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Advances in Understanding and Treating Childhood Sexual Abuse: Implications for Research and Policy

Johnson, Regina Jones DrPH, MSN, RN

doi: 10.1097/01.FCH.0000304015.67513.ea
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Childhood sexual abuse is a major public health problem affecting thousands of children and adolescents in the United States each year. For more than 20 years, researchers, healthcare professionals, and policymakers have had considerable disagreements about various aspects of child sexual abuse. Although everyone agrees that sexual abuse is a harmful thing for children to experience, there is a lack of consensus on a definition of sexual abuse, investigation of allegations, long-term consequences, what constitutes appropriate psychotherapy, and what public health policies should be developed to prevent sexual abuse. The purpose of this article is to explore advances that have been made in understanding and treating child sexual abuse, to look at the implications for further research, and to address the public health policies that exist for preventing child sexual abuse.

From the School of Nursing, University of Texas at Austin.

Corresponding author: Regina Jones Johnson, DrPH, MSN, RN, Assistant Professor, School of Nursing, The University of Texas at Austin, 1700 Red River St, Austin TX 78701 (e-mail: rjohnson@mail.nur.utexas.edu).

CONSIDERABLE ADVANCES have been made in the changing context of childhood sexual abuse (CSA). As recently as 40 years ago, CSA was thought to be extremely uncommon, especially among males. Heightened awareness of the problem may stem from a growing societal concern over child abuse in general, an increased comfort level in discussing sexual violence, or perhaps even the publicity surrounding several recent cases in the media involving clerical sexual abuse.

CSA is not just an isolated problem in the United States, it is a global problem. The World Health Organization (WHO) reported that worldwide CSA prevalence is higher than many find comfortable or plausible. In the World Health Report of 2002, prevalence estimates of CSA were reported from 39 countries. Although data varied considerably among countries, the prevalence of noncontact abuse for females was 6%, contact 11%, and intercourse types of CSA 4%. In males, it was about 2% for all categories combined. The WHO surmises that more than 800 million people worldwide may have experienced CSA, with more than 500 million having experienced contact or intercourse types of abuse.1 The findings from the WHO have implications for guiding prevention, intervention, and public policy development for youth and adults who have been victims of CSA.

The precise incidence and prevalence of CSA in the general population are not known. It is difficult to establish incidence rates because most sexual abuse is not reported at the time it occurs. In addition, CSA is largely a hidden crime because of the stigma attached; therefore, it is difficult to estimate its prevalence. Both adults and children may be reluctant to report sexual abuse for many reasons. Their reluctance may be related to the historical norm of keeping such behavior secret because of the sense of shame associated with it. If the abuser is someone close to the victim in terms of kinship or other bonds, he or she may be deterred by the likelihood that criminal charges and penalties may be imposed. Finally, the fact that the victims are young and dependent tends to be a major obstacle to disclosure.

However, Finkelhor and colleagues2,3 reported that sexual abuse started to decline in the early 1990s, after at least 15 years of steady increases. According to Finkelhor and Jones,2 substantiated reports of CSA were down 49% from 1990 to 2004 and the number of cases declined 31% in the United States from 1992 to 1998.3 In addition to these declines, the Department of Health and Human Services reported that nationally only 9.7% of the maltreated children were sexually abused in 2004, which was a decline of 2% from their 2003 report.4,5 Unfortunately, some of the statistics showing declines in sexual abuse have provoked skepticism.3 Because the sexual abuse figures are based on reported cases known to and substantiated by state child protection agencies, researchers and policy makers have concluded that the decline might not be an accurate representation and may, in fact, reflect a change in standards of investigation, a decrease in reporting by the agencies, a reduction in funding, or an artifact.3,6 Leventhal7 commended Finkelhor and colleagues for drawing attention to the fact that a decline in CSA may exist and for trying to determine what contributed to the decline. However, Leventhal emphasized the fact that “without adequate data systems, the understanding of either the increases or decreases in the number of substantiated CSA cases will continue to be a problem for the field of CSA.”7(p1137)

