CHILDHOOD SEXUAL ABUSE

Although child abuse is probably as old as childhood itself, serious research into child abuse arguably began in 1962 with the publication of Kempe and colleagues' seminal paper, "The Battered Child Syndrome" (Kempe, Silverman, Steele, Droegemuller, and Silver 1962). Not long afterwards, health care professionals began to direct their attention to the specific problem of childhood sexual abuse (Cosentino and Collins 1996). In the past few decades, numerous instances have been documented in detailed case histories, and important research into the causes and consequences of childhood sexual abuse has been initiated.

Numerous extensive reviews have been published that summarize what is presently known about childhood sexual abuse, focusing on the following domains.

• Short-term effects (Beitchman et al. 1991; Beitchman et al. 1992; Briere and Elliott 1994; Browne and Finkelhor 1986; Finkelhor 1990; Gomes-Schwartz et al. 1990; Green 1993; Kelley 1995; Kendall-Tackett et al. 1993; Trickett and McBride-Chang, 1995).
• Long-term consequences (Beitchman et al. 1991; Briere 1988; Briere and Elliott 1994; Briere and Runtz 1991; Cahill et al.1991a; Collings 1995; Ferguson 1997; Finkelhor 1987; Gibbons 1996; Glod 1993; Green 1993; Murray 1993; Polusny and Follette 1995; Trickett and McBride-Chang 1995; Wolfe and Birt, 1995).
• Prevention of abuse (Adler and McCain 1994; Berrick and Barth 1992; MacMillan et al. 1994; Olsen and Widom 1993; Wolfe et al. 1995).
• Treatment of both survivors and abusers (Cahill et al. 1991b; Cosentino and Collins 1996; Faller 1993; Finkelhor and Berliner 1995; O'Donohue and Elliot 1993).

Consequently, this chapter is not intended to provide a detailed analysis and review of the literature on childhood sexual abuse. Rather, it is meant to serve as a brief overview of, and introduction to, this area of inquiry.

DEFINITION OF THE PROBLEM

Before delving into the field of childhood sexual abuse, one must first understand what is meant by the term. Indeed, the lack of a standard definition has been a major criticism of the field and controversies abound (Finkelhor 1994a; Gibbons 1996; Gough 1996a; Green 1993). In general, the legal and practical research definitions of child sexual abuse require the following two elements: (1) sexual activities involving a child (sometimes construed as including adolescence), and (2) the existence of an "abuse condition" indicating lack of consensuality (Faller 1993; Finkelhor 1994a). "Sexual activities" refer to behaviors intended for sexual stimulation; such activities need not involve physical contact, however, leading to separate definitions for "contact sexual abuse" and "noncontact sexual abuse." Contact sexual abuse includes both penetrative (e.g., insertion of penis or other object into the vagina or anus) and nonpenetrative (e.g., unwanted touching of genitals) acts. Noncontact sexual abuse refers to activities such as exhibitionism, voyeurism, and child pornography (see Faller 1993 and Finkelhor 1994a for reviews on definitions of childhood sexual abuse).

An abuse condition is said to exist when there is reason to believe that the child either did not, or was incapable of, consenting to sexual activity. Three main conditions can be distinguished: (1) the perpetrator has a large age or maturational advantage over the child; or (2) the perpetrator is in a position of authority or in a caretaking relationship with the child; or (3) activities are carried out against the child's will using force or trickery. As evident from this brief summary, "Childhood Sexual Abuse" covers a wide range of acts and situations, and therefore is open to considerable subjective interpretation.

INCIDENCE AND PREVALENCE OF CHILDHOOD SEXUAL ABUSE

Increasing attention has been directed toward childhood sexual abuse not only because of the psychosocial sequelae associated with its occurrence, but also because it now appears to be more widespread than previously thought (Adler and McCain 1994). However, accurate estimates of the occurrence of childhood sexual abuse are difficult to obtain because many cases are never reported. Thus, available statistics represent only those cases reported to child protection agencies or to law enforcement, and therefore underestimate the true magnitude of the problem.

