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Sexual Abuse: Prevalence, Risk Factors, and Referrals

I. Definition: Sexual Abuse is defined as:

• Employment, use, persuasion, inducement, enticement, or coercion of any child to engage in, or assist any other person to engage in, any sexually explicit conduct or any simulation of such conduct for the purpose of producing any visual depiction of such conduct; or
• rape, and in cases of caretaker or inter-familial relationships, statutory rape, molestation, prostitution, or other form of sexual exploitation of children, or incest with children. (Child Abuse Prevention and Treatment Act)

II. Prevalence Information

• A national study conducted with 2000 adults revealed sexual abuse histories among 27% of the women and 16% of the men surveyed (Finkelhor, 1987).
• Females are sexually victimized more frequently than males.
• Most sexual victimizations occur before the age of 18. Thus, children and youth have the highest incidence of sexual assault.

III. Distribution of Different Types of Sexual Abuse:

• In general, individuals familiar to the victims perpetrate most sexual assaults.
• Females are more likely to be sexually abused within the family, and males are more likely to be sexually victimized by people outside of the family.
• Most women and children with sexual abuse histories are sexually victimized by family members or people known to them. Data obtained from a random sample of 930 adult women in San Francisco revealed that approximately 29% of the women had experienced interfamilial sexual abuse before the age of 18. Sixty percent of the women were abused by friends or acquaintances, and 11% were abused by strangers (Russell, 1983).
• Abuse by strangers is the least common type of sexual abuse
• The average duration of interfamilial sexual abuse is 4 years; whereas sexual abuse outside of the family is most commonly short-term.

IV. Most cases of child sexual abuse are NOT reported.

• Estimated underreported incidence of child sexual abuse ranges from 2 to 10 times the reported rate (Kercher & McShane, 1984).
• Most child sexual abuse involves coercion through secrecy and threats. The child is manipulated by the unequal power in the relationship. They do not disclose the abuse for fear of harm befalling themselves or loved ones (such as the non-offending parents).
• Children often do not have open lines of communication with parents to disclose the abuse. Many don't feel that their parents can or will protect them from the abuse.
• Adult victims of sexual assault do not report sexual abuse because of:
• Fear of retribution by perpetrator
• The stigma attached to being a victim of a sexual crime
• Fear of being blamed for the assault
• History of negative outcomes following past disclosures
• Fear of psychological consequence of disclosure (increased anxiety and depression) (Acierno, Resnick, & Kilpatrick, 1997).

V. Risk Factors for Sexual Abuse:

• Peak vulnerability for sexual abuse is between the ages of 9 and 12 (Finkelhor, 1987 ).
• Female gender: Women are at an increased risk for all forms of sexual victimization (whereas men are more likely to experience physical assault).
• Poor parental supervision
• Poor parent-child relationships, or parental attachments make children vulnerable to ploys of child molesters; these children are easier to manipulate.
• Residing with a stepfather at a young age
• Low income
• History of sexual assault is strongly associated with risk of future victimization. In fact, the most powerful predictor of adult sexual assault is childhood sexual victimization (Acierno et al., 1997). Two possible explanations for this are decreased ability to perceive danger in certain situations, and increased likelihood that victim will be targeted by perpetrator. Perpetrators generally choose victims who are less likely to defend themselves, or less competent at defending themselves.

VI. Symptoms that can result from sexual abuse:

40% of survivors of sexual abuse suffer aftereffects serious enough to require therapy (Courtois, 1988).

In Adults:

• Post-Traumatic Stress Disorder (PTSD) symptoms (i.e., a revisiting of traumatic event, avoidance of stimuli associated with trauma, hyper-vigilance).
• Low self-esteem
• Distrust of others: Many survivors of a sexual abuse have been betrayed by people they trusted such as primary caregivers.
• Anxiety & fear
• Depression
• Anger
• Self mutilation
• Interpersonal Problems
• Sexual difficulties
• Substance abuse (alcohol & drug abuse)
• Suicidal ideation/gestures
• Prostitution, promiscuity
• Eating disorders (also common in adolescents)

VII. Referral Information:

• The first question to ask: "Is the child/adult in danger?" (i.e., the child resides with perpetrator or the adult woman is living with or having frequent contact with an abusive partner). If so, report the abuse to Department of Human Services (DHS) immediately (in the case of minors) and/or refer the victim to a shelter/ crisis line (e.g., YWCA Crisis Services, (405) 943-7273; Women’s Resource Center, (405) 222-1818).
• If the victim is a minor, the situation MUST be reported to DHS. Identity can remain anonymous.
  To report child abuse or neglect, contact DHS at the following: in Oklahoma County: (405) 713-6800 Statewide: 1 (800) 522-3511.
• If psychological services are needed, contact:
• The Center for Child Abuse and Neglect (CCAN) at (405) 271-8858 is located in the Children's Hospital of OUHSC. CCAN is an excellent referral source for children with suspected histories of child abuse and/or neglect. CCAN also provides psychological services to children and families with child abuse concerns.
• The Helping Oklahomans Prepare for Emergency Stress (HOPES) project of CCAN provides psychological services for children who have experienced trauma. This program can be reached through CCAN's main number listed above.

