The Impact of Child Sexual Abuse

Author: Vikki Rowe

Child sexual abuse (CSA) has received increasing recognition as an important social issue over the past couple of decades (Webster, 2001). While reports of CSA are certainly increasing, it is unclear as to whether this is due to an actual increase in occurrence, or merely a greater awareness in the community and reporting to the authorities.

The uncertainty surrounding reporting is not unique in this field, with conflicting and controversial results being found in many areas of the CSA literature. Much of the confusion stems from the lack of a solid definition, which has sabotaged attempts to readily identify, report, treat and predict cases of CSA.

This essay attempts to address the impact of CSA. To do so, it seems pertinent to first tackle the issues of definition and prevalence, before moving on to look at the reported effects of CSA. Regardless of the mixed findings in the research, there is a general consensus in the field that CSA is an intense and highly destructive phenomenon which negatively affects many of its victims and their families (Esman, 1994; McMillan, Zuravin, & Rideout, 1995).

Definition

Initial consideration of a definition of CSA may seem straight forward. For example, the anal rape of a three year old elicits highly emotive feelings, and most would not hesitate to label this as CSA. However, the problems with definition appear to lie more in the periphery. Details such as the age of the victim, the age of the perpetrator, the type of contact or non-contact, and the situation/environment (for example, culture, religion) in which the alleged abuse occurs, all contribute to the inconsistencies in CSA definition (Kuyken, 1995; Webster, 2001).

While it is widely accepted that a sexual relationship between an adult and a young child is abusive (Kuyken, 1995) – due to the child’s inability to give informed, voluntary consent, and the abuse of the adult’s authority over the child – there is less consensus around consent of “almost-adults” (for example, a 17 year old), and even the exact definition (age) of a “child.” Further, the issue still remains concerning the sexual interaction between two “children.”

Kuyken (1995) suggests that the key issues in defining child sexual abuse are “that a relationship is sexual, there is an age gap such that the perpetrator is significantly older and the victim can be regarded as a child and/or, the sexual contact cannot be regarded as non-coercive play between two children of different ages” (p109). However this definition by Kuyken is still quite vague; for example, what constitutes a “significant age gap,” and what defines “sexual contact”? Rind, Tromovitch, and Bauserman, (1998) suggested that hurt or harm must occur as a result of sexual interaction between an adult and a child. However, how is it determined that harm has or has not occurred? What about the portion of children who do not experience negative effects straight away? And how does one know whether harm will occur until after the act has taken place?

Webster (2001) defines CSA as involving “either actual physical or non-physical contact experiences between a child and an adult in which the child is subject to sexually based exploitation, humiliation, or degradation. The physical contact can be either genital or nongenital” (p534). This inclusion of physical and non-physical is important as voyeurism, exhibitionism and pornography are also widely considered forms of sexual abuse. Webster also attempts to categorise the child’s experience of the abuse – exploitation, humiliation, degradation.

Barnett, Miller-Perrin and Perrin (1997) further include the “intent” of the perpetrator in the definition of CSA. While intent is a hugely subjective phenomenon, the express use of a child for the sexual gratification (or need for power) of an adult or another child, can quite arguably be conceived as CSA. It is clear from the above discussion that CSA cannot be simply defined in a sentence or two. Unfortunately, this lack of a parsimonious definition results in operational problems in the research, identification, reporting and treatment of CSA.

Incidence

While the incidence of reporting has increased substantially over the years, it is believed that CSA still goes largely unreported (see Kuyken, 1995 and Webster, 2001). While incidence rates (in America) currently estimate that 25% of all girls and 18% of all boys experience some form of sexual abuse (Edwards, Holden, Felitti, & Anda, 2003), these figures are believed to represent the bare minimum. For example, professionals may decide not to report some incidences due to factors such as a perceived lack of solid “evidence,” unclear definitions, and lack of trust in “the system” (see Barnett et al., 1997). Parents may also choose not to report for a variety of reasons; for example feelings of shame, guilt, embarrassment, fear of ridicule and disbelief.

