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Introduction

     Child sexual abuse (CSA) is a serious violation of a child’s trust and safety, that has been associated with issues related to hygiene, developmental lags, altered arousal templates, intimacy disorders, and recidivism. Furthermore, disclosure of CSA may create extreme disruption within the family system that is affected. A child may face many barriers to the disclosure of abuse because of difficulties in communication as well as family dynamics, such as drug use, domestic violence, disbelief, and placing blame on the child for the occurrence of the sexual abuse.

     Thus, in consideration of the extreme toll that sexual abuse has on both the child and family, additional research is warranted. This paper will utilize a family systems approach and examine current literature concerning the: (1) underreporting; (2) perpetrator profile; (3) prevalence and risk factors; (4) the biological-psychological-social impacts that sexual abuse may have and; (5) prevention measures that may be implemented to reduce recidivism and protect our nation’s children from experiencing the trauma caused by sexual abuse.

What is CSA?
     The World Health Organization CSA is defined as “any activity of a sexual nature between a child and an adult or another child who by age or development is in a relationship of responsibility, trust, or power, the activity being intended to gratify or satisfy the needs of the other person” (“Child sexual abuse” - WHO., n.d.). However, much controversy still exists in the definition of CSA, as CSA may occur in a variety of ways and different mediums including: in person, online, forcing a child to watch pornographic material, and/or engaging in sexually explicit acts in the presence of a child.

Perpetrator Profile
     In consideration of the magnitude of CSA and the widespread trauma that can occur because of it, gives rise to the question; what causes an individual to become a sexual perpetrator? Vizard (2013) attempts to answer this question and reports that three developmental variables significantly increase an individual’s risk of becoming a perpetrator, they include: (1) past physical, sexual, and/or emotional abuse; (2) witnessing familial violence, such as domestic abuse and; (3) physical neglect. These findings provide evidence for the fact that a dysfunctional home environment and the failure to meet a child’s basic needs are significant risk factors for an individual to become a perpetrator. Thus, further intervention at all levels of society to address these issues are necessary to reduce the negative impact that CSA may have on survivors.

     When looking at different aspects of a perpetrator, it is necessary to identify what characteristics a perpetrator looks for in the children they choose to abuse. The Darkness to Light organization reports that there are several different factors that a perpetrator looks for in their target. Specifically, a perpetrator may look for children who are passive, quiet, troubled and lonely; the child of a single parent; or from a broken home. Additionally, a perpetrator may look for a child who is particularly trusting and work to establish a relationship with the child before abusing them. Lastly, it is not uncommon for the perpetrator to establish a trusting relationship with the survivor’s family as well (Child Sexual Abuse Statistics, n.d.).

     Current literature shows that are a significantly higher number of male perpetrators, in comparison to females; as (Negriff, Schneiderman, Smith, Schreyer, & Trickett, 2014) report that in a sample of CSA survivors, 91.7% were victimized by males, whereas only 21.7% were victimized by females. However, some differences between genders exist in regards to the demographic factors of the crime. Specifically, females are more likely to: (1) be younger; (2) abuse older male children and adolescents; (3) are less likely to be a stranger to the survivor and; (4) more likely to be in a position of authority over the child, in comparison to males (Bourke, Doherty, Mcbride, Morgan, & Mcgee, 2013).

     Individuals can become perpetrators at any age, as (Macmillan, Tanaka, Duku, Vaillancourt, & Boyle, 2013) report that perpetrators in childhood are often younger than 18. The National Center for Victims of Crime support this finding and report that 23% of offenders are under the age of 18 (Statistics on Perpetrators of CSA, n.d.). Furthermore, perpetrators of CSA are often known to the survivor. Specifically, 60% of CSA cases are perpetrated by a person that the child trusts, such as a friend, family member or adult in a position of authority (Statistics on Perpetrators of CSA, n.d.). This fact is alarming, as close relationships with the perpetrator have been associated with poorer recovery outcomes in part because of the additional trauma caused by the betrayal of that individual (Edwards, Freyd, Dube, Anda, & Felitti, 2012).

     Unfortunately, CSA perpetrated by a church pastor or clergy member is an all too common occurrence. When this occurs, the perpetration is not only a betrayal of the family and child’s trust, but the church congregations as well. Furthermore, these perpetrators seem to know when a child, particularly boys, in the church congregation are questioning their sexuality, and they hone in on this fact when they choose their target. Lastly, when CSA does occur within the church, the parents often try to keep the abuse quiet, but will make every attempt to have that clergy member moved from their position of authority in the church (B. Maas, personal communication, October 25th, 2016).