There are two official sources of incidence data for cases in the United States: The National Incidence Study of Child Abuse and Neglect (NIS), a federally funded research project; and statistics from state child protection agencies (Finkelhor 1994a). The NIS conducted in 1993 documented over 300,000 cases of sexual abuse among children known to professionals in the course of a year, or a rate of approximately forty-five cases per 10,000 children (Sedlak and Broadhurst 1996). Child protective services data suggest that approximately 140,000 cases of childhood sexual abuse occur annually, or twenty-one cases per 10,000 children (Leventhal 1998). An editorial by Finkelhor (1998) suggested that the incidence may be declining. However, this remains to be substantiated. In general, reports suggest that the rate of childhood sexual abuse has increased substantially over the past decades (Sedlak and Broadhurst 1996).

Retrospective surveys provide a second source of information on the occurrence of childhood sexual abuse. Reported rates depend upon how it is defined and operationalized in any given survey. When childhood sexual abuse has been assessed with a single item that narrowly defines it as rape or sexual intercourse, reported prevalence rates tend to be low (e.g., less than 12 percent). Conversely, when it is defined more broadly (e.g., touching genitalia) and assessed using multiple items, prevalence rates tend to be much higher, but with a wide range. The discrepancies observed in the estimated prevalence of childhood sexual abuse points to the need for increased standardization and the use of better assessment instruments in this research.

Because rates of childhood sexual abuse are substantially greater among females than males (e.g., Cosentino and Collins 1996; Finkelhor et al. 1990; Sedlak and Broadhurst 1996), the majority of this research has focused on women. Surveys suggest that anywhere from 18 percent to 30 percent of college women and 8 percent to 33 percent of male and female high school students report having experienced this abuse at some point in their lives (Ferguson 1997; Finkelhor 1994a; Gibbons 1996; Green 1993; Gorey and Leslie 1997). Among the general adult female population, prevalence rates range from 2 percent to 62 percent (Finkelhor 1987; Finkelhor et al. 1990; Saunders et al. 1992). Rates are even higher within various clinical populations, with 35 percent to 75 percent of female clients reporting a history of some form of sexual abuse during childhood (Gibbons 1996; Wurr and Partridge 1996).

The number of males who have been sexually abused is difficult to estimate because it has been the subject of fewer high-quality studies (Holmes and Slap 1998; Watkins and Bentovim 1992). Nonetheless, a few studies have examined this issue among men and estimate that approximately 3 percent to 16 percent of all men in the United States were sexually abused during childhood (Finkelhor et al. 1990; Gibbons 1996; Holmes and Slap 1998). As is the case for women, rates are higher when studying clinical populations, with estimates ranging from 13 percent to 23 percent (Holmes and Slap 1998; Metcalfe et al. 1990).

In sum, based on the evidence available in the literature, Finkelhor (1994a) estimates that 20 percent of adult women and 5 percent to 10 percent of adult men are survivors of childhood sexual abuse. Similarly, a synthesis of sixteen cross-sectional surveys on the prevalence of it among nonclinical populations reported unadjusted estimates of 22.3 percent for women and 8.5 percent for men (Gorey and Leslie 1997).

SEQUELAE

Research conducted over the past decade indicates that a wide range of psychological and interpersonal problems are more prevalent among those people who have been sexually abused than among those who have not been sexually abused. Although a definitive casual relationship between such problems and sexual abuse cannot be established using retrospective or cross-sectional research methodologies (Briere 1992a; Plunkett and Oates 1990), the aggregate of consistent findings in this literature has led many investigators and health care providers to conclude that childhood sexual abuse is a major risk factor for a variety of problems, both in the short-term and in later adulthood (Briere and Elliott 1994; Faller 1993). The various problems and symptoms described in the literature can be categorized as follows: (1) posttraumatic stress; (2) cognitive distortions; (3) emotional distress; (4) impaired sense of self; (5) avoidance phenomena; (6) personality disorders; and (7) interpersonal difficulties. In the remainder of this section, each of these categories is defined and illustrated using examples from the research literature.

