OhioCanDo4Kids

Ten-Year Research Update Review: Child Sexual Abuse

FRANK W. PUTNAM, M.D.

ABSTRACT

Objective: To provide clinicians with current information on prevalence, risk factors, outcomes, treatment, and prevention of child sexual abuse (CSA).To examine the best-documented examples of psychopathology attributable to CSA. Method: Computer literature searches of Medline and PSYCInfo for key words. All English-language articles published after 1989 containing empirical data pertaining to CSA were reviewed. Results: CSA constitutes approximately 10% of officially substantiated child maltreatment cases, numbering approximately 88,000 in 2000. Adjusted prevalence rates are 16.8% and 7.9% for adult women and men, respectively. Risk factors include gender, age, disabilities, and parental dysfunction. A range of symptoms and disorders has been associated with CSA, but depression in adults and sexualized behaviors in children are the best-documented outcomes. To date, cognitive-behavioral therapy (CBT) of the child and a nonoffending parent is the most effective treatment. Prevention efforts have focused on child education to increase awareness and home visitation to decrease risk factors. Conclusions: CSA is a significant risk factor for psychopathology, especially depression and substance abuse. Preliminary research indicates that CBT is effective for some symptoms, but longitudinal follow-up and large-scale “effectiveness” studies are needed. Prevention programs have promise, but evaluations to date are limited. J. Am. Acad. Child Adolesc. Psychiatry, 2003, 42(3):269–278.

Childhood sexual abuse is a complex life experience, not a diagnosis or a disorder. An array of sexual activities is covered by the term child sexual abuse (CSA). These include intercourse, attempted intercourse, oral-genital contact, fondling of genitals directly or through clothing, exhibitionism or exposing children to adult sexual activity or pornography, and the use of the child for prostitution or pornography. This diversity alone ensures that there will be a range of outcomes. In addition, the age and gender of the child, the age and gender of the perpetrator, the nature of the relationship between the child and perpetrator, and the number, frequency, and duration of the abuse experiences all appear to influence some outcomes. Thus sexually abused children constitute a very heterogeneous group with many degrees of abuse about whom few simple generalizations hold. The outcomes summarized in this review are based on studies in which the majority of subjects experienced more severe forms of sexual abuse, generally including some form of child or adult genital contact.

EPIDEMIOLOGY OF CSA

Before the late 1970s, CSA was regarded as rare. In the following decades, the incidence—based on official statistics— increased dramatically (Finkelhor, 1984; U.S. Department of Health and Human Services, 1998). Although much of this apparent increase probably reflected a growing awareness among the public and professionals, some studies suggest that the overall incidence of child abuse and neglect increased. Using as official observers a variety of professionals who routinely came in contact with children, counting both reported and nonreported cases, the series of National Incidence Studies found a 67% increase (from 931,000 to 1,553,800 children) in all forms of child abuse from 1986 to 1993 (U.S. Department of Health and Human Services, 1996). Officially reported cases of CSA, however, declined during this same period (Atabaki and Paradise, 1999; Jones and Finkelhor, 2001). There is little agreement on reasons for this decline or whether it represents a decline in actual cases (Jones et al., 2001). In 2000 (most recent data available) CSA constituted approximately 10% of all officially reported child abuse cases and numbered approximately 88,000 substantiated or indicated cases, a 41% decrease from the peak estimate of 149,800 cases in 1992 (U.S. Department of Health and Human Services, Press Release, April 19, 2002).

Statistics on the prevalence of CSA are derived primarily from retrospective accounts by adults and can be roughly divided into studies using clinical versus nonclinical samples. It is not surprising that prevalence figures vary widely as a function of the selection and response rate, the definition used, and the method (e.g., self-report versus structured interview) by which an abuse history is obtained. Community samples typically range from 12% to 35% of women and 4% to 9% of men reporting an unwanted sexual experience prior to age 18 years. Adjusting for samplerelated variation, response rates, and differences in definitions across 16 cross-sectional community sample surveys, Gorey and Leslie (1997) calculated the prevalence of CSA as 16.8% for women and 7.9% for men.

Large community survey studies of the incidence and prevalence of CSA in children and adolescents are rare. The most comprehensive study to date is a telephone survey of 2000 children aged 10 to 16 years conducted by Finkelhor and Dziuba-Leatherman (1994). For the year preceding the interview, they found an incidence rate of 3.2% for girls and 0.6% for boys for contact CSA, defined as “…a perpetrator touching the sexual parts of a child under or over the clothing, penetrating the child, or engaging in any oral-genital contact with the child” (Finkelhor and Dziuba-Leatherman, 1994, p. 419). The lifetime prevalence rate for a combination of the attempted and completed CSA categories was 10.5% for the overall sample.

When they are available, rates of CSA in other countries are reasonably comparable with those found in the United States. A review of large sample population–based studies in 19 countries found a range of prevalence rates of 7% to 36% for females and 3% to 29% for males (Finkelhor, 1994). Female-to-male ratios were typically between 1.5:1 and 3:1. Across all the studies, only about half of victims had disclosed to anyone.

RISK FACTORS FOR CSA

CSA occurs across all socioeconomic and ethnic groups (Finkelhor, 1993). A number of factors, however, have been identified that increase risk for CSA.

Gender

Girls are at about 2.5 to 3 times higher risk than boys, although approximately 22% to 29% of all CSA victims are male (Fergusson et al., 1996b; Finkelhor, 1993; Sobsey et al., 1997; U.S. Department of Health and Human Services, 1998). Boys are underrepresented in psychiatric samples, especially older boys who may be reluctant to disclose or who may be shunted into the criminal justice
or substance abuse treatment systems. Research indicates that mental health professionals rarely ask adult males about childhood sexual abuse (Lab et al., 2000).

Age

Risk for CSA rises with age (Finkelhor, 1993; U.S. Department of Health and Human Services, 1998). Data from 1996 indicate that approximately 10% of victims are between ages 0 and 3 years. Between ages 4 and 7 years, the percentage almost triples (28.4%). Ages 8 to 11 years account for a quarter (25.5%) of cases, with children 12 years and older accounting for the remaining third (35.9%) of cases (U.S. Department of Health and Human Services, 1998). Some authorities believe that, as a risk factor, age operates differentially for girls and boys, with high risk starting earlier and lasting longer for girls.

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