General Considerations on Child sexual abuse
Although there is no universal definition, sexual abuse is generally defined as the involvement of developmentally immature children or adolescents in sexual activities that they do not fully comprehend, to which they are unable to give informed consent and that violate social taboos of family or other adultchild relationships. Adults take advantage of the power and age differential which removes meaningful consent. The adult’s intention to use children for his (or her) sexual arousal and gratification is an important element of the definition.
Other definitions describe the unwanted, manipulative and exploitative character of the interaction and recognize the importance of age difference (mostly 4–5 years). Developmental asymmetry and the use of coercion differentiate abuse from normal sexual play [Kempe, 1978; AAP, 1999; Hobbs et al., 1999a; Friedrich et al., 2001; Finkel and De Jong, 2001].
Sexual abuse includes a spectrum of sexual activities ranging from nontouching to invasive penetrative abuse. In contrast to the general public opinion CSA is mostly a chronic sexualized relationship over months and years between fathers, step-fathers, other relatives or known individuals and the child.
Abuse may start in early childhood and continue into adolescence.
Strangers as offenders make up approximately 10% of all cases. These occurrences tend to be rather single events and often are more accurately characterized as ‘sexual assault’. Most of sexual abuse is committed by men (approx. 90%), with higher numbers of female perpetrators when boys are victimized (up to 25%). At least 20–25% of perpetrators are juveniles. This underscores the importance of early intervention including perpetrator treatment.
Probably this is the most effective measure of prevention of further abuse of other children. Offenders appear to be ‘normal’, socially well-adapted people essentially of all social backgrounds. Many, but not all, have been sexually abused as children, and many abuse more than one child.
Victims are girls in 70–80% of the subjects including all age groups, peaking in the prepubertal school age. Adolescents make up at least 25% of sexual abuse victims and tend to be victimized by peers (‘date rape’). Lower socioeconomic status is not consistently demonstrated in the research and may be caused by assessment bias. However, unstable social conditions may predispose a child to sexual abuse. Single-parent homes and step-parents seem to be significant risk factors [Finkelhor, 1994; Leventhal, 1998; Finkel and De Jong, 2001]. Although not reported in all studies, developmentally disabled or handicapped children appear to be at higher risk for sexual abuse particularly when the disability affects communication [Elvik et al., 1990; AAP, 2001b].
Current research indicates a prevalence of CSA way in the percent range.
That makes CSA for example far more prevalent than all malignancies in childhood together (for Germany: 0.2% – Gutjahr ). Finkelhor  summarized 19 prevalence studies and concluded that a prevalence of 15–20% of women and 5–10% of men having experienced sexual abuse as children would be a reasonable conservative estimate. Incidence studies do not report the true occurrence, but only those cases that are recognized. Substantiated reports of CSA to US American Child Protection Agencies increased dramatically from 6,000 to 132,000 from 1976 to 1986, being relatively stable until 1994 and declining since then for unknown reasons [Leventhal, 1998; Atabaki and Paradise, 1999; Jones and Finkelhor, 2001; Finkel and Giardino, 2002].
Because of possible devastating short- and long-term effects, CSA has marked but varying effects on children’s health and well-being. A large variety of short-term behavioral abnormalities and symptoms have been reported as indicators and presenting symptoms of CSA. They include nearly all emotional, psychosomatic, self-destructive and anti-social behaviors in children and adolescents, focusing on age-inappropriate sexualized behavior, especially when coercive. However, there is no single diagnostic criterion or specific syndrome within the variety of symptoms which proves CSA by itself. A basic understanding of normative sexual behavior is important to distinguish normal and abnormal sexual play and activity. Inadequate sexual behavior should be interpreted as indicator but not as proof of CSA and its absence does not rule out abuse.
Masked presentations of CSA are common and include the whole range of psychosomatic disorders, with gastrointestinal complaints being most prevalent in younger and chronic pelvic pain in older victims. Feelings of guilt, shame, isolation, lowered self-esteem, criminal behavior and self-injuring behaviors are prevalent among victims of abuse [Hunter et al., 1985; Beitchman et al., 1991, 1992; Berkowitz, 1998; Koverola and Friedrich, 2000; Friedrich, 1998; Friedrich et al., 1998, 2001; Drach et al., 2001]. The abnormal behavior frequently is an important coping mechanism of the victim, well described by Summit as ‘Child Sexual Abuse Accommodation Syndrome’ [Summit, 1983].
The difficulty in evaluating a history and the non-specific complaints of an individual has been widely discussed in the psychosocial literature [Jones and McGraw, 1987; Everson, 1997].
CSA is associated with substantial increased risk of subsequent psychopathology. Several factors contribute to the great variety of long-term outcomes of victims of former CSA from severe to asymptomatic. Sexual abuse varies significantly in severity and extent, the amount of physical force used, the relationship with the offender, frequency and duration of the abuse, the age of the child, preexisting psychosocial problems and positive or negative effects of professional intervention. Other important factors that influence the outcome are preexisting adverse psychological circumstances, coexisting physical abuse or neglect in terms of additional vulnerability potentially compensated by resilience factors (intra- or extrafamilial support) [Paradise et al., 1994].
A variety of reports have highlighted mental health problems (e.g. depression, suicide, multiple personality disorders, post-traumatic stress disorder, eating disorders, anxiety disorders, substance abuse), physical health problems (e.g. functional gastrointestinal disorders, chronic pelvic pain, dysmenorrhea), and psychosexual dysfunction (e.g. sexual dysfunction, promiscuity, adolescent pregnancy, re-victimization, prostitution). Interpersonal, close relationships are often difficult for abuse victims. They tend to have problems with issues of control, anger, shame, trust, dependency and vulnerability [Beitchman et al., 1992; Berkowitz, 1998; Dickinson et al., 1999; Koverola and Friedrich, 2000; Molnar et al., 2001].
Revision date: July 9, 2011
Last revised: by Jorge P. Ribeiro, MD