• Vaginal intercourse

  - Example: A 7-year-old girl was placed in foster care by her father because she was incorrigible. She was observed numerous times "humping" her stuffed animals. In therapy she revealed that her father "humped" her. There was medical evidence of vaginal penetration.

• Anal intercourse

  - Example: Upon medical exam an 8-year-old boy was found to have evidence of chronic anal penetration. He reported that his father "put his dingdong in there" and allowed two of his friends to do likewise.

• Intercourse with animals.

Circumstances of Sexual Acts

Professionals need to be aware that sexual acts with children can occur in a variety of circumstances. In this section, dyads, group sex, sex rings, sexual exploitation, and ritual abuse will be discussed. These circumstances do not necessarily represent discrete and separate phenomena.

• Dyadic sexual abuse. The most common circumstance of sexual abuse is a dyadic relationship, that is, a situation involving one victim and one offender. Because dyadic sex is the prevalent mode for all kinds of sexual encounters, not merely abusive ones, it is not surprising that it is the most common.
  
• Group sex. Circumstances involving group sex are found as well. These may comprise several victims and a single perpetrator, several perpetrators and a single victim, or multiple victims and multiple offenders. Such configurations may be intrafamilial (e.g., in cases of polyincest) or extrafamilial. Examples of extrafamilial group victimization include some instances of sexual abuse in day care, in recreational programs, and in institutional care.
  
• Sex rings. Children are also abused in sex rings; often this is group sex. Sex rings generally are organized by pedophiles (persons whose primary sexual orientation is to children), so that they will have ready access to children for sexual purposes and, in some instances, for profit. Victims are bribed or seduced by the pedophile into becoming part of the ring, although he may also employ existing members of the ring as recruiters. Rings vary in their sophistication from situations involving a single offender, whose only motivation is sexual gratification, to very complex rings involving multiple offenders as well as children, child pornography, and prostitution.
  
• Sexual exploitation of children. The use of children in pornography and for prostitution is yet another circumstance in which children may be sexually abused.
  

• Child pornography. This is a Federal crime, and all States have laws against child pornography.¹⁹ Pornography may be produced by family members, acquaintances of the children, or professionals. It may be for personal use, trading, or sale on either a small or large scale. It can also be used to instruct or entice new victims or to blackmail those in the pictures. Production may be national or international, as well as local, and the sale of pornography is potentially very lucrative. Because of the availability of video equipment and Polaroid cameras, pornography is quite easy to produce and difficult to track.

  - Child pornography can involve only one child, sometimes in lewd and lascivious poses or engaging in masturbatory behavior; of children together engaging in sexual activity; or of children and adults in sexual activity.

  - It is important to remember that pictures that are not pornographic and are not illegally obscene can be very arousing to a pedophile. For example, an apparently innocent picture of a naked child in the bathtub or even a clothed child in a pose can be used by a pedophile for arousal.

• Child prostitution. This may be undertaken by parents, other relatives, acquaintances of the child, or persons who make their living pandering children. Older children, often runaways and/or children who have been previously sexually abused, may prostitute themselves independently.

  - Situations in which young children are prostituted are usually intrafamilial, although there are reports of child prostitution constituting one aspect of sexual abuse in some day care situations. Adolescent prostitution is more likely to occur in a sex ring (as mentioned above), at the hand of a pimp, in a brothel, or with the child operating independently. Boys are more likely to be independent operators, and girls are more likely to be in involved in situations in which others control their contact with clients.

• Ritual abuse. This is a circumstance of child sexual abuse that has only recently been identified, is only partially understood, and is quite controversial. The controversy arises out of problems in proving such cases and the difficulty some professionals have in believing in the existence of ritual abuse.

  - As best can be determined, ritual sexual abuse is abuse that occurs in the context of a belief system that, among other tenets, involves sex with children. These belief systems are probably quite variable. Some may be highly articulated, others "half-baked." Some ritual abuse appears to involve a version of satanism that supports sex with children. However, it is often difficult to discern how much of a role ideology plays. That is, the offenders may engage in "ritual" acts because they are sadistic, because they are sexually aroused by them, or because they want to prevent disclosure, not because the acts are supported by an ideology. Because very few of these offenders confess, their motivation is virtually unknown.

