Child sexual abuse (CSA) refers to the use of children in sexual activities when, because of their immaturity and developmental level, they cannot understand or give informed consent. A wide range of activities is included in sexual abuse, including contact and noncontact activities. Contact activities included are sexualized kissing, fondling, masturbation, and digital and/or object penetration of the vagina and/or anus, as well as oral-genital, genital-genital, and anal-genital contact. Noncontact activities include exhibitionism, inappropriate observation of child (eg, while the child is dressing, using the toilet, bathing), the production or viewing of pornography, or involvement of children in prostitution.
The sexual activities are imposed on the child and represent an abuse of the caregiver’s power over the child. The sequence of activities often progresses from noncontact to contact over a period of time during which the child’s trust in the caregiver is misused and betrayed.
Since the mid 1970s, health care professionals have paid serious attention to sexual abuse of children. Despite the recognition of the clinical importance of sexual abuse of children, some pediatricians may not feel adequately prepared to perform medical evaluations. However, pediatricians are often in trusted relationships with patients and families and are in an ideal position to offer essential support to the child and family. Thus, pediatricians need to be knowledgeable about available community resources, such as consultants and referral centers for the evaluation and treatment of sexual maltreatment. Several paradigms have been proposed to help professionals understand the events that surround the sexual maltreatment of children.
Preconditions for sexual abuse
- Motivation of perpetrator: The perpetrator is willing to act on impulses associated with sexual arousal related to children.
- Overcoming internal inhibitions: The perpetrator ignores internal barriers against sexually abusing children.
- Overcoming external inhibitions: The perpetrator is able to bypass the typical barriers in the caregiving environment that normally serve to impede the sexual misuse of children.
- Overcoming child resistance: The perpetrator is able to manipulate the child to the point of involving the child in the sexual activity. Manipulation often involves either implicit or explicit coercion to ensure that the child keeps the inappropriate activities a secret.
Longitudinal progression of sexual abuse
- Engagement: The perpetrator begins relating to the child during nonsexual activities to gain the child’s trust and