Sexual Victimization of

Children and Adolescents:

An Overview

Marilyn Kaufhold, MD, FAAP

 Learning Objectives

The participant will be able to:

• Describe the disclosure process of a young
child sexual abuse victim.
• List features that distinguish sexual abuse of
a young child from that of an adolescent.
• Explain factors that discourage and
complicate victimization reporting by young
children and adolescents.
 Child Sexual Abuse
(WHO 2006)

• Definition: Involvement of a child in

sexual activity that s/he…
• does not fully comprehend
• is unable to give informed consent to,
• or is not developmentally prepared for,
• or violates the laws or social taboos of
society
 Types of Child Sexual Abuse
• Exposing oneself or • Using a child to produce
masturbating in front of a pornography
child
• Rape, sodomy, engaging a
• Fondling or touching of child in sexual activity
the sexual or erogenous
zones • Voyeurism

• Sexual penetration of • Virtual: Exposure to

vagina, anus, mouth by developmentally
other objects inappropriate ‘sexualized’
material through
• Engaging or promoting a electronic media
child’s sexual performance
• Sex trafficking /tourism
 Prevalence of Child Sexual Abuse

• Documented in written /verbal histories worldwide

• Issue for peoples of all nations, races, cultures, religions

• Global recognition increasing due to

• Improved professional knowledge and response
• Social understanding of the extent/forms of sexual abuse

• Challenge to study due to differing definitions, populations,

study methods, secrecy surrounding sexual abuse
• Finkelhor (1994): 20-25% women, 5-15% men
• Dong, Felitti (2003): 24.7% women, 16% men
 Risk Factors
Associated with Child Sexual Abuse
Risk factor: A characteristic that is likely to increase the
chance that a particular event will occur
• Girls>boys
• Single parent household
• Mother unavailable
• Family life perceived as unhappy
• Psychological or cognitive vulnerability
• Other adverse childhood experiences (ACEs) e.g.
substance abuse, esp. alcohol, DV, PA etc.
• Family has difficulties with communication, lacks
emotional closeness/flexibility, is socially isolated
 When to Suspect Child Sexual
Abuse
• Child discloses intentionally or unintentionally to parent,
teacher, other trusted adult or friend

• Sexual abuse is witnessed by someone

• Sexual abuse is suspected because the child

• Exhibits significant behavior change, especially
sexualized behavior
• Complains of genital discomfort, genital bleeding or
other medical symptoms; anogenital injuries
• Diagnosed with sexually transmitted disease, pregnancy

• All the above need evaluation/investigation to confirm

More about Behaviors

Other behavior
Sexualized changes may be
behaviors are nonspecific
most concerning • Sleep, appetite,
but must be toileting
distinguished • Fears, sadness
from normal • Aggressive or
sexual behaviors overly
of children submissive
behavior
Child-Perpetrator Relationship:
Who sexually abuses children?

Saunders (1999) Percentage of victims in age groups at

first child rape by relationship of perpetrator to victim
 Perpetrating the Sexual Abuse

Single Offenders may Repeat

event or gradually sexualize offenders
multiple the relationship with calculate
the child over time approach

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The Child Victim’s Experience

• The sexual contact is…

• unwanted or forced
• upsetting and confusing
• sometimes painful
• frightening and shame inducing

• It alters the relationship in which it

occurs

• It can lead to changes in a child’s

perceptions of others and safety in the
world
 Case Discussion
• Mother brings her 6-year-old
daughter to the doctor
because of a concern 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.
 Short Term Experience for the
Child Victim
Pain, injury, Infection Behavioral
bleeding during changes
the abusive acts
as well as School performance/
during healing discipline
or
none of the Fears
above
Family disruption

Disturbance of sleep,
appetite, toileting
 Long Term Consequences of
Sexual Abuse (De Bellis 2011)
• Delays in all • Increased rate of violent
developmental spheres crimes
manifested by stress • Substance use disorder
response dysregulation
• School discipline problems,
• Multiple health risk poor long-term intellectual
and academic achievement
behaviors /medical
illnesses • Greater likelihood of
becoming a teen parent
• Increased psychiatric
impairment/medical • Developmental
disorders/impaired
utilization attachment
 Characteristics of Adolescent Sexual
Victimization
• Both young children and teens
are sexual abuse victims and
there are many similarities but
also differences…
• Perpetrator relationship
• Risk factors
• Professional approach
• Genital injury characteristics
• Post abuse medical care

16
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
Normal Adolescent Developmental
Changes Set Up Risks
• Gradual development • Implementation of a
as an independent realistic plan to achieve
individual social and economic
• Evolution of satisfying, stability
realistic body image
• Transition from
• Appropriate control concrete to abstract
and expression of thinking
sexual drive
• Integration of values
• Expansion of applicable to life events
relationships outside
the home
 Teen Risk Factors for Sexual
Victimization
• Personal
• Normal adolescent
interest in autonomy,
sexuality, peer acceptance
• Lack of knowledge and
skills to recognize
potentially dangerous life • Familial
situations • Parental history
• Experimentation with of substance use
drugs/alcohol • Household
• Past victimization violence
 Teen Risk Factors for Sexual
Victimization
• Societal : Living where there is
• General tolerance for sexual violence and child
abuse in general
• Weak sanctions against sexual violence and abuse
• Strong belief in male sexual entitlement and
weakness of women’s rights
• Rigid gender roles and gender discrimination
 The Many Contexts of Sexual Abuse
• Sexual assault by
acquaintance, stranger, or
date/intimate partner, gang
• Drug-facilitated sexual
assault (DFSA)
• Intrafamilial sexual abuse
• Statutory rape
• Forced prostitution in
homeless, runaways
• Sex trafficking
• Sexual harassment –
demands for sexual favors
in return for jobs, grades,
safety (police custody,
prison, refugee camp)
• Sexual assault in the
context of war and
population displacement
• Child marriage
• Violent acts against
women’s integrity (female
genital cutting/ mutilation)
Signs of Possible Victimization

