Child Sexual Abuse: An Overview
1Delphine Collin-Vézina, PhD, 2Lise Milne, PhD
1McGill University, Canada, 2University of Regina, Canada
Child sexual abuse (CSA) is a form of maltreatment that is recognized globally as a serious human rights violation and a major public health concern. This paper will provide an overview of the state of knowledge on CSA.
It is now recognized that the definition of CSA includes both contact and non-contact abuse. CSA comprises any sexual activity perpetrated against a minor by threat, force, intimidation or manipulation. The array of sexual activities includes fondling, inviting a child to touch or be touched sexually, intercourse, rape, incest, sodomy, exhibitionism, or involving a child in prostitution or pornography.1 There is a general consensus that CSA is a complex phenomenon occurring for multiple reasons, in various ways, and in different relationships within families, peer groups, institutions, and communities.2 Two important overlapping unresolved issues include the lack of a conceptual model of CSA and the absence of a shared definition or understanding of what constitutes CSA worldwide.
Scope of the Problem
Most studies emphasize that the full extent of CSA perpetration remains unknown.1,3 It is difficult to determine given differences in the way data is collected,4 as well as the reticence of most children to disclose the abuse.5
Disclosure of traumatic events such as CSA can often be a very complex, iterative life-long process.6 Victims of CSA often delay reporting, or never tell.5 For example, in a review by Finkelhor7 only about half of survivors across all studies had disclosed the abuse to anyone. In another study, the vast majority of survivors (93%) did not report the abuse to authorities prior to the age of 15.8
In a 2013 systematic review and meta-analysis of recent studies worldwide, CSA prevalence rates were found to be 8 to 31% for girls and 3 to 17% for boys. Forced intercourse was self-reported by 9% of girls and 3% of boys.9 In contrast, incidents of CSA reported annually to formal, official bodies such as child protection services is drastically lower (e.g., .43% in Canadian child protection systems;10 2.4% in U.S. child protection and community agencies).11 Clearly, official reports to authorities underestimate the extent of CSA; in another worldwide CSA prevalence meta-analysis, rates were more than 30 times higher in self-report than official-report studies (12.7% versus 0.4%).12
Key Research Questions
For the past few decades, several questions have been central in guiding CSA research. These include: What are the risk factors for CSA? What are the mental health outcomes of CSA? What are the protective factors that make some children less likely to experience impairment following CSA exposure? What are the most effective prevention, assessment and treatment strategies?
Recent Research Results
Female children are about two times more likely to be victims of CSA than males.12 There is a strong likelihood, however, that boys are more frequently abused than the ratio of reported cases would suggest given their probable reluctance to report the abuse.13 Risk for CSA rises with age, with the highest number of victims in the 12 to 17-year age range. Girls are considered to be at high risk for CSA starting at an earlier age and of longer duration, while risk for boys peaks later and for a briefer period of time.1
CSA is a major risk factor for developing a host of negative consequences in both childhood and adulthood. Victims have been shown to experience more post-traumatic stress and dissociative symptoms than non-abused children,14 as well as more depression and conduct problems.15 They engage more often in at-risk sexual behaviours.16 Victims are also more prone to abusing substances,17 and to suicide attempts.18 These mental health problems are likely to continue into adulthood.19 CSA victims are also more at risk than non-CSA youth to experience violence in their early romantic relationships;20 women exposed to CSA have a two to three-fold risk of being sexually revictimized in adulthood compared with women without a history of CSA exposure.21
However, about one third of victims may not manifest any clinical symptoms at the time the abuse is disclosed.22 This can be explained, in part, by the extremely diverse characteristics of CSA which lead to a wide range of potential outcomes. Also, several factors influence the resilience of CSA victims; for example, children who receive support from their non-offending parents23 and those who have not experienced prior abuse24 seem to fare better. In all cases, however, early assessment and where indicated, intervention to address the negative outcomes, are important.
In the area of assessment, two forensic protocols have undergone considerable evaluation. These include the National Institute of Child Health and Human Development (NICHD) Structured Interview Protocol and the Sexual Assault Nurse Examiner (SANE) Model.