Posttraumatic stress refers to certain enduring psychological symptoms that occur in reaction to a highly distressing, psychiatric disruptive event. To be diagnosed with posttraumatic stress disorder (PTSD) an individual must experience not only a traumatic event, but also the following problems: (1) frequent re-experiencing of the event through nightmares or intrusive thoughts; (2) a numbing of general responsiveness to, or avoidance of, current events; and (3) persistent symptoms of increased arousal, such as jumpiness, sleep disturbances, or poor concentration (American Psychiatric Association (APA) 1994). In general, researchers have found that children and adults who have been sexually abused are significantly more likely to receive a PTSD diagnosis than their nonabused peers (McLeer et al. 1992; Murray 1993; Rowan and Foy 1993; Saunders et al. 1992; Wolfe and Birt 1995).

Cognitive distortions are negative perceptions and beliefs held with respect to oneself, others, the environment, and the future. In the abused individual, this type of thought process is reflected in his or her tendency to overestimate the amount of danger or adversity in the world and to underestimate his or her worth (Briere and Elliott 1994; Dutton et al. 1994; Janoff-Bulman 1992). Numerous studies document such feelings and perceptions such as helplessness and hopelessness, impaired trust, self-blame, and low self-esteem among children who have been sexually abused (Oates et al. 1985). Moreover, these cognitive distortions often continue on into adolescence and adulthood (Gold 1986; Shapiro and Dominiak 1990).

Emotional distress or pain, which typically manifests itself as depression, anxiety, anger, or all of these, is reported by many survivors of childhood sexual abuse. Depression is the most commonly reported symptom among adults with a history of childhood sexual abuse (Beitchman et al. 1992; Browne and Finkelhor 1986; Cahill et al. 1991a; Polusny and Follette 1995). Greater depressive symptomatology is also found among children who have been abused (Lipovsky et al.1989; Yama et al.1993).

Similarly, elevated anxiety levels have been documented in child victims of sexual abuse and adults who have a history of it (Gomes-Schwartz et al. 1990; Mancini et al. 1995; Yama et al. 1993). Adults with a history of childhood sexual abuse are more likely than their nonabused counterparts to meet the criteria for generalized anxiety disorder, phobias, panic disorder, obsessive compulsive disorder, or all of these (Mancini et al. 1995; Mulder et al. 1998; Saunders et al. 1992).

Another common emotional sequel of childhood sexual abuse is anger; specifically, chronic irritability, unexpected or uncontrollable feelings of anger, difficulties associated with expressing anger, or all of these (Briere and Elliott 1994; Van der Kolk et al. 1994). During childhood and adolescence, anger is most likely to be reflected in behavioral problems such as fighting, bullying, or attacking other children (Chaffin et al. 1997; Garnefski and Diekstra 1997).

Sexual abuse also can damage a child's developing sense of self, with adverse long-term consequences. The development of a sense of self is thought to be one of the earliest developmental tasks of the infant and young child, typically unfolding in the context of early relationships (Alexander 1992). Thus, how a child is treated early in life critically influences his or her growing self-awareness. Childhood sexual abuse can interfere with this process, preventing the child from establishing a strong self image (Cole and Putnam 1992). Without a healthy sense of self, the person is unable to soothe or comfort himself or herself adequately, which may lead to overreactions to stressful or painful situations, and to an increased likelihood of re-victimization (Messman and Long 1996). Indeed, numerous studies have found high rates of sexual re-victimization (e.g., rape, coercive sexual experience) among individuals reporting a history of childhood sexual abuse (Fergusson et al. 1997; Urquiza and Goodlin-Jones 1994; Wyatt et al. 1992)