Further, studies have found that parents rarely report CSA if they know the perpetrator; in fact it seems that the closer the perpetrator is to the family, the less likely they are to report (Finkelhor, 1984; Rathus, Nevid, & Fichner-Rathus, 2005). Rathus et al. cites an alarming Boston community survey finding (Finkelhor, 1984) which revealed that: 0% of parents reported abuse perpetrated by family members, 23% reported abuse by acquaintances and 73% reported abuse by strangers. This finding serves to highlight the striking occurrence of underreporting by parents who discover the abuse of their child. Many children may also never report the abuse, or may only do so at a later date.

This may be due to factors such as feelings of guilt and/or shame, fear (of the perpetrator and/or the “system”), fear of not being believed and/or being labelled or stigmatised, and memory loss (see Kuyken, 1995 and Rathus et al., 2005). The lack of reporting of CSA not only reflects a false (lower) incidence of CSA, but denies researchers access to an important sample (sub-population) of CSA victims when accessing, understanding and interpreting the phenomenon of CSA. This not only taints present understanding of the “effects” of CSA, but impedes accuracy and effectiveness of correctly identifying, treating and preventing the problem of CSA (for victims/survivors, families and society alike).

Effects

Research into the effects of CSA has produced varied and often conflicting results. While some investigators have stated that they found CSA victims to be only “slightly less well adjusted than controls” (Rind et al., 1998, p. 22), most researchers agree that the emotional, psychological, and social impact of CSA is often very serious and intense (Webster, 2001). Much of the scientific controversy exists around the “research-level precision” of the research, with methodological problems rampant in the literature.

Sample population problems, such as the sole use of clinical versus non-clinical, abused persons versus non-abused persons, problems with self-report versus clinician report, differences between volunteer, university student and community samples, cross-sectional designs, different definitions of abuse, corelational designs, and the frequent lack of a control group, have all muddied the validity of findings and made it difficult to draw sound conclusions (see Callahan, Price & Hilsenroth, 2003; Corbett & Harris, 1995; Kuyken, 1995; Rind, & Tromovitch, 1997; Wagner, 1997; and Widom, 1995).

The possibility of coexisting mental illness has made it difficult to attribute symptoms solely to CSA. Further, the high prevalence of co-occurrence of other family and environmental problems in families of CSA victims (for example, child physical abuse (CPA) and other types of child-maltreatment, family violence, unemployment, poverty and alcoholism/drug problems) has led researchers to be sceptical of attributing victims’ problems to the sexual abuse alone (Nash, Neimeyer, Hulsey, & Lambert, 1998; Widom, 1995).

Despite problems in research design and the absence of a concise definition, much of the research community concur that several effects of CSA appear to be quite apparent. For example, it is widely believed that a victim of CSA has an increased likelihood of experiencing negative physical, psychological, emotional and social problems; while the abuse is occurring, immediately after it ceases, and right through to long-term, even life-long effects (Esman, 1994; McMillan el al., 1995).

Webster (2001) suggests that the specific emotional and behavioural reactions of CSA victims vary markedly based on “genetic predisposition and temperament characteristics, socially taught patterns within the family unit and/or larger cultural group about how to express feelings, as well as the degree of emotional constriction or expressiveness shown by the child.” (p.536). However several studies have still found a number of common problems among CSA victims (see Corby, 2000). Firstly, many children who have been sexually abused show “sexualised conduct” (Beitchman, Zucker, Hood, DaCosta, & Akman, 1991; Edwards et al., 2003; Friedrich, Bielke, & Uriquiza, 1987; Kendall-Tackett, Williams, & Finkelhor, 1993).

In fact Friedrich (1996) found age-inappropriate sexualised behaviour to be one of the most predictive consequences of sexual abuse. Further, survivors of CSA frequently become involved in sexual activity at a younger age, are often more “promiscuous,” engage in more “risky” sexual practices, and have a higher likelihood of becoming involved in prostitution (Browning, 2002; Herrera & McCloskey, 2003; Kendler, Thornton, Gilman, & Kessler, 2000).

Female survivors are also more likely to be re-victimised, raped and/or further traumatised (physically and emotionally) – especially by intimate partners (Finkelhor & Browne, 1985; Fromuth, 1986; Russell, 1986). Alternatively, the survivor may become fearful of physical intimacy and adult relationships, and may have serious aversions to sex; these aversions may include feeling guilty, ashamed, or anxious about their sexuality (Tharinger, 1990).  Finkelhor and Browne (1985) found that “almost all clinically-based studies show later sexual problems among child sexual abuse victims, particularly among victims of incest” (p.70).