Underreporting
     It is important to realize that a child may face many barriers to the disclosure of CSA. Examples of which include, shame, fear, or if the perpetrator is a family member, the child may fail to disclose to “protect” the family unit. Frías, & Erviti, (2014) assert that there are three main reasons that boys tend to underreport; (1) if the perpetrator is male, boys are fearful of being labeled as gay; (2) if the perpetrator is female, boys may view the abuse as a “sexual initiation” that is culturally accepted and; (3) perpetrators tend to use more threats of violence to prevent boys from reporting than with girls. Conversely, the reasons for girls failing to disclose include; (1) feelings of embarrassment, dirtiness, and guilt; (2) fear of not being believed and; (3) believing that they would be admonished more so than males.

     In the event that the perpetrator is the mom’s boyfriend or step-dad and the survivor is a girl, mothers get mad at the child because they are convinced that their child hypersexualized themselves in an attempt to “steal” the partner away from mom. This is especially true with preteen girls. When minors disclose CSA to me, it is often by accident [because I am a mandatory reporter]. The child doesn’t want to deal with the aftermath, parents overloading them with questions, and possible blame. Unfortunately, the criminal justice system is also a significant barrier (B. Maas, personal communication, October 25th, 2016).

Prevalence & Risk Factors
     In a discussion of CSA (Collin-Vézina, Daigneault, & Hébert, 2015) assert that the prevalence is likely much higher than reported by current literature for a variety of reasons including, ethnicity, religious beliefs, and the age of sexual consent in different countries throughout the world. Despite these confounds, (Barth, Bermetz, Heim, Trelle, & Tonia, 2012) conduct a meta-analysis of 55 different studies from 24 different countries looking at the prevalence of CSA. The researchers report that prevalence estimates range from 8 to 31% for girls; 3 to 17% for boys, and report that 9 girls and 3 boys out of 100 are survivors of forced intercourse.

     Finkelhor, Shattuck, Turner, & Hamby, (2014) attempt to discern the prevalence of CSA and the effect of age among a sample of late adolescent youth in the United States. The authors report that the lifetime prevalence of CSA of 15 year olds within this study was 16.8% for girls and 4.3% for boys. Moreover, the researchers report that late adolescence may be a possible risk factor for CSA. Specifically, for males and females, age 17, the rate of CSA increased to 5.1% for males, and 26.6% for females. Finally, current research reports an additional effect of age and the perpetrator; that is, the younger a child is, the more likely the perpetrator is a family member (Child Sexual Abuse Statistics, n.d.).

     In a study of siblings, (Macmillan et al., 2013) found that if one child reported physical or sexual abuse, the sibling of that child faced an increased risk of experiencing both types of abuse as well. In addition, the researchers report that the children of young mothers living in a low socioeconomic, urban area appear to be at increased risk of experiencing CSA. Moreover, the researchers note that although physical abuse was more likely to occur from the parent(s) of the child, the same was not true for sexual abuse. Specifically, the participants in this study were 2 times more likely to report that a sibling was the perpetrator of CSA. Lastly, the researchers report that these findings indicate the necessity for clinical evaluations to consider sibling relationships while screening for CSA.

     Sexual orientation appears to be a risk factor for CSA. Such that, even as children, LGBT individuals face an increased risk of experiencing abuse. Zou, & Andersen, (2015) reviewed the rates of CSA of LGBT children and compared them to that of heterosexual children. Their results showed that: (1) heterosexual women reported lower rates of CSA than bisexual women (22.7% vs 31%); (2) heterosexual men were less likely to report experiencing CSA than gay men (6.8% vs. 29.7% and; (3) gay men were more likely to report experiencing CSA than both heterosexual and bisexual men (Zou & Andersen, 2015).

     Ethnic background may also serve as a risk factor. In a national study concerning the prevalence of CSA, (Pérez-Fuentes, Olfson, Villegas, Morcillo, Wang, & Blanco, 2013) report that individuals who reported CSA were more likely to be Black or Native American than Caucasian or Asian. Furthermore, the authors note that there are three risk factors that appear to increase a child’s risk of experiencing sexual abuse; (1) a history of physical abuse or neglect; (2) parental psychopathology and; (3) low family support. Lastly, other risk factors include parents with substance use disorders, witnessing domestic violence, and/or having an absent parent before the age of 18 (Pérez-Fuentes et al., 2013).

Biological-Psychological-Social Impact
     Sexual trauma, at any age, is traumatic. However, if a child or adolescent experiences CSA, it may be even more traumatic, because of the extreme vulnerability witnessed in this age group (Pérez-Fuentes et al., 2013). Specifically, study participants who experienced CSA were almost 3 times more likely to experience a psychiatric disorder, such as bipolar disorder, depression and PTSD; and almost 8 times more likely to report a suicide attempt than those who did not (Pérez-Fuentes et al., 2013).