- The use of a structured investigative protocol, such as the NICHD model, specifies that police officers receive extensive training to elicit detailed information from CSA victims in a non-suggestive manner. This protocol clearly enhances the quality of interviews and facilitates the assessment of credibility by child investigators.25
- The SANE nurses provide, usually in the context of a hospital emergency unit, a first response that addresses victims’ emotional and physical needs while gathering the forensic evidence that could potentially lead to prosecution of the person responsible for the abuse. The effectiveness of SANE in regard to forensic evidence collection and prosecution rates in CSA cases involving children has been demonstrated.26
In terms of interventions for reducing impairment associated with CSA, a recent meta-analysis found that treatment is effective in reducing PTSD symptoms as well as externalizing and internalizing problems.27 Of the handful of evidence-based treatments, Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) is the most established treatment for children who have experienced CSA and present with post-traumatic stress disorder (PTSD) symptoms.28 Randomized controlled trials have shown this treatment to be effective in improving participant symptomatology as well as parenting skills and children’s personal safety skills, even when the duration of the program was as short as eight weeks.29 Sustained improvement following TF-CBT has been shown for anxiety, depression, sexual problems and dissociation at the 6-month follow-up and in PTSD and dissociation at the 12-month follow-up.30,31
Although school-based educational programs are widely disseminated and promoted as a primary prevention strategy, little evidence exists that they are effective in preventing actual exposure to CSA; they appear to improve children’s knowledge and protective behaviours and may increase the likelihood of disclosure, but it is unknown whether they prevent the occurrence of CSA.32
Two main gaps are worth highlighting: First, since most CSA victims remain unidentified, current knowledge is likely biased in its focus on information from victims where CSA has been detected; further investigation is needed to understand the variable ways in which children exposed to CSA present. Second, there is a need to identify additional evidence-based approaches for assessment, treatment and prevention of CSA.
While there is now a general consensus regarding the definition of CSA, the magnitude of the problem remains difficult to estimate given the differences in data collection systems. A 2011 meta-analysis on CSA prevalence showed that 12.7% of adults were sexually abused in their childhood or teenage years, with females and older children showing an increased risk. CSA is a major risk factor in the development of short- and long-term negative consequences, such as depression, PTSD, and substance abuse, although not all victims experience impairment. Two forensic protocols – the NICHD Structured Interview Protocol and the SANE Model – are well established in the field. The most effective treatment of children exposed to CSA and presenting with PTSD symptoms is TF-CBT. Future research should focus on developing strategies to facilitate the disclosure and reporting processes of CSA, to better identify the needs of CSA victims, and to develop prevention strategies.
Implications for Parents, Services and Policy
Beyond the broad range of deleterious health and social impacts of CSA, the lifetime economic costs have been estimated to be $9.3 billion.33 To address this major public health problem, we should prioritize the development of strategies to prevent sexual abuse from happening in the first place and address the barriers to disclosure and reporting. Although the taboo of CSA might not be as prominent as a few decades ago, stigma as well as difficulty accessing services may still prevent victims from receiving necessary resources.
- Putnam FW. Ten-year research update review: Child sexual abuse. Journal of the American Academy of Child & Adolescent Psychiatry. 2003;42(3):269-278.
- Mathews B, Collin-Vézina D. Child sexual abuse: Toward a conceptual model and definition. Trauma, Violence, & Abuse. 2017: Advance online publication.
- Johnson RJ. Advances in understanding and treating childhood sexual abuse: Implications for research and policy. Family & Community Health. 2008;31(Suppl1):S24-S34.
- Martin EK, Silverstone PH. How much child sexual abuse is below the surface, and can we help adults identify it early. Frontiers of Psychiatry. 2013: 4(58):1-10.
- Hunter SV. Disclosure of child sexual abuse as a life-long process: Implications for health professionals. The Australian and New Zealand Journal of Family Therapy. 2011:32:159-172.
- Alaggia R, Collin-Vézina D, Lateef R. Facilitators and barriers to child sexual abuse (CSA) disclosures: A research update (2000-2016). Trauma, Violence, & Abuse. 2017:Advance online publication.
- Finkelhor D. Current information on the scope and nature of child sexual abuse. Sexual Abuse of Children.1994;4(2):31-53.
- Burczycka M, Conroy S. Family violence in Canada: A statistical profile, 2016. Juristat: Canadian Centre for Justice Statistics. 2018 Jan 17:1-96.
- Barth J, Bermetz L, Heim E, Trelle S, Toni T. The current prevalence of child sexual abuse worldwide: A systematic review and meta-analysis. International Journal of Public Health. 2013;58:469-483.
- Collin-Vézina D, Hélie S, Trocmé N. Is child sexual abuse declining in Canada? An analysis of child welfare data. Child Abuse & Neglect. 2010;34(11):807-812.
- Sedlak AJ, Mettenburg J, Basena M, Petta I, McPherson K, Greene A et al. Fourth National Incidence Study of Child Abuse and Neglect (NIS–4): Report to Congress, 2010.Washington, DC: U.S. Department of Health and Human Services, Administration for Children and Families
- Stoltenborgh M, van IJzendoorn MH, Euser EM, Bakermans-Kranenburg MJ. A global perspective on child sexual abuse: Meta-analysis of prevalence around the world. Child Maltreatment. 2011;16(2):79-101.
