began to create greater prosecution and detection of child sexual abusers. During the 1970s a large transition began in the legislature related to child sexual abuse. Megan's Law which was enacted in 2004 gives the public access to knowledge of sex offenders nationwide.[191]
Anne Hastings described these changes in attitudes towards child sexual abuse as "the beginning of one of history's largest social revolutions."[192]
According to John Jay College of Criminal Justice professor B.J. Cling,
"By the early 21st century, the issue of child sexual abuse has become a legitimate focus of professional attention, while increasingly separated from second wave feminism...As child sexual abuse becomes absorbed into the larger field of interpersonal trauma studies, child sexual abuse studies and intervention strategies have become degendered and largely unaware of their political origins in modern feminism and other vibrant political movements of the 1970s. One may hope that unlike in the past, this rediscovery of child sexual abuse that began in the 70s will not again be followed by collective amnesia. The institutionalization of child maltreatment interventions in federally funded centers, national and international societies, and a host of research studies (in which the United States continues to lead the world) offers grounds for cautious optimism. Nevertheless, as Judith Herman argues cogently, 'The systematic study of psychological trauma...depends on the support of a political movement.'"[193]
Civil lawsuits
In the United States growing awareness of child sexual abuse has sparked an increasing number of civil lawsuits for monetary damages stemming from such incidents. Increased awareness of child sexual abuse has encouraged more victims to come forward, whereas in the past victims often kept their abuse secret. Some states have enacted specific laws lengthening the applicable statutes of limitations so as to allow victims of child sexual abuse to file suit sometimes years after they have reached the age of majority. Such lawsuits can be brought where a person or entity, such as a school, church or youth organization, was charged with supervising the child but failed to do so with child sexual abuse resulting. In the Catholic sex abuse cases the various Roman Catholic Diocese in the United States have paid out approximately $1 billion settling hundreds of such lawsuits since the early 1990s. As lawsuits can involve demanding procedures there is a concern that children or adults who file suit will be re-victimized by defendants through the legal process, much as rape victims can be re-victimized by the accused in criminal rape trials. The child sexual abuse plaintiff's attorney Thomas A. Cifarelli has written that children involved in the legal system, particularly victims of sexual abuse and molestation, should be afforded certain procedural safeguards to protect them from harassment during the legal process.[194]In June 2008 in Zambia the issue of teacher-student sexual abuse and sexual assault was brought to the attention of the High Court of Zambia where a landmark case decision, with presiding Judge Philip Musonda, awarded $45million Zambian Kwacha ($13,000 USD) to the plaintiff, a 13-year-old girl for sexual abuse and rape by her school teacher. This claim was brought against her teacher as a "person of authority" who, as Judge Musonda stated, "had a moral superiority (responsibility) over his students" at the time.[195]
A 2000 World Health Organization – Geneva report, “World Report on Violence and Health (Chap 6 – Sexual Violence)” states, “Action in schools is vital for reducing sexual and other forms of violence. In many countries a sexual relation between a teacher and a pupil is not a serious disciplinary offence and policies on sexual harassment in schools either do not exist or are not implemented. In recent years, though, some countries have introduced laws prohibiting sexual relations between teachers and pupils. Such measures are important in helping eradicate sexual harassment in schools. At the same time, a wider range of actions is also needed, including changes to teacher training and recruitment and reforms of curricula, so as to transform gender relations in schools.”[196]
In March 2011 Europol, the European Police, in a mission called Operation Rescue, arrested 184 alleged members out of 670 identified, of an online paedophile ring and rescued 230 children which is considered as the biggest case of its kind.[197]
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