  - Often sexual abuse plays a secondary role in the victimization in ritual abuse, physical and psychological abuse dominating. The following is a nonexhaustive list of characteristics that may be present in cases of ritual abuse:

  • costumes and robes: animal, witch's, devil's costumes; ecclesiastical robes (black, red, purple, white);
    
  • ceremonies: black masses, burials, weddings, sacrifices;
    
  • symbols: 666, inverted crosses, pentagrams, and inverted pentagrams;
    
  • artifacts: crosses, athames (daggers), skulls, candles, black draping, representations of Satan;
    
  • bodily excretions and fluids: blood, urine, feces, semen;
    
  • drugs, medicines, injections, potions;
    
  • fire;
    
  • chants and songs;
    
  • religious sites: churches, graveyards, graves, altars, coffins; and
    
  • torture, tying, confinement, murder.

Most allegations of ritual abuse come from young children, reporting this type of abuse in day care, and from adults, who are often psychiatrically very disturbed and describe ritual abuse during their childhoods. Issues of credibility are raised with both groups. Moreover, accounts of ritual abuse are most disturbing, to both those recounting the abuse and those hearing it.

Scope of the Problem of Child Sexual Abuse

Clinicians and researchers working in sexual abuse believe that the problem is underreported. This belief is based on assumptions about sexual taboos and on research on adults sexually abused as children, the overwhelming majority of whom state that they did not report their victimization at the time of its occurrence. Moreover, it is probably true that situations involving female offenders as well as ones with boy victims are underidentified, in part because of societal perceptions about the gender of offenders and victims.

Estimates of the extent of sexual abuse come from three main sources – research on adults, who recount their experiences of sexual victimization as children; annual summaries of the accumulated reports of sexual abuse filed with child protection agencies; and two federally funded studies of child maltreatment entitled the National Incidence Studies. In addition, anecdotal information is supplied by some convicted/self-acknowledged offenders, who report sexually abusing scores and even hundreds of children before their arrest.

Prevalence of Child Sexual Abuse

Studies of the prevalence of sexual abuse are those involving adults that explore the extent to which persons experience sexual victimization during their childhoods. Findings are somewhat inconsistent for several reasons. First, data are gathered using a variety of methodologies: telephone interviews, face-to-face interviews, and written communications (i.e., questionnaires). Second, a study may focus entirely on sexual abuse, or sexual abuse may be one of many issues covered. Third, some studies are of special populations, such as psychiatric patients, incarcerated sex offenders, and college students, whereas others are surveys of the general population. Finally, the definition of sexual abuse varies from study to study. Dimensions on which definitions may differ are maximum age for a victim, the age difference required between victim and offender, whether or not noncontact acts are included, and whether the act is unwanted.

The factors just mentioned have the following effects on rates of sexual abuse reported. Face-to-face interviews, particularly when the interviewer and interviewee are matched on sex and race, and multiple questions about sexual abuse may result in higher rates of disclosure. However, it cannot be definitively stated that special populations such as prostitutes, drug addicts, or psychiatric populations have higher rates of sexual victimization than the general population, because some studies of the general population report quite high rates. Not surprisingly, when the definition is broader (e.g., inclusion of noncontact behaviors and "wanted" sexual acts) the rates go up.

Rates of victimization for females range from 6 to 62 percent,with most professionals estimating that between one in three and one in four women are sexually abused in some way during their childhoods. The rates for men are somewhat lower, ranging from 3 to 24 percent, with most professionals believing that 1 in 10 men and perhaps as many as 1 in 6 are sexually abused as children. As noted earlier, many believe that male victimization is more underreported than female, in part because of societal failure to identify the behavior as abusive. However, the boy himself may not define the behavior as sexual victimization but as sexual experience, especially if it involves a woman offender. Moreover, he may be less likely to disclose than a female victim, because he has been socialized not to talk about his problems. This reticence may be increased if the offender is a male, for he must overcome two taboos, having been the object of a sexual encounter with an adult and a male. Finally, he may not be as readily believed as a female victim.