Two factors seriously affect the accuracy of CSA incidence data: the lack of consensus about the definition of CSA, and the lack of a consistent, state-by-state data collection system. Because of these factors, the data available on incidence should be considered approximations. Retrospective research indicates that an estimated 3 of 4 incidents of CSA and assault are never reported to a legal agency.8,9,10 Holmes and Slap reviewed more than 169 empirically based studies published between 1985 and 1997 and concluded that 3 of every 4 adolescents (71%) and men (77%) sexually victimized prior to age 12 years never reported their abuse experience(s) to parents, friends, physician, or a reporting agency.11 Unfortunately, we are a long way from knowing why some cases are reported and others are not. Finding out why some cases are reported and others are not is a high priority. Advances continue to be made in the area of disclosure of CSA. Aalsma and colleagues12 examined the consistency of CSA reporting among 217 adolescents and young adults (aged 14–24 years) who were enrolled in an urban healthcare clinic. They found that the stability of CSA self-reporting at 2 time points was poor (58% consistent nonreporters of CSA, 20% consistent reporters, 22% inconsistent reporters). The authors suggested assessing CSA at 2 time points to enhance the accuracy of reporting. Alaggia13 explored influences that inhibit or promote CSA disclosure and found that one of the problems is that previously undefined dimensions of disclosure are emerging in the literature. Alaggia recommended that we use a broader framework to understand and respond to child victims and adult survivors of sexual abuse. Jones and colleagues suggested that further discussion and increased analysis of child maltreatment system data are important next steps in investigating trends in the incidence of CSA.3

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LONG-LASTING EFFECTS OF CHILD SEXUAL ABUSE

One of the challenges to linking CSA with adult functioning is the passage of time and the number of experiences that precede and follow the abuse.12 The long-term, negative consequences of CSA on mental and physical health have been well documented among adolescents and adults.14–22 Paolucci et al reported a metanalysis of the published research on the effects of child sexual abuse. These researchers reviewed 37 studies published from 1981 to 1995 that addressed posttraumatic stress disorder (PTSD), depression, suicide, sexual promiscuity, victim–perpetrator cycle, and poor academic performance. The analysis of the findings provide evidence confirming the link between CSA and subsequent negative short- and long-term effects on development, and support the multifaceted model of traumatization rather than a specific sexual abuse syndrome of CSA.23 In a recent publication by Steel and colleagues, the psychological aftereffect of CSA, abuse-related characteristics, coping strategies, and attributional style among 285 males and females from a nonpatient setting, a psychiatric outpatient setting, and a psychiatric inpatient institution were investigated.24 The results of their study indicated that those who had a history of CSA reported higher levels of psychological distress in adulthood, and a positive correlation was found between the duration of abuse and the level of psychological distress. There continue to be advances in identifying long-lasting effects of CSA. However, there is increasing evidence that procedures for obtaining long-delayed, adult retrospective accounts of sexual abuse are fairly unreliable and miss substantial information and are recognized for introducing considerable inaccuracy in details of the events.25

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HEALTH IMPACT OF CHILD SEXUAL ABUSE

Several researchers have evaluated the health impact of sexual violence among children and adolescents. In a review and synthesis of the impact of sexual abuse on children, Kendall-Tackett and colleagues found that sexually abused children had more symptoms (anxiety, fear, PTSD, depression, poor self-esteem, mental illness, etc) than nonabused children.25 Interestingly, Kendall-Tackett et al found that in the first year or year and a half after disclosure of sexual abuse, one half to two thirds of all children became less symptomatic while 10% to 24% became more symptomatic. In a survey of 4,023 adolescents between the ages of 12 and 17 years, Kilpatrick and colleagues demonstrated that exposure to interpersonal violence (physical and sexual assault, or witnessing violence) increased the risk for PTSD, depression, and substance abuse/dependence.26 Basile and colleagues reported that a history of forced sexual intercourse among high school students was associated with recent dating violence and participation in health-risk behaviors such as unhealthy dieting, alcohol or drug use, and physical fighting.15 In a recent study by Arata et al, youth (N = 1,452) with a history of maltreatment self-reported more depression, were prone to suicide, and experienced more hopelessness than nonabused individuals.27

The impact of sexual abuse varies from child to child. Some literature suggests that there are no ill effects from childhood sexual abuse.28,29 Some victims of CSA appear relatively unscathed, demonstrating asymptomatic or healthy functioning.29 Burge suggests that the experiences may contribute favorably to psychosexual development or that they diminish the chance of developing psychosis.30 This is a minority view, and most studies suggest adverse effects in both the short and long term as a result of childhood sexual abuse. Of course, if researchers can identify a group of individuals sexually abused in childhood but not subsequently suffering from adverse effects, then those in the field of CSA might learn a considerable amount about those factors that protect individuals and enable them to go through life with resilience.