VIII: Discussion Question:

Data obtained from a survey conducted in 1997 (Acierno, Resnick, and Kilpatrick, 1997) revealed that 10% to 15% of physicians have inquired about interpersonal violence during routine medical examinations. None of the physicians surveyed reported that they routinely assess sexual assault history with their patients. Fifty-five of the physicians reported that assessing histories of trauma might offend their patients. Fifty reported that they did not inquire about abuse history because they felt powerless about intervening effectively. 2/3 of the surveyed physicians reported that they had not seen a rape victim in the previous year. The authors of this study stated that this rate is suspect in light of incidence rates of interpersonal violence.

Do you think that inquiries about sexual/physical trauma histories should be included in a routine medical examination?

Helpful tip: If you are going to inquire whether a patient has a history of sexual abuse, you can do so in a way that conveys acceptance, empathy, normalization, and encouragement to seek help if necessary. For example: "Another type of stressful event that many women have experienced is unwanted sexual advances. Women don't always report these experiences to the police or other authorities or discuss them with family or friends. The person making the advances isn't always a stranger, but can be a friend, boyfriend, or even a family member. Such experiences can occur anytime in a woman's life- even as a child. Has anything like this ever happened to you?" Adapted from Acierno et al. (1997).

Behavioral & Physical Indicators of Possible Abuse in Children
	Physical Indicators	Other Indicators
Physical Abuse	unexplained bruises (in various stages of healing), welts, human bite marks, bald spots unexplained burns, especially cigarette unexplained fractures, lacerations or abrasions	self-destructive withdrawn and aggressive - behavioral extremes uncomfortable with physical contact arrives at school early or stays late as if afraid to be at home chronic runaway (adolescents) complains of soreness or moves uncomfortable wears clothing inappropriate to weather, to cover body
Physical Neglect	abandonment unattended medical needs consistent lack of supervision consistent hunger, inappropriate dress, poor hygiene lice, distended stomach, emaciated	regularly displays fatigue or listlessness, falls asleep in class steals food, begs from classmates reports that no caretaker is at home frequently absent or tardy self-destructive school dropout
Sexual Abuse	torn, stained or bloody underclothing pain or itching in genital area difficulty walking or sitting bruises or bleeding in external genitalia venereal disease frequent urinary or yeast infections	withdrawal, chronic depression excessive seductiveness role reversal, overly concerned for siblings poor self-esteem, self-devaluation, lack of confidence peer problems, lack of involvement massive weight change suicide attempts (especially adolescents) hysteria, lack of emotional control sudden school difficulties inappropriate sex play or premature understanding of sex threatened by physical contact promiscuity
Emotional Maltreatment	speech disorders delayed physical development substance abuse ulcers, asthma, severe allergies	habit disorders (sucking, rocking) antisocial, destructive neurotic traits (sleep disorders, inhibition of play) passive and aggressive - behavioral extremes delinquent behavior (especially adolescents) developmentally delayed

IX. Useful Links:

• Oklahoma Association of Youth Services, Inc. (www.oays.org)
• Youth, Family and Adult Services (http://www.okdhs.org/index.html)

X. References:

• Acierno, R., Resnick, H., & Kilpatrick, D. (1997). Health impact of interpersonal violence 1: Prevalence rates, case identification, and risk factors for sexual assault, physical assault, and domestic violence in men and women. Behavioral Medicine, 23(2), 53 -64.
• Courtois, C. (1988). Healing the incest wound: Adult survivors in therapy. New York: W.W. Norton & Company.
• Finkelhor, D. (1987). The sexual abuse of children: Current research reviewed. Psychiatric Annals, 17(4), 233-241.
• Kercher, G., McShane, M. (1984). The prevalence of child sexual abuse victimization in an adult sample of Texas residents. Child Abuse & Neglect, 8, 495-501.
• Russell, D. (1983). The incidence and prevalence of intrafamilial and extrafamilial sexual abuse of female children. Child Abuse & Neglect, 7(2), 133 -146.