Child sexual abuse is a broad term that includes many acts that can be sexually abusive toward children. The most common acts covered in the loosest definition of child sexual abuse are sexual assault, rape, incest and sexual exploitation of children for commercial and financial reasons. Child sexual abuse can be considered as completed or non-completed (attempted).
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Overview and Important Definitions of Child Sexual Abuse

Child Abuse

Represents intentional harm to a minor that can be physical, psychological, and sexual abuse or forms such as neglect. It leaves lifelong impact on them.

Sexual act with children

A sexual act with children, according to the US Centers for Disease Control and Prevention (CDC), can be defined as any form of sexual activity that involves penetration of a child. A form of child sexual abuse might be that of sexual contact. It leads to change in their behavior and emotional responses.

Sexual contact

A sexual contact is defined as any form of intentional sexual touching of the child without penetration. Exploitation of the child, also known as non-contact sexual interaction per the CDC definitions, involves taking sexual photographs of the child, sexual harassment, trafficking or prostitution.

Sexual activity

For the sexual activity to be considered as abusive, the World Health Organization has put some important definitions. The involved child should be unable to give consent, or unable to understand and comprehend the nature of the sexual activity being performed, the child is not developed enough to involve in the sexual activity and the perpetrator should be an adult or another child who is mature enough to be in position of power and responsibility. This definition by the World Health Organization considers the cultural and law differences between different societies.

Non-contact sexual activities might involve a child who is unaware that he or she is being filmed or victimized.

Epidemiology of Child Sexual Abuse

Every case of sexual abuse is not registered and recognized. Therefore, the exact prevalence of the problem can be only estimated.

The retrospective questioning of adults about a previous incident of sexual abuse during their childhood is an indirect way of estimating the prevalence of sexual abuse among children. Whether children are more likely to disclose contact versus non-contact sexual abuse is a debatable subject among scholars.

Note: The annual frequency of child sexual abuse worldwide is around 150 million girls and 73 million boys. Contact child sexual abuse in the United States had an estimated prevalence of 10% in a retrospective study that targeted adults.

The estimated incidence of sexual abuse in adolescents in the United States is around 16%. Females are more likely to experience sexual abuse compared to males, with an estimated 3 to 1 ratio. It is estimated that 1 in 3 females and 1 in five males have been victims of sexual abuse before the age of 18 years. Sexual abuse in Asian countries appears to be either less common or less likely to be reported.

Children who experience other forms of abuse, such as physical or verbal abuse, are more likely to be victims of sexual abuse. Additionally, children of poor families and non-educated parents, history of parental substance abuse and domestic violence are risk factors for child sexual abuse.

Adolescents who run away from home for one reason or another are more likely to get involved with sexual activities such as prostitution. This can happen as a trade-off for food, shelter, money or drugs. Detained children, child soldiers, working children and children with disabilities are also more likely to experience sexual abuse.

Disclosure of Child Sexual Abuse

In many cases, the perpetrator can make the child feel guilty and responsible for the sexual act, or contact, that happened. This feeling of guilt can inhibit the child from coming forward to the authorities and disclose the abusive activities perpetrated against them. Additionally, many children fear that no one will believe them, or they will lose an important figure of their family if they disclose the abusive act. Perpetrator may threaten the child by threats like, “I will kill you or your mother, if you tell anyone.” The child may be forced to get indulged into the act and then feeling of trapped and helpless overpowers the child. Then the child may develop accommodative behavior. This also prevent to disclose.

Age of the child

The age of the victim also plays an important role in determining the likelihood of disclosure. Very young children who experience sexual abuse are very unlikely to be able to understand the nature of the act, therefore, they rarely, if ever, disclose such information intentionally. Instead, a tongue slip during an interview or an abnormal behavior might trigger the pediatrician to suspect sexual abuse.

On the other hand, children aged between 7 and 13 years are more likely to understand the nature of the sexual activities being performed with them. This age group is more likely to be abused sexually. Despite this, this age group is still very vulnerable to manipulation by the caregiver who could also be the perpetrator. Because of this, disclosure in this age group usually happens within one month from the actual sexual act or contact.

Adolescents who experience some form of sexual abuse are unlikely to disclose such an event directly to the interviewer. Instead, they tend to share the details of such an experience with their friends and peers from school, for instance. Adolescents are also more likely to understand the negative effect of disclosing sexual abuse on the integrity of the family, especially when the perpetrator is a close relative. Because of this, they might choose to inhibit disclosure willingly.