Post-Traumatic Stress Disorder (PTSD) is another problem commonly experienced by victims of CSA (Beichtman et al., 1991; Deblinger, Steer, & Lippmann, 1999; Finkelhor, 1990; Herrera & McCloskey, 2003; Kendall-Tackett et al., 1993; Kiser, Ackerman, Brown, Edwards, McColgan, Pugh, & Pruitt, 1988; Lang, 1997; McLeer, Deblinger, Henry, & Orvashel, 1992; Windom, 1999; Winfield, George, Swartz, & Blazer, 1990). For example, McLeer et al. (1992) found that roughly 50% of their CSA victims met either full or partial PTSD criteria.

PTSD in these victims often manifests as: general agitation, sleep problems, hypervigilance, vague and scary nightmares, behavioural disorganisation, repetitive re-play of the abuse using toys or objects, or attempts to re-enact the sexual abuse with peers and/or adults, numbing of emotions, symptoms of dissociation, flashbacks, repressed memories and feelings of isolation, numbness and estrangement from others (Herrera & McCloskey, 2003; also see Webster, 2001).

Finkelhor (1990) however, has challenged the diagnosis of PTSD in Child Sexual Abuse. He posits that PTSD only covers the affective symptoms, (for example, depression and fear) and does not account for problems in the way survivors perceive themselves, their family, or for their sexual problems. Finkelhor argues that reactions to acute stressors (such as rape or war) are more consistent with symptoms for PTSD, and that sexual abuse is more correctly conceived of as a “chronic stressor;” usually occurring over several years and often not involving violence or sudden physical force. Many would disagree with Finkelhor on several accounts. For example, CSA may involve actual or implied physical violence, and several more recent studies (such as Herrera & McCloskey, 2003 and Windom, 1999) have continued to find clinical evidence of PTSD in CSA victims.

Two other symptoms commonly seen in CSA victims and survivors are anxiety and depression (Beitchman, Zucker, Hood, DaCosta, Akman, & Cassavia, 1992; Briere & Runtz, 1988; Edwards et al., 2003; Murphy, Kilpatrick, Amick-McMullen, Veronen, Paduhovich, Best, Villeponteaux, & Saunders, 1988; Shapiro, Leifer, Martone, & Kassem, 1990; Winfield, et al., 1990). Depression associated with CSA is usually seen as a “symptom,” rather than as a “syndrome” (Browne & Finkelhor, 1986).

However, other common characteristics of depression, for example, suicide ideation and self-mutilation, are also strongly related to CSA (Briere & Runtz, 1988; Brown & Anderson, 1991; Bryant and Range, 1997; Davidson, Hughes, George, and Blazer, 1996; Gutierrez, Thakkar, & Kuczen, 2000; Peters and Range, 1995; Stepakoff, 1998; Van der Kolk, Perry & Herman, 1991).

In addition to depression and anxiety, sleep problems and panic attacks are also frequently associated with CSA (Bagley and Ramsay, 1986; Kolko, Moser, & Weldy, 1988; Wolfe, Gentile, & Wolfe, 1989). Further, other problems commonly found in CSA victims are: low self-esteem, anger, eating disorders, obsessive compulsive symptoms, tantrums, aggressive, antisocial and self-destructive behaviour, substance abuse, regressive behaviours, multiple personality disorders, withdrawal, guilt, shame, self-blame, powerlessness, helplessness, attention deficit hyperactivity disorder (ADHD), agitation and acting out.

Also, victims are more likely to be arrested and have problems with interpersonal relationship and childrearing, and may experience a sense of being fundamentally damaged (Burkett, 1991; Edwards et al., 2003; Etherington, 1995; Finkelhor & Browne, 1985; Herrera & McCloskey, 2003; Kendler et al., 2000; Kolko et al., 1988; Kuyken, 1995; Murphy et al., 1988; Nash, Hulsey, Sexton, Harralson, & Lambert, 1993; Ross, Norton, & Wozney, 1989; Webster, 2001; Widom, 1995). Physical and psychosomatic complaints often include bruises, genital injuries, headaches and stomach aches (see Rathus et al., 2005 and Webster, 2001).

