Sexual Victimization of Children and Adolescents: An Overview

1. Sexual Victimization of Children and Adolescents: An Overview Marilyn Kaufhold, MD, FAAP

2. Learning Objectives

3. Child Sexual Abuse (CSA)

4. Historical Aspects of CSA

5. Prevalence of CSA • Prevalence (definition): the total number of cases of a disease in the population at a given time • Used to estimate how common a disease or condition is within a population over a certain period of time • Assists health professionals to understand the probability of certain diagnosis • WHO 2002 report: 20% of women and 5-10% of men were sexually abused as children • Figures derived are believed by some to be low estimates

7. Risk Factors Associated with CSA

8. When to Suspect CSA • Child discloses intentionally or unintentionally to parent, teacher, other trusted adult or friend • Sexual abuse is witnessed by someone • Sexual abuse is suspected because… • Child exhibits sexualized behavior or other significant change in behavior • Child complains of genital discomfort, genital bleeding or other medical symptoms • Child diagnosed with sexually transmitted disease • All the above need evaluation/investigation to confirm

9. More about Behaviors

10. Studies show abuse by someone known to the child far more likely than abuse by stranger Child-Perpetrator Relationship: Who sexually abuses children? *Father, stepfather, mother’s boyfriend, mother, other relatives, babysitters, teachers, coaches, clergy, medical provider, etc.

11. Perpetrating the Sexual Abuse

12. How do children adapt to being sexually abused? • The following stages have been described • Secrecy • Helplessness • Entrapment and accommodation • Delayed, unconvincing disclosure • Retraction • This is known as the child sexual abuse accommodation syndrome

13. Case Discussion • Mother brings her 6-year-old daughter for a medical examination because she is worried that her daughter is being sexually abused by an uncle. This child goes to the home of the uncle and aunt every day after school because mother works until 6 PM. The aunt and uncle have 3 children around the same age.

14. Short Term Experience for the Child Victim

15. Long Term Consequences of Sexual Abuse • Delays in all developmental spheres which may persist into adulthood manifested by stress response dysregulation • Multiple health risk behaviors leading to medical illnesses • Increased psychiatric impairment • Impaired attachment • Increased rate of violent crimes • School discipline problems

16. Young Children v. Adolescents • Both young children and teens can be victims but there are important differences in… • Dynamics – • Perpetrator relationship • Risk factors • Anatomy – sexual immaturity vs. maturity • Injuries – incidence and healing • Medical care – STDs, trauma symptoms

17. Adolescence: a Paradigm of Chronologic Age Interacting with Biologic Change • Individuals in the developmental phase between childhood and adulthood marked by rapid changes in growth: • Physical • Moral • Psychosocial • Cognitive

18. Gradual development as an independent individual Evolution of satisfying, realistic body image Appropriate control and expression of sexual drive Expansion of relationships outside the home Implementation of a realistic plan to achieve social and economic stability Transition from concrete to abstract thinking Integration of values applicable to life events Adolescent Developmental Changes Set Up Risks

19. Risk Factors for Sexual Assault • Normal adolescent interest in autonomy, sexuality, peer acceptance • Lack of knowledge and skills to recognize potentially dangerous life situations • Experimentation with drugs/alcohol • Past victimization • Parental history of substance use • Living where there is • General tolerance for sexual violence • Weak sanctions against sexual violence • Strong belief in male sexual entitlement • Rigid gender roles

20. Definition: Sexual Assault

21. Types of Sexual Assault/Abuse • Sexual assault by acquaintance, stranger, or date/intimate partner, gang • Drug-facilitated sexual assault (DFSA) • Continuation of child sexual abuse-incest • Statutory rape • Prostitution, homeless runaways • Trafficking • Sexual harassment – demands for sexual favors in return for jobs, grades, safety (police custody, prison, refugee camp) • Armed conflict • Child marriage • Violent acts against women’s integrity (female genital cutting)

22. How Common is Sexual Assault?WHO 2002 Report • Common • One-third of adolescents report their first sexual experience was forced • Worldwide, hundreds of thousands of women are trafficked annually, most are <25 yr., many <18 yr. • Between one-third and two-thirds of all victims of sexual assault are <age 15 Young age itself increases the individual’s vulnerability to all forms of sexual victimization

24. Signs of Possible Victimization

25. Reasons Teens May Not Report the Crime

26. Common Rape Myths Sexual assault is an impulsive, spontaneous act Sexual assault usually occurs between strangers Women "ask for it" by their dress or actions If the assailant, victim, or both are drunk, the assailant cannot be charged with rape Men can't be raped Rape is sex Women incite men to rape There is a "right way" to respond to a rape situation Women fantasize about being raped Women frequently cry rape (false reporting)

27. Case Discussion • 15-year-old girl went with a 17-year-old boy she liked after school to his house in a different neighborhood. They had not dated before. At his house, they talked for a while. He proposed having sex. She said no. He held her down and forced sex. He kept her with him until after she was due home. Then he took her home and told her not to tell anyone.

28. Consequences of Sexual Assault

29. Prevention of Sexual Violence

30. Questions?

31. References • Berliner, L. and D. M. Elliott (1996). Sexual abuse of children. The APSAC Handbook on Child Maltreatment. J. Briere, L. Berliner, J. Bulkley, C. Jenny and T. Reid. Thousand Oaks, CA, Sage Publications: 51-71. • Bureau of Justice Statistics National Crime Victimization Survey 2010: http://bjs.ojp.usdoj.gov/index.cfm?ty=pbdetail&iid=4393 • De Bellis, M., E. Spratt, et al. (2011). "Neurodevelopmental biology associated with childhood sexual abuse." Journal of Child Sexual Abuse 20: 548-587.

32. Finkelhor, D. and A. Browne (1985). "The traumatic impact of child sexual abuse: a conceptualization." Am J Orthopsychiatry 55(4): 530-541. • Finkelhor, D. (2007). "Prevention of sexual abuse through educational programs directed toward children." Pediatrics 120(3): 640-645. • Friedrich, W. N., J. L. Fisher, et al. (2001). "Child Sexual Behavior Inventory: normative, psychiatric, and sexual abuse comparisons." Child Maltreat 6(1): 37-49.

33. Summit, R. (1983). "The child sexual abuse accommodation syndrome." Child Abuse and Neglect 7: 177-193. • WHO World Report on Violence and Health 2002: http://www.who.int/violence_injury_prevention/violence/world_report/en/