Severity and nature of the sexual activity

Finally, it was found that the severity and nature of the sexual activity might have a relationship with the likelihood of reporting the sexual act or contact to the authorities or to a professional. Children who experience a severe form of sexual abuse that, for example, involves complete penetration are less likely to report the event because of overwhelming guilt and fear. When the abuser is a stranger, when the event has occurred many times or when the nature of the sexual activity was of non-contact type, the chances of disclosure were higher. Stranger abuse is more likely to happen to boys. Abuser usually target children who are physically disabled like deaf, blind or mentally retarded.

Children and adolescents who come from a culture that overvalues virginity and honor—or looks towards men as if it were normal for them to want sex and therefore it is the girl’s fault if something happens because of temptation—are less likely to disclose sexual abuse.

Long-Term Effects of Child Sexual Abuse

Note: Child sexual abuse is a recognized risk factor for anxiety disorders in adulthood, eating disorders, excess anger or irritability in child, poor school performance,  post-traumatic stress disorder, withdrawn behavior, physiological hyperactivity, substance abuse, low self-esteem and major depressive disorder. It adversely interferes with the development of the child physically and mentally.  Additionally, child sexual abuse might also put the child at an increased risk of partaking in inappropriate sexual behavior as per the societal and cultural norms.

Alcoholism, suicidal risk, marriage problems and the use of illicit drugs were also more common in adults who have previously reported or encountered sexual abuse as children. Additionally, children who experience sexual abuse are more likely to be involved in high-risk sexual activities during childhood, which puts them at an increased risk of acquiring sexually transmitted illnesses, teen pregnancy or human immunodeficiency virus. Teen pregnancy may have complications like preterm births risking the life of teen mother also.

Children who experience repeated sexual abuse are also more likely to face a stressful life during their bringing up. This can put them at an increased risk of heart disease. Additionally, the use of illicit drugs, which is more common in victims of sexual abuse, has been linked to an increased risk of life-threatening heart diseases such as infective endocarditis.

Who Should be Contacted in Case of Child Sexual Abuse

Note: The child protective services (CPS), police, medical teams, foster care, child welfare agencies and other child protection agencies can be all contacted and should work together whenever the suspicion of child sexual abuse is raised.

Courts involved in cases of child sexual abuse

The main courts involved in cases of child sexual abuse are the Juvenile Court, the Criminal Court and the Family Court. The Family Court is concerned with victims of familial child sexual abuse. The Juvenile Court’s main responsibility is the protection of the child. The Criminal Court deals with the offender or the perpetrator.

Child Protective Services

When the CPS decides that the child’s safety is compromised at home, and that the likelihood of recurring sexual abuse is high, they can request for the child to be removed and placed with a relative or a foster family. In some cases, where the offender is a close relative or the caregiver itself, he or she might be removed from home.

Signs & Symptoms of children with a history of sexual abuse

These children usually present with:

  • Mistrust of adults.
  • Fear of being touched/ examined.
  • Suicidal ideation.
  • Difficulty in relating to others in seductive ways and lack of sexual desire.
  • Sleep problems and nightmares.
  • Eating disorders
  • Regressive behavior, excess anger or irritability
  • Withdrawn behaviors, poor participation in school or social activities like social functions or gatherings
  • Self-inflicted injuries.
  • Habit disorders such as biting and rocking.
  • Forced sexual acts on other children.

Treatment Interventions for Child Sexual Abuse

STI testing and HIV screening should be done before the medical treatment is started to protect the child from them. Pregnancy test should be done in adolescent girls to rule out pregnancy. Oral medicines are prescribed based on the diagnostic tests. Sex- related co-morbidity are managed with specific treatment.

Children who experience sexual abuse are very likely to experience post-traumatic stress disorder.

Note: Treatment of post-traumatic stress disorder in children includes cognitive behavior therapy, narrative psychotherapy, supportive counseling or eye-movement desensitization and reprocessing (EDMR) therapy.

Cognitive behavior therapy is believed to be the most effective approach in children. Trauma-focused cognitive behavioral therapy is the most effective form of psychotherapy for child sexual abuse victims. It focusses on identification, evaluation and reframing of the dysfunctional conditions related to the specific trauma and its sequelae that bring negative emotions and reactions.

A biopsychosocial approach is recommended when dealing with a child sexual abuse case. Therefore, in addition to psychotherapy, family counseling and interventions to change the social surroundings of the child to prevent the recurrence of sexual abuse are needed.

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