Some children who have experienced CSA have been found to exhibit a cluster of behaviours known as “compulsive compliance” (Crittendon, 1992). Compulsive compliance is characterised by the child being overly compliant to adult requests and even modifying or falsifying feelings and truth to gain (especially parental) approval. These children are very vigilant about how to behave and what to say (based on adult nonverbal cues) and tend to highly structure their lives, even to the point of ritualistic conduct (see Crittendon, 1992 and Webster, 2001).

Gender Issues

Studies concerning gender differences amongst CSA girls and boys have reported somewhat mixed results. Some researchers have concluded that males react in more neutral, or even positive, ways to Child Sexual Abuse compared to girls (Bauserman & Rind, 1997). However many studies have found that children of both genders exhibit a range of negative effects resulting from CSA (Boney-McCoy & Finkelhor, 1998; Edwards et al., 2003; Flisher, Kramer, Hoven, Greenwald, Alegria, Bird, Canino, Connell, & Moore, 1997).

The finding that boys tend to show more “externalising” symptoms (such as aggression and acting out) and girls show more “internalising” symptoms (such as depression and anxiety), has been favoured by some (Edwards et al., 2003; Watkins & Bentovim, 1992; Turner, 1993) and rebutted by others (Garnefski & Diekstra, 1997; Jumper, 1995). Further, some studies have shown that females also frequently report marital distress (Ingram, 1985), and often drug abuse and alcoholism (Pribor & Dinwiddie, 1992).

Although research consistently reports that the overwhelming majority of perpetrators are males (Edwards et al., 2003), it is believed that the number of female perpetrators may be underestimated (Banning, 1989). This underestimation may be due to female physical contact with children being seen as more acceptable, and therefore inappropriate touching is more likely to be “missed” by other adults and confused by victims. Female motivation to sexually abuse children is also little understood. Some authors (Matthews, 1990) have theorised that it may be due to serious emotional issues resulting from previous (and, frequently, current abuse) by males in these women’s lives.

It also seems that many of these women are manipulated into abusive acts by their current male partners (see Rathus et al., 2005). Whilst it seems that majority of the perpetrators are males, many studies have found that more females than males (at a ratio of 3-4 females to 1 male) are the victims of CSA (Webster, 2001; also, see Edwards et al., 2003, and Finkelhor, 1984). However these results may not be as accurate as they initially seem, due to an even higher likelihood of males not reporting their abuse. The reasons for this may lie in the even greater stigmatisation and shame of male victims, a higher expectancy that males should be able to look after themselves, and issues concerning homosexuality – as the perpetrator is most often male (Briggs, 1986; Etherington, 1995).

Long-Term Effects

Some research has found that around one-third of children may not show any negative effects of CSA straight away (Kendall-Tackett et al., 1993; Mannarino & Cohen, 1986). This does not necessarily mean, however, that these children are not affected by the abuse, or that they do not experience problems later on. Several interpretations of these “symptom-free” victims have been proposed. For example, Kuyken (1995) suggests that the measures used to detect symptoms in these cases were perhaps not sensitive enough, whereas other authors have posited that these victims may be in a state of shock or denial. The shock/denial hypothesis gave rise to the investigation of “sleeper effects,” which has led to findings of serious emotional, behavioural and social problems for some of these children later on in life (Mannarino, Cohen, Smith, & Moore-Motily, 1991; Saunders, Kilpatrick, Hansen, Resnick, & Walker, 1999; Widom, 1999).

It has further been suggested that individuals who continue to show few or no symptoms, may have experienced: shorter periods of abuse, less severe abuse, abuse without penetration, violence or force, abuse by a person other than a “father figure,” and had the reactive support of their family (Finkelhor, 1990; Ketring & Feinauer, 1999; also see Kuyken, 1995). In fact, much of the variation in symptoms found in CSA survivors has been attributed to these variables. Webster (2001) links the degree of trauma experienced to three specific variables: the amount of actual or implied violence/fear associated with the sexual abuse, the parents’ reactions to disclosure of the abuse and the actions taken thereafter, and the age of the child when the assault occurs.