Although most studies find a relationship between CSA and psychological problems in adults, a metanalysis of the literature by Rind and colleagues has drawn controversy. Rind et al31 concluded that among university students, the relationship between CSA and psychological problems was very small or nonexistent and could be accounted for by other nonspecific family dysfunction. The authors also suggested that the term child sexual abuse should continue to be applied as a valid term to describe a sexual encounter during which the “young person felt that he or she did not freely participate in the encounter and if he or she experienced negative reactions to it, then child sexual abuse, a term that implies harm to the individual, would be valid.”31(p46) Among the various criticisms of this article are (1) its generalization from university students to all sexual abuse survivors, (2) the use of statistical procedures that have been criticized by others as especially conservative in identifying possible abuse effects,32 and (3) minimization of abuse effect sizes that are roughly equivalent to the relationship found between smoking and the development of lung cancer.33 The controversy over the Rind et al article highlights the need for editorial review by considering social policy implications. This is especially true when conclusions or inferences stray from previous empirical findings and pertain to topics of great public importance. The findings from accumulated empirical research on CSA have implications for guiding prevention, intervention, and public policy efforts for children. However, according to Roman and colleagues, future studies should focus on postvictimization mitigating and buffering experiences so that professionals can intervene appropriately.34

A recent article by Rind and Tromovitch continues to make very important points about CSA research and “the need for researchers to adhere to valid scientific principles in inference and precision when reporting the results of CSA research.”35(p102) The authors suggest that the scientific reporting of CSA findings has generally shown a bias in inferring harm when not warranted. They also point out that “it is incumbent upon scientific researchers to transcend popular trends and/or prejudices and to express as precisely as they can the empirical reality regarding CSA and its correlates or effects.”35(p102)

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TREATMENT ISSUES

While many children who have been victimized by sexual abuse will get better over time without any treatment, research indicates that interventions for these children are more effective than the mere passage of time. Despite the prevalence of CSA and its preponderance of evidence, there is not yet a clear understanding of how best to treat CSA survivors. Physicians and nurses have a long history of participating as team members in the interdisciplinary assessment and treatment of children with histories of CSA.36,37 Friedrich emphasized the importance of viewing sexually abused children and adolescents as a heterogeneous population with correspondingly diverse treatment needs.38 Psychotherapy is 1 way of moderating the negative effects of CSA and potentially reducing some of the risk factors.39 Much of the early literature on treating adolescent and adult victims of sexual abuse, however, focuses only on females.40,41

Reviews of the literature highlight several treatment modalities for those who have a history of CSA. For both children and adults, the most common form of treatment is some form of psychotherapy. The goal of therapy generally focuses on helping adolescents communicate about the abuse experience, enhancing self-esteem, learning about appropriate family roles and boundaries, overcoming isolation, and developing healthy peer relationships.41,42 Common treatments include “abuse-focused therapy,”39,43,44 “education as therapy,”45,46 “individual therapy,”47–49 and “group therapy.”41,42 Recent research shows that cognitive–behavioral therapy can be effective in the treatment of sexually abused children.50–52 “Since the early 1990s, the practice of cognitive–behavioral therapy specifically with sexually abused children has been well studied, and the available research strongly suggests that this approach is efficient and valuable for children.”53(p15)

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STATE REPORTING LAWS AND FEDERAL POLICY