The Incidence of Child Sexual Abuse

Incidence of a problem is defined as the number of reports during a given time frame, yearly in the case of sexual abuse. From 1976 to 1986, data were available on the number of sexual abuse cases reported per year to child protection agencies, as part of data collection on all types of maltreatment. These cases were registered with the National Center on Child Abuse and Neglect, and data were analyzed by the American Humane Association. Over that 10-year period, there was a dramatic increase in the number of reports of sexual abuse and in the proportion of all maltreatment cases represented by sexual abuse. In 1976, the number of sexual abuse cases was 6,000, which represented a rate of 0.86 per 10,000 children in the United States. By 1986, the number of reported cases was 132,000, a rate of 20.89 per 10,000 children. This represents a 22-fold increase. Moreover, whereas in 1976 sexual abuse cases were only 3 percent of all reports, by 1986, they comprised 15 percent of reports.

Striking though these findings may be, their limitations must be appreciated. First, current data are not available. Second, cases included in this data set are limited to those that would warrant a CPS referral, generally cases in which the abuser is a caretaker or in which a caretaker fails to protect a child from sexual abuse. Thus, cases involving an extrafamilial abuser and a protective parent are not included. Third, the data only refer to reported cases. This means those cases that are unknown to professionals and those known but not reported are not included. Moreover, these are reports, not substantiations of sexual abuse. The national average substantiation rate is generally between 40 and 50 percent. Substantiation rates vary from State to State and among locations.

The National Incidence Studies (NIS-1 and NIS-2) provide additional data on the rates of child maltreatment, including sexual abuse. Information for these studies was collected in 1980 and 1986; thus, they do not provide annual incidence rates, as the Child Protection data do. In addition, these studies project a national rate of child maltreatment based on information from 29 counties, rather than using reports from all States. Nevertheless, these studies do allow for some analysis of trends because data were collected at two different time points. Moreover, one of the most important features of the NIS studies is that they gathered information on unreported as well as reported cases.

Differences between the first and second studies indicate there was a more than threefold increase in the number of identified cases of sexual maltreatment.***** An estimated 42,900 cases were identified by professionals in 1980 compared with 133,600 cases in 1986. These figures represent a rate of 7 cases per 10,000 children in 1980 and 21 cases per 10,000 in 1986. Despite the fact that the 1986 number and rate are quite close to the figures for suspected sexual abuse reported to child protection agencies in 1986, only about 51 percent of cases identified by professionals in the National Incidence Study were reported to child protective services (CPS). Furthermore, the proportion of cases identified but not reported to CPS did not change significantly between 1980 and 1986.

It is clear that available statistics on the prevalence and incidence of sexual abuse do not completely reflect the extent of the problem. However, they do provide a definite indication that the problem of sexual victimization is a significant one that deserves our attention and intervention.

The Effects of Sexual Abuse on its Victim

Concern about sexual abuse derives from more than merely the fact that it violates taboos and statutes. It comes principally from an appreciation of its effects on victims. In this section, the philosophical issue of why society is concerned about sexual abuse and documented effects will be discussed.

What's Wrong About Sex Between Adults and Children?

It is important for professionals, particularly if they dedicate a substantial part of their careers to intervening in sexual abuse situations, to distance themselves from their visceral reactions of disgust and outrage and rationally consider why sex between children and adults is so objectionable.

Organizations such as the North American Man Boy Love Association (NAMBLA) and the René Guyon Society challenge the assertion that sexual abuse is bad because of its effects on children. These organizations argue that what we label as harmful effects are not the effects of sexual abuse but the effects of societal condemnation of the behavior. Thus, children feel guilty about their involvement, suffer from "damaged goods syndrome," have low self-esteem, are depressed and suicidal, and experience helpless rage because society has stigmatized sex between adults and children. If society would cease to condemn the behavior, then children could enjoy guilt-free sexual encounters with adults. Such organizations also argue that we, as adults, are interfering with children's rights, specifically their right to control their own bodies and their sexual freedom, by making sex between children and adults unacceptable and illegal.

How can we respond to this argument? It is true that many of the effects of sexual abuse at least indirectly derive from how society views the activity. However, the impact also reflects the experience itself. The reader will recall the earlier discussion of differentiating abusive from nonabusive encounters on the basis of power, knowledge, and gratification.