- O’Leary PJ, Barber J. Gender differences in silencing following childhood sexual abuse. Journal of Child Sexual Abuse. 2008;17(2):133-143.
- Collin-Vézina D, Hébert M. Comparing dissociation and PTSD in sexually abused school-aged girls. Journal of Nervous Mental Disorders. 2005;193(1):47-52.
- Danielson CK, Macdonald A, Amstadter AB, et al. Risky behaviors and depression in conjunction with—or in the absence of—lifetime history of PTSD among sexually abused adolescents. Child Maltreatment.2010;15(1):101-107.
- Lalor K, McElvaney R. Child sexual abuse, links to later sexual exploitation/high- risk sexual behavior, and prevention/treatment programs. Trauma, Violence, & Abuse 2010;11(4):159-177.
- Shin SH, Edwards EM, Heeren T. Child abuse and neglect: Relations to adolescent binge drinking in the National Longitudinal Study of Adolescent Health (AddHealth) Study. Addiction Behaviors. 2010;34(3):277-280.
- Brezo J, Paris J, Tremblay R, Vitaro F, Hebert M, Turecki G. Identifying correlates of suicide attempts in suicidal ideators: A population-based study. Psychological Medicine. 2007;31(11):1551-1562.
- MacMillan HL, Fleming JE, Streiner DL, et al. Childhood abuse and lifetime psychopathology in a community sample. American Journal of Psychiatry. 2001;158(11):1878-1883.
- Vezina J, Hebert M. Risk factors for victimization in romantic relationships of young women: a review of empirical studies and implications for prevention. Trauma, Violence, & Abuse. 2007;8(1):33-66.
- Classen CC, Palesh OG, Aggarwal R. Sexual revictimization: A review of the empirical literature. Trauma, Violence, & Abuse. 2005;6(2):103-129.
- Kendall-Tackett K, Meyer-Williams L, Finkelhor D. Impact of sexual abuse on children: A review and synthesis of recent empirical studies. Psychological Bulletin. 1993;113(1):164-180.
- Elliott AN, Carnes CN. Reactions of nonoffending parents to the sexual abuse of their child: a review of the literature. Child Maltreatment. 2001;6(4):314-341.
- Hébert M, Collin-Vézina D, Daigneault I, Parent N, Tremblay C. Factors linked to outcomes in sexually abused girls: a regression tree analysis. Comprehensive Psychiatry. 2006;47(6):443-455.
- Lamb ME, Orbach Y, Sternberg KL, et al. Use of a structured investigative protocol enhances the quality of investigative interviews with alleged victims of child sexual abuse in Britain. Applied Cognitive Psychology. 2009;23(4):449-467.
- Campbell R, Patterson D, Lichty L. The effectiveness of sexual assault nurse examiner (SANE) programs: A review of psychological, medical, legal, and community outcomes. Trauma, Violence, & Abuse. 2005;6(4):313-329.
- Trask EV, Walsh K, DiLillo, D. Treatment effects for common outcomes of child sexual abuse: A current meta-analysis. Aggression and Violent Behavior. 2011:16(1):6-19.
- Cohen JA, Deblinger E, Mannarino AP, Steer RA. A multisite, randomized controlled trial for children with sexual abuse-related PTSD symptoms. Journal of the American Academy of Child & Adolescent Psychiatry. 2004;43(4):393-402.
- Deblinger E, Mannarino AP, Cohen JA, Runyon MK, Steer RA. Trauma-focused cognitive behavioral therapy for children: impact of the trauma narrative and treatment length. Depression and Anxiety. 2011;28(1):67-75.
- Cohen JA, Mannarino AP. Treating sexually abused children: 1-year follow-up of a randomized controlled trial. Child Abuse & Neglect. 2005;29(2):135-145.
- Mannarino AP, Cohen JA, Deblinger E, Runyon MK, Steer RA. Trauma-focused cognitive-behavioral therapy for children: sustained impact of treatment 6 and 12 months later. Child Maltreatment. 2012;17(3):231-241.
- Walsh K, Zwi K, Woolfenden S, Shlonsky A. School-based education programmes for the prevention of child sexual abuse. Cochrane Database of Systematic Reviews. 2015 Apr 16;(4):CD004380.
- Letourneau EJ, Brown DS, Fang X, Hassan A, Mercy JA. The economic burden of child sexual abuse in the United States. Child Abuse & Neglect. 2018;79:413-422.
How to cite this article:
Collin-Vézina D, Milne L. Child Sexual Abuse: An Overview. In: Tremblay RE, Boivin M, Peters RDeV, eds. MacMillan HL, topic ed. Encyclopedia on Early Childhood Development [online]. http://www.child-encyclopedia.com/maltreatment-child/according-experts/child-sexual-abuse-overview. Updated May 2019. Accessed June 18, 2019.