Avoidance is another major response to having been sexually abused. Avoiding activities among victims may be viewed as attempts to cope with the chronic trauma and dysphoria induced by the abuse. Among the dysfunctional activities associated with efforts to avoid recalling or reliving specific memories are: dissociative phenomena, such as losing time, repression of unpleasant memories, detachment, or body numbing (APA 1994; Cloitre et al. 1997; Mulder et al. 1998; Nash et al. 1993); substance abuse and addiction (Arellano 1996; Briere 1988; Wilsnack et al. 1997); suicide or suicidal ideation (Briere and Runtz 1991; Saunders et al. 1992; Van der Kolk et al. 1991); inappropriate, indiscriminate, and/or compulsive sexual behavior (McClellan et al. 1996; Widom and Kuhns, 1996), (for reviews see Friedrich 1993; Kendall-Tackett et al. 1993; Tharinger 1990); eating disorders (Conners and Morse 1993; Douzinas et al. 1994; Schwartz and Cohn 1996; Wonderlich et al. 1997); and self-mutilation (Briere 1988; Briere and Elliott 1994). Each of these behaviors serve to prevent the individual from experiencing the considerable pain of abuse-specific awareness and thus reduces the distress associated with remembrance. However, avoidance and self-destructive methods of coping with the abuse may ultimately lead to higher levels of symptomatology, lower self-esteem, and greater feelings of guilt and anger (Leitenberg et al. 1992).

Numerous investigations have found a greater rate of borderline personality and dissociative identity (formerly multiple personality disorder) disorders among adult female survivors of chilhood sexual abuse (Green 1993; Polusny and Follette 1995; Silk et al. 1997). Borderline personality disorder includes symptoms of impulsiveness associated with intense anger or suicidal, self-mutilating behavior, and affective instability with depression which are typical sequelae in sexually abused children and in adult survivors of sexual abuse (APA 1994). Childhood trauma, especially continued sexual abuse, is an important etiological factor in many cases of dissociative identity disorder, the most extreme type of dissociative reaction (APA 1994).

Finally, interpersonal difficulties and deficient social functioning often are observed among individuals who have been sexually abused (Briere 1992b; Cloitre et al. 1997). Such difficulties stem from the immediate cognitive and conditioned responses to victimization that extend into the longer term (e.g., distrust of others), as well as the accommodation responses to ongoing abuse (e.g., passivity). Often, victims of childhood sexual abuse know the perpetrator, who might be a family member, clergy, or friend of the family. The abuse is thus a violation and betrayal of both personal and interpersonal (relationship) boundaries. Hence, it is not surprising that many children and adults with a history of childhood sexual abuse are found to be less socially competent, more aggressive, and more socially withdrawn than their nonabused peers (Cloitre et al. 1997; Mannarino et al. 1991; Mullen et al. 1994).

Among adults, interpersonal difficulties are manifested in difficulties in establishing and maintaining relationships (Finkelhor et al. 1989; Liem et al. 1996) and in achieving sexual intimacy (Browne and Finkelhor 1986; Mullen et al. 1994). Children who have been sexually abused are more likely to exhibit increased or precocious sexual behavior, such as kissing and inappropriate genital touching (Cosentino et al. 1995).

The consequences of childhood sexual abuse can be quite severe and harmful. However, it is important to note that an estimated 10 to 28 percent of persons with a history of it report no psychological distress (Briere and Elliott 1994; Kendall-Tackett et al. 1993). This raises the question of why some persons exhibit difficulties while others do not. Research addressing this question has found the following to be important mediators of individual reactions to childhood sexual abuse:

• Age at onset of abuse. Although further elucidation is needed, the available evidence suggests that postpubertal abuse is associated with greater trauma and more severe adverse sequelae than is prepubertal abuse (Beitchman et al. 1992; Browne and Finkelhor 1986; McClellan et al. 1996; Nash et al. 1993);
• Gender of the victim. One of the main findings in this area is that male victims appear to show greater disturbances of adult sexual functioning (Beitchman et al. 1992; Dube and Herbert 1988; Garnefski and Diekstra 1997);
• Relationship to perpetrator. Abuse involving a father or father figure (e.g., stepfather), which accounts for an estimated 25 percent of all cases (Sedlak and Broadhurst 1996), is associated with greater long-term harm (Browne and Finkelhor 1986; Gold 1986);
• Duration and frequency of abuse. In general, the greater the frequency and duration of abuse, the greater the impact on later psychological and social functioning (Nash et al. 1993);
• Use of force. The use of force or threat of force is associated with more negative outcomes (Kendall-Tackett et al. 1993);
• Penetration or invasiveness. Penetrative abuse is generally associated with greater long-term harm than are most other forms of abuse (Kendall-Tackett et al. 1993); and
• Family characteristics and response to abuse disclosure. Individuals who have been abused are more likely to originate from single-parent families, families with a high level of marital conflict, and families with pathology (e.g., parent is an alcoholic, violence between parents, maternal disbelief, and lack of support); all of which are associated with a poorer outcome and greater levels of distress (Beitchman et al. 1992; Draucker 1996; Green 1996; Romans et al. 1995).

CROSS-CULTURAL ISSUES

This review has focused exclusively on studies done in the United States. This is important to keep in mind because the nature of abuse varies according to one's cultural belief system (Gough 1996). As a result, attempts to compare societies on the basis of their care of children or the extent of violence in family relations are fraught with problems (Gough 1996b; Levinson 1989). In addition, methodological factors, such as the questions asked and how childhood sexual abuse is defined and measured, hamper the ability to make direct comparisons among the rates across different countries. All that can be surmised, to date, is that it is not a phenomena just of the United States, but is an international problem (Finkelhor 1994b). Finkelhor's synthesis indicates that most countries have rates similar to those found in the United States and that females are abused at a greater rater than males.

Nonetheless, cross-cultural studies can shed new light on the origins and impact of sexual abuse (Leventhal 1998; Runyan 1998). Such investigations may enable us to understand better the relative importance of different factors that influence the occurrence of abuse and teach us about societies that have been successful at protecting children. Intercultural comparative investigations can also help us appreciate the range of sexual behaviors that are, or can be considered "normal," and thereby contribute to a better understanding of abnormality in childhood sexual behavior and adult behaviors toward children.

It is not surprising that definitions of abuse not only vary within a culture, but also between cultures. The meaning of "abuse," especially, depends upon ideas of individual rights and roles and responsibilities between people and groups within society (Gough 1996a). How a child is viewed will influence what is evaluated as abuse. Definitions of child abuse would be quite different, for example, in a feudal state in which children are considered to be their parents' possessions. Cultural expectations about sexual interactions among adolescents and between different age groups will also affect whether particular practices are defined as abuse (Abramson and Pinkerton 1995). Among the Sambia people of the highlands of Papua, New Guinea, for example, all young boys are expected to participate in ritualized fellatio with older boys as part of their initiation into manhood (Abramson and Pinkerton 1995). In essence, the younger boys are forced to submit; thus, this practice fulfills the two main criteria for childhood sexual abuse as defined above (coercive sex with a child or adolescent). Nevertheless, the Sambia consider ritualized fellatio to be critical for survival (they believe that semen is the source of manly strength and that it must be obtained through ingestion).

Definitions of abuse can also be expected to change over time to reflect societal changes. For instance, anecdotal evidence suggests that in Victorian England it was considered acceptable for a nurse or nanny to quiet a male infant by putting his penis in her mouth (Abramson and Pinkerton 1995). Today, this practice would clearly be considered childhood sexual abuse. The recent broadening of definitions of abuse has been accompanied by a greater sensitivity to signs of abuse that fit these changing definitions, and a greater willingness for professionals and others to intervene into the private family lives of others, or beyond the walls of institutional life, and so to offer greater visibility of children's experiences (Gough 1996a).