Because the adult has more power, he/she has the capacity to impose the sexual behavior, which may be painful, intrusive, or overwhelming because of its novelty and sexual nature. This power may also be manifest in manipulation of the child into compliance. The child has little knowledge about the societal and personal implications of being involved in sex with an adult; in contrast, the adult has sophisticated knowledge of the significance of the encounter. The child's lack of power and knowledge means the child cannot give informed consent. Finally, although in some cases the adult may perceive him/herself providing pleasure to the child, the main object is the gratification of the adult. That is what is wrong about sex between adults and children.

The Impact of Sexual Abuse

Regardless of the underlying causes of the impact of sexual abuse, the problems are very real for victims and their families. A number of attempts have been made to conceptualize the effects of sexual abuse. In addition, recent efforts to understand the impact of sexual abuse have gone beyond clinical impressions and case studies. They are based upon research findings, specifically controlled research in which sexually abused children are compared to a normal or nonsexually abused clinical population. There are close to 40 such studies to date.

Finkelhor, whose conceptualization of the traumatogenic effects of sexual abuse is the most widely employed, divides sequelae into four general categories, each having varied psychological and behavioral effects.

• Traumatic sexualization. Included in the psychological outcomes of traumatic sexualization are aversive feelings about sex, overvaluing sex, and sexual identity problems. Behavioral manifestations of traumatic sexualization constitute a range of hypersexual behaviors as well as avoidance of or negative sexual encounters.
  
• Stigmatization. Common psychological manifestations of stigmatization are what Sgroi calls "damaged goods syndrome" and feelings of guilt and responsibility for the abuse or the consequences of disclosure. These feelings are likely to be reflected in self-destructive behaviors such as substance abuse, risk-taking acts, self-mutilation, suicidal gestures and acts, and provocative behavior designed to elicit punishment.
  
• Betrayal. Perhaps the most fundamental damage from sexual abuse is its undermining of trust in those people who are supposed to be protectors and nurturers. Other psychological impacts of betrayal include anger and borderline functioning. Behavior that reflects this trauma includes avoidance of investment in others, manipulating others, re-enacting the trauma through subsequent involvement in exploitive and damaging relationships, and engaging in angry and acting-out behaviors.
  
• Powerlessness. The psychological impact of the trauma of powerlessness includes both a perception of vulnerability and victimization and a desire to control or prevail, often by identification with the aggressor. As with the trauma of betrayal, behavioral manifestations may involve aggression and exploitation of others. On the other hand, the vulnerability effect of powerlessness may be avoidant responses, such as dissociation and running away; behavioral manifestations of anxiety, including phobias, sleep problems, elimination problems, and eating problems; and revictimization.

Our understanding of the impact of sexual abuse is frustrated by the wide variety of possible effects and the way research is conducted. Researchers do not necessarily choose to study the same effects, nor do they use the same methodology and instruments. Consequently, a particular symptom, such as substance abuse, may not be studied or may be examined using different techniques. Furthermore, although most studies find significant differences between sexually abused and nonabused children, the percentages of sexually abused children with a given symptom vary from study to study, and there is no symptom universally found in every victim. In addition, often lower proportions of sexually abused children exhibit a particular symptom than do nonabused clinical comparison groups. Finally, although some victims suffer pervasive and debilitating effects, others are found to be asymptomatic.

In addition, a variety of factors influence how sexual maltreatment impacts on an individual. These factors include the age of the victim (both at the time of the abuse and the time of assessment), the sex of the victim, the sex of the offender, the extent of the sexual abuse, the relationship between offender and victim, the reaction of others to knowledge of the sexual abuse, other life experiences, and the length of time between the abuse and information gathering. For example, the findings for child victims and adult survivors are somewhat different.

It is important for professionals to appreciate both the incomplete state of knowledge about the consequences of sexual abuse and the variability in effects. Such information can be helpful in recognizing the wide variance in symptoms of sexual abuse and can prevent excessive optimism or pessimism in predicting its impact.

* When children are victims, sexual comments are usually made in person. However obscene remarks may be made on the telephone or in notes and letters.

** Activities in parenthesis are not illustrative of the sexual act being defined.

*** Sexual contact can be either above or beneath clothing.

**** The offender may inflict oral sex upon the child or require the child to perform it on him/her or both.

***** These statistics from the revised second National Incidence Study reflect the revised definition of child abuse and neglect, which includes the combined total children who were demonstrably harmed and threatened with harm.