Webster further expands on these three variables with the support of many other authors. For example, in determining the level of fear/violence associated with the abuse, issues of trust, control, obligation and level of emotional connectedness to the perpetrator are all considered; along with the degree of physical invasiveness (especially penetration), pain and violence connected with the act (Bennett, Hughes, & Luke, 2000; Browne & Finkelhor, 1986; Callahan, et al., 2003; Cohen & Mannarino, 2000; Collings, 1995; Mannarino & Cohen, 1996; Russell, 1986).

Family reaction (for example, issues concerning belief and blame), support (for example, counselling) and follow-up (for example, protection of the child from the perpetrator, legal proceedings), also contribute to how the child will cope and recover (or worsen) following disclosure (Kazdin & Weisz, 1998; Saywitz, Mannarino, Berliner, & Cohen, 2000). Lastly, the age (developmental status) of the child when the abuse begins, and the length of time the abuse continues for, also contribute to the degree of trauma experienced by the victim (Tremblay, Herbert, & Piche, 1999). While effects of CSA vary markedly among victims and no single “syndrome” has been identified, the above three variables are somewhat helpful in terms of treating cases of CSA. Of course, the most important component of working with survivors of CSA is their unique understanding and experience of the event/s and intervention/therapy is best approached from within the individual’s own framework and network of supports.

Lastly, several studies have produced findings that suggest that some female CSA victims suffer several long-term negative physiological changes as they get older (Altemus, Cloitre, & Dhabhar, 2003; DeBellis, Burke, Trickett, & Putnam, 1996; DeBellis, Lefter, Trickett, & Putnam, 1994). Not only are CSA females likely to physically “develop” earlier (generating increased male attention), but specific hormonal and neuroendocrine changes have also been evidenced. DeBellis, Chrousos, Dorn, Burke, Helmers, Kling, Trickett, & Putnam (1994) found that a group of 8-15 year old CSA girls had significantly elevated epinephrine, norepinephrine and dopamine levels (catecholamines typically secreted in response to stress) when compared with non-abused girls.

Other studies (DeBellis et al., 1994b, 1996) have found elevated levels of adrenocorticotrophic hormone (ACTH) and cortisol in 7-15 year old girls. Heim, Newport, Miller, & Nemeroff (2000, 2002) found that women who had been sexually abused as children had significantly higher levels of ACTH and cortisol than women who had not been abused (whether they suffered depression or not), and that women who had been sexually abused and suffered depression had significantly higher levels than any other group. Further, stress hormone levels where not found to differ significantly between non-sexually abused depressed and non-depressed women. This study concluded that depression alone does not show the same, significant physiological “stress effect” that CSA does, but that the interaction of depression and CSA can significantly compound stress levels.

Conclusion & References

In conclusion, it is evidenced from the above discussion that CSA is a complex and perplexing phenomenon. Whilst definition and methodological issues present problems in the research and clinical arenas, most professionals in the field agree that CSA is a highly destructive and problematic experience for the majority of survivors. Lack of clarity surrounding a specific definition, and massive underreporting of cases has lead to prevalence statistics presenting, at best, “bare minimum” figures. Issues concerning survivor memory, co-occurrence of other problems in childhood upbringing (such as child abuse, poverty, family violence, and drug and alcohol abuse) and co-morbidity of other mental illness, all contribute to the problem of attributing “causal” inference.

While increases in the standard of “research-level precision” of future studies will hopefully culminate in clearer findings, variation in the actual acts of CSA, and individual differences in response to trauma will no doubt continue to confound the issue. While statistics and categorisation remains important in psychology, the individual therapist encountering a survivor/victim in the treatment setting is best to take the approach of educating themselves as much as possible in the issues surrounding CSA and its treatment. Further, it is imperative to remember that the experience of CSA is different for every victim, and to always proceed at a pace that is comfortable for the individual client.

Author Information: Vikki Rowe is a graduate of AIPC’s Diploma of Professional Counselling and currently studying a Masters of Clinical Psychology course at the Australian Catholic University.

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