DIRECTIONS FOR FUTURE RESEARCH

Perusal of the literature in this domain suggests several avenues for future studies. First and foremost, large-scale, longitudinal investigations of child victims are needed that examine global functioning, abuse-specific functioning, and attributional and coping strategies along with abuse, child, family, and community factors. Such studies could provide information about both the initial effects of sexual abuse and the factors that influence adjustment at later developmental stages and into adulthood. Because not all victims of childhood sexual abuse develop adjustment problems, a better understanding of who is likely to experience such problems is needed.

Second, further research is needed regarding the efficacy of various approaches for the treatment of related problems (see Cosentino and Collins 1996; O'Donohue and Elliot 1993 for reviews). The utility or effectiveness of any particular treatment modality has yet to be demonstrated using a large-scale, randomized study in which treatment outcomes are measured using standardized instruments and untreated control groups. Consequently, treatment decisions often are made by clinicians without empirically tested guidelines.

Third, greater attention needs to be paid to methodological rigor in the conduct of childhood sexual abuse studies (Green 1993; Plunkett and Oates 1990; Trickett and McBride-Change 1995). In particular, investigators need to: (1) define it clearly and consistently; (2) use instruments with documented psychometric properties; (3) use control or comparison groups, when appropriate; and (4) employ large sample sizes whenever this is feasible. Studies of treatment modalities should also conduct multiple follow-up assessments to determine whether intervention effects are sustained over time. Finally, studies are needed that clearly disentangle the effects of sexual abuse from other forms of abuse or maltreatment.

SUMMARY

Childhood sexual abuse is a significant and widespread problem in our society, no matter how it is defined. Since it was first brought to the public's attention in the 1960s, a vast amount of research has been conducted in an effort to understand its impact on victims. From the various reviews on the topic, several conclusions can be drawn. First, despite the considerable heterogeneity among sexual abuse victims, as a group, sexually abused children and adolescents tend to display significantly higher levels of symptomatology than their nonabused, nonclinic-referred peers. Second, compared to other clinic-referred children, two problem areas appear to differentiate sexually abused children and adolescents: post-traumatic stress disorder symptomatology and sexuality problems. Third, the type and severity of sequelae experienced by victims depends on the specific characteristics of the abuse situation and the perpetrator. Fourth, research on adult survivors suggest that abuse-related problems tend to persist into adulthood. Indeed, childhood sexual abuse histories are common among several clinical populations, including patients initially diagnosed as depressed or as having a borderline personality disorder.

Taken together, these findings suggest that clinicians and health care providers should screen for sexual abuse among children, adolescents, and adults. For instance, questions about childhood sexual abuse could become part of routine intake procedures. Moreover, it is important that a wide range of service providers are sensitive to, and have staff trained to deal with, issues of childhood sexual abuse when it emerges. Service providers' policy and practice guidelines should explicitly acknowledge the prevalence and impact of it on women, men, and children.

Schools also need to have greater involvement in the prevention and diagnosis of childhood sexual abuse, especially since it generally occurs between the ages of six and twelve (Finkelhor 1994a; Sedlak and Broadhurst 1996). School-based education programs may be a useful vehicle for intervention and prevention. Teachers need to be educated and trained about their role in recognizing and reporting suspected cases.

Finally, further community awareness is needed to help prevent it from occurring. Greater community efforts toward providing treatment services for persons with a history of childhood sexual abuse are needed as are programs targeting potential perpetrators. Society must work together to stamp out this abhorrence and to assist its survivors.

Preparation of this article was supported in part by a training grant from the Maternal and Child Health Bureau, U.S. Department of Health and Human Services (MCJ 9040). The author thanks Steven D. Pinkerton, Ph.D. for his helpful comments on this manuscript.

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Heather Cecil