Behavior changes noted by parents,

friends, teachers
• Sudden changes in mood, sleeping or eating
patterns
• Depression, anxiety, suicidal ideation, self-cutting
• High risk sexual behavior
• Sudden changes in clothes, make-up
• Failing grades, truancy, dropping out of school,
running away
 Adolescence: A High Risk Time for
Sexual Assault
• Kilpatrick (2003) National Survey of Adolescents (USA)
• National sample of 4,023 youth (12-17 yr)
• 326 (8.1%) reported sexual assault
• Expanded to general population of US youths yields a
prevalence of 1.8 million

• McCauley (2009) USA

• National sample of 1,763 adolescent girls (12-17 yr)
• 11.8% reported sexual assault

• WHO World Report on Violence and Health 2002

One-third of teens report first sexual experience was forced
 Incidence of Serious Violent Crime
by Age (per 1,000 persons)

U.S. Bureau of Justice Statistics National Crime Victimization Survey

 Reasons Teens May Not
Report the Sexual Victimization
Rape myths: false beliefs about
rape that are commonly held by
many, even the victim
Victim’s mistaken Fear of not being
definition of sexual believed by police,
assault parents, boyfriend,
others

Fear of reprisal Wish to avoid the

from perpetrator stigma society
attaches to rape
Self-blame
Common Rape Myths
• Women incite men to
rape. Women "ask for it"
by their dress or actions
• There is a "right way" to
respond to a rape
• Women can’t be raped
without their implicit
consent
• Women frequently cry
rape (false reporting)
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• Sexual assault is an
impulsive, spontaneous
• Women "ask for it" by
their dress or actions
• If the assailant, victim, or
both are intoxicated
(drugs or alcohol), the
assailant cannot be
charged with rape
• Males can't be raped by
men or women
Legal Protection: a Right for Children

• The convention on the Rights of the child (CRC) asserts

the rights of children to physical and personal integrity,
and establishes high standards for protection.
• Article 19 requires States to take “all appropriate
legislative, administrative, social and educational
measures to protect the child from all forms of physical
or mental violence, injury or abuse, neglect or negligent
treatment, maltreatment or exploitation, including
sexual abuse, while in the care of parents, legal
guardians, or any other person who has the care of the
child.” UNVAC 2006
 Laws relating to Sexual
Victimization of Children

National and
Exact wording/
International
understanding of
Laws: criminal, Goals: Child
laws differs across
family, juvenile, Protection,
jurisdictions and
international Prosecution of
may be
criminal, offenders,
intrinsically
humanitarian, community
divergent across
refugee and labor safety
settings and
law (UNVAC
cultures
2006)

28
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.
 Consequences of Sexual Assault

Reproductive Mental Health Social Well

consequences Consequences Being

Pregnancy, Depression, Loss of

HIV, other PTSD, honor and
infections suicide, self-esteem
behavior
Loss of sense of problems Risk of
control over own alcohol/
sexuality - less likely substance
to use contraception abuse
Prevention of Sexual Violence
Individual level: Programs that encourage positive
attitudes and sexual awareness in young children
and adolescents

Relationships (Families): Programs that provide

education to parents and assist them in creating an
environment that protects children from violence

Community: Reduce exposure to violence and set

landmarks for child protection

Social: Promote norms and values that depict sexual

violence as illegal
Questions?
 References

• Berliner, L. (2011). Child sexual abuse: definitions,

prevalence and consequences. The APSAC Habdbook on
Child Maltreatment, 3rd ed. J. E. B. Myers. Los Angeles,
Sage.

• 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.
• Dong, M., R. F. Anda, Felitti, V. (2003). "The relationship of
exposure to childhood sexual abuse to other forms of abuse,
neglect, and household dysfunction during childhood."
Child Abuse Negl 27(6): 625-639.

• Finkelhor, D. and J. Dziuba-Leatherman (1994). "Children

as victims of violence: a national survey." Pediatrics 94(4 Pt
1): 413-420.

• 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.
• ISPCAN Denver Thinking Space 2011: Child Sexual Abuse
http://c.ymcdn.com/sites/www.ispcan.org/resource/resmg
r/events/ispcan_denver_thinking_space.pdf

• Kilpatrick, D. G., Saunders, B. E., & Smith, D. W. (2003).

Youth victimization: Prevalence and implications.
Washington, DC: U.S. Department of Justice, Office of
Justice Programs, National Institute of Justice.

• McCauley, J. L., et al. (2009). "Prevalence and correlates of

drug/alcohol-facilitated and incapacitated sexual assault in a
nationally representative sample of adolescent girls." J Clin
Child Adolesc Psychol 38(2): 295-300

• Saunders, B. E. (1999). "Prevalence, Case Characteristics,

and Long-Term Psychological Correlates of Child Rape
among Women" Child Maltreatment 4(3): 187-200.
• “Sexual Violence,” Chapter 6. World Report on Violence
and Health (2002) WHO
http://whqlibdoc.who.int/publications/2002/9241545615_
eng.pdf

• Summit, R. (1983). "The child sexual abuse

accommodation syndrome." Child Abuse and Neglect 7:
177-193.

• UN Violence against Children and International Human

Rights Law and Standards 2006
http://www.unviolencestudy.org/

• WHO World Report on Violence and Health 2002:

http://www.who.int/violence_injury_prevention/violence/
world_report/en/