All states in the United States have laws prohibiting sexual abuse of children.54 Each state individually defines and labels prohibited activities, and thus criminal statues vary from state to state. Child abuse statues usually define sexually abusive behavior quite broadly but sometimes extend jurisdiction only to acts committed by caretakers. States identify an age that an individual can consent to sexual contact, usually between 14 and 18 years. Sexual contact between an adult and a minor under the age of consent is illegal. For example, in the state of Texas, abuse includes the following acts or omissions by a person, “sexual conduct harmful to a child's mental, emotional, or physical welfare; compelling or encouraging a child to engage in sexual conduct as defined by Section 43.01 of the Texas Penal Code; and sexual contact means any touching of the anus, breast, or any part of the genitals of another person with intent to arouse or gratify the sexual desire of any person.”55

There have been several initiatives at the federal level regarding policy issues related to child maltreatment and sexual abuse. A significant key piece of federal legislation was the Child Abuse Prevention and Treatment Act, which established several programs specifically for maltreated children. The Child Abuse Prevention and Treatment Act was originally enacted in Congress in 1974 and has been amended 6 times. The most recent amendment occurred in 2003.56 During former President Bill Clinton's administration in 2000, there was a federal response to child abuse and neglect. Olivia Golden, Assistant Secretary of Children and Families at the US Department of Health and Human Services reported that the Children's Bureau, Administration for Children, Youth, and Families in the Administration on Children and Families (ACF) is the organizational focal point of the federal response to child maltreatment. The Administration on Children and Families administers a number of programs that seek to improve the lives of children at risk and their families.57 While Golden highlighted several significant federal efforts to address the problem of child maltreatment, she also emphasized that child maltreatment is a vast and complex problem. These are just a few recent legislative initiatives, and more are pending. The increased efforts at the state and federal level are to be commended.

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IMPLICATIONS FOR RESEARCH AND POLICY

With recent heightened concern about childhood sexual abuse, information about it has accumulated rapidly, although often not soon enough to inform public policy and clinical practice. Our challenge now is to be conscious of what we have learned, to monitor our expanding knowledge base, and to continually entertain new insights and new experiences that contribute to our ability to understand why sexual abuse happens and how it can be stopped. Then, our commitment must be to base our policies and our program decisions and our budget allocations on that which is empirically evidence-based. It is only by embarking on a variety of initiatives at the same time that we can address all the sources of sexual abuse in our society and have any hope for success in combating this deeply rooted problem.

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CONCLUSIONS

Advances in understanding and treating adolescents with CSA have been made in the past 20 years. However, although the research and clinical literatures concerning CSA have grown dramatically, this growth has occurred without a generally accepted definition that clearly demarcates which behaviors are considered CSA and which are not. As healthcare providers, researchers, teachers, and citizens, we must look for ways to promote community involvement in the prevention of CSA. One way is to lobby for the inclusion of exemplary intervention and prevention programs for CSA in local, state, and federal budgets, with a prioritization for integrated programs across federal, state, and local agencies including the departments of defense, justice, education, and Health and Human Services; the Centers for Disease Control and Prevention; and the Substance Abuse and Mental Health Services Administration. The best interest of children should be paramount in all our decisions and actions. Professionals who provide assistance to victims of CSA should receive specialized training.

Although CSA may prove difficult to prevent, it is imperative that public policy be implemented at the local, state, and federal levels to promote the primary and secondary prevention of CSA as part of a comprehensive plan for preventing poor outcomes among youth. Detecting the presence of threat or harm to children is the first step in preventing future harm to children. Second, children who are well informed about inappropriate touching, who are taught to trust their feelings about situations and people, and who know where to get help if they require it are less likely to be victims of any type of assault. The development of programs that educate parents as preventive agents of victimization may also be beneficial. And last, prevention education is particularly important for children who have been sexually abused, as they are at higher risk of revictimization than children who have not been sexually assaulted.

According to Mullings et al, there are emerging trends in the victimization of children regarding the different perspectives of present and future issues related to child abuse.58 The authors highlight issues such as how terrorism, or clergy sexual abuse affects children, the fact that the Internet has made children more vulnerable, and how the legal or healthcare systems issues impact child victimization. Childhood sexual victimization is a serious and ongoing problem in the United States and the world; therefore, we must act accordingly and give priority to the issues of CSA by acting on it directly, teaching children more about sexuality, and creating a more open environment to discuss CSA. Finally, collaboration must exist among healthcare providers, protective services, law enforcement agencies, and researchers.

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Keywords:

childhood sexual abuse; public health policy; research and policy

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