     Sexual abuse carries a heavy toll on children and adolescents in all areas of development. When CSA occurs at a young age, it changes a child’s arousal template and oftentimes leads to earlier masturbation, sexual intercourse, etc. Other effects include; developmental lags (e.g. speech), serious hygiene issues (excessive cleanliness or complete lack of hygiene), STI’s UTI’s, depression, anxiety, sex addiction, and intimacy disorders (B. Maas, personal communication, October 25th, 2016). In addition, (Collin-Vézina, Daigneault, & Hébert, 2013) report that children who have been sexually abused are more likely to present behavior problems, such as inappropriate sexualized behavior. Moreover, as teenagers they are more likely to exhibit conduct problems, engage in risky sexual behavior, adopt self-harming behaviors and develop substance use disorders (Collin-Vézina et al., 2013).

     CSA may negatively affect an individual throughout adulthood. Specifically, survivors of CSA face an increased risk of sexual revictimization, and may become perpetrators themselves if they never seek treatment for their trauma (Hornor, & Fischer, 2016; Vizard, 2013). Moreover, a survivor of CSA may experience: (1) difficulties in maintaining a healthy intimate partner relationship; (2) increased substance use; (3) communication problems; (4) anger, anxiety and low self-esteem; (5) feelings of loneliness, guilt, shame, and isolation and; (6) sexual identity concerns (Payne, Galvan, Williams, Prusinski, Zhang, Wyatt, & Myers, 2014; Berthelot, Godbout, Hébert, Goulet, & Bergeron, 2013). Given these findings, early intervention and treatment to address the mental and emotional trauma that may be caused by CSA is vital for a survivor’s well-being throughout the lifespan.

Family Systems Theory
     In order to understand what a family system is, several key terms and concepts must be understood: (1) a family is hierarchical, or divided into different groups based on the person's authority within the family; (2) family systems strive to achieve homeostasis, or a balance when conflicts arise; (3) morphostasis, or the ability of the family to maintain organizational consistency despite challenges over time; (4) morphogenesis, the system’s ability to grow and adapt over time to meet the needs of the family and; (5) feedback loops, the positive or negative channels of communication and interaction that move the family to morphostasis or morphogenesis (Charles & Rutherford, n.d.).

     Brown, (1999) states of the basic tenets of family systems theory is that a two-person system is unstable because the system handles minimal conflict before the involvement of a third individual. Therefore, the smallest stable unit of a family is a triangle, with the family system itself being a series of interconnected triangles; or in layman’s terms, the family system is an interconnected network of individuals and the subsystems to which they belong. If the amount of conflict is too high for one triangle to contain, it is spread throughout the interconnected triangles; effectively stabilizing, but not resolving the conflict. In other words, when conflict overwhelms one family subsystem, its effects are felt throughout the rest of the system. Because the effects of conflict are felt throughout the system; the entire system must work together to restore equilibrium. 

CSA Disclosure & The Family System
     Disclosure of CSA within the family system is an incredibly complex event that affects all individuals in the family unit. Unfortunately, this effect is even more pronounced if the perpetrator is a family member. When a perpetrator is a family member, disclosure throws the entire system into a state of disequilibrium. This may carry a negative impact on the organizational structure of the system, and the family may never again achieve morphogenesis, because one or more subsystems refuse to accept the disclosure of CSA.

      Parental reaction to disclosure is perhaps the most important factors for the system to regain homeostasis. Specifically, if a positive feedback loop occurs, a child can receive help and regain their feelings of safety and security. Conversely, if a negative feedback loop occurs, a child may: (1) be blamed for the occurrence of the abuse; (2) blame themselves for the occurrence of CSA and; (3) never seek the help that they need to recover from their trauma.

     Disclosure of CSA sends a shockwave throughout the entire family system; and can be extremely traumatic for the parent as well as the child. If the parent subsystem is experiencing feelings of self-blame, anger, and confusion, it may lead to the creation of a negative feedback loop between the parent and child subsystem. This, in turn, may have a negative impact on the child’s recovery. Thus, for the child to fully heal from their experience, it is vital that both the parent and child receive help at the same time (B. Maas, personal communication, October 25th, 2016; Toledo & Seymour, 2013).

CSA Prevention
     Because the family and community play a pivotal role in child-rearing, intervention strategies should be focused at both the micro and mezzo level. More specifically, parents should teach and reinforce the importance of areas that are “off limits” for anyone besides their own self to touch. Furthermore, parents should teach their children the difference between “good” and “bad” touch. Children, by their nature, are very curious and trusting, so teaching a child the proper boundaries with other individuals may serve as a powerful protective factor against CSA (B. Maas, personal communication, October 25th, 2016).

     Mendelson, & Letourneau, (2015) state that, parent-focused prevention has been largely ignored in research up to this point in time, and argue that this approach is the logical next step for research to take. The researchers believe that parents are an effective target of intervention, because they carry a considerable amount of influence on child behavior. Therefore, the goal of behavioral family intervention is to increase the effectiveness of parent-child relationships by promoting parent warmth, and appropriately firm control of the child.

     In addition, the researchers report that positive family communication concerning sexual behavior presents parents with the opportunity to discuss CSA and prevention measures with their children. The researchers note that a benefit of this approach is that parents can repeat this process at different stages of a child’s development, matching the information provided with the child’s readiness to receive such information. Because most cases of CSA are perpetrated by individuals known to the child, and not “the stranger in the bushes”, the researchers in this study also highlight the importance of increased education regarding the different risk factors, signs and symptoms to protect against CSA (Mendelson & Letourneau, 2015).

     In a discussion regarding the prevention of CSA, (Collin-Vézina, Daigneault, & Hébert, 2015) report that there are two prevention measures that have been studied at great length: (1) offender management, an approach which monitors known perpetrators via, background checks, registries or lengthier prison sentences and; (2) universal education programs aimed at the potential targets of CSA. In addition, the researchers note that while the public tends to approve of the offender management approach, it is ineffective as a prevention measure, because it is based on a misconception. Specifically, it is based on the belief that all offenders are “pedophiles;” when, in reality the perpetrator profile is subject to wide variation.

     Therefore, (Collin-Vézina et al., 2015) assert that universal education programs are more effective because they are (1) cost-effective; (2) easy to implement and; (3) accessible to a wide audience while avoiding the stigmatization of a certain population. Additionally, the researchers state these programs are most effective when they: (1) are longer in duration; (2) use repetition; (3) provide children with opportunities to practice what they learned and; (4) use concrete concepts. However, the authors state that further research and adaptations are necessary for the program to be effective with some lower SES and ethnic minority individuals (Collin-Vézina et al., 2015). Lastly, the authors emphasize that an educational approach is not the only solution and promote the use of a multifactorial approach to address a social problem as complex as CSA.

Conclusion 

     In summary, CSA occurs in many different forms and can be carried out in a variety of different ways ranging from voyeurism to forced sexual intercourse. In addition, perpetrators: (1) may be a person the child knows; (2) exist in all age groups and; (3) differ widely from one to the other. While this reality is incongruent with commonly held stereotypes, one factor remains consistent; a power-differential exists between the perpetrator and child survivor. CSA is widely underreported for a multitude of reasons that range from fear of not being believed, to fearing the threat of severe bodily harm and/or death.

     Many individuals are unaware of the true prevalence of CSA in our society. Current research reports that up to one-third of children may experience CSA in their lifetime and; that girls appear to face an increased risk of CSA in comparison to boys. However, it is likely that males and females experience CSA at similar rates, but males may fail to disclose their CSA because of the social stigma surrounding their gender and sexual abuse.

     Many other risk factors for CSA exist. Specifically, research shows that factors such as: (1) low socioeconomic status; (2) parental substance use and; (3) sexual orientation may increase an individual’s risk of experiencing CSA. Moreover, children who have experienced CSA are more likely to express inappropriate sexualized behavior, and engage in self-harm. Similarly, CSA survivors are more likely to attempt suicide and experience a mental health disorder, such as depression, and PTSD. Altogether, these findings indicate that increased access for a survivor to different mental health services is paramount to their overall well-being throughout their lifespan.

     Furthermore, CSA affects not only the survivor, but the family unit as well. The acceptance or denial of disclosure may bring a family closer, or rip them apart entirely. Research shows that parental reactions to disclosure of CSA may affect the child’s recovery in different ways. Specifically, acceptance of CSA has been associated with decreased levels of self-blame, and more positive mental health outcomes, whereas, denial has been associated with an increased severity of mental health disorders and higher levels of self-blame. Finally, if acceptance of disclosure occurs, it is critical for the parent and child to receive help at the same time.

     Many different prevention programs for CSA exist. However, the efficacy of these programs differ widely from one another. Specifically, programs that adopt an “offender management” approach appear to be less effective than the universal education approach. Research purports that this difference is caused by the fact that the first is based on the misconception that perpetrators are strangers to the child, whereas the second educates both the parents and children to the fact that offenders are more likely to have a relationship with the child, and that perpetrator profiles vary widely.
Although, these two intervention measures differ from one another; researchers caution against adopting a single approach, as a social problem as complex as CSA requires intervention at different system levels to be effective. In conclusion, it is evident that further education at all levels of society is necessary to bring increased awareness to the problem of CSA. Ultimately, both awareness and education are the only effective measures in existence that will dispel the many myths and stereotypes surrounding CSA, and enable a survivor to move on, to heal and to grow from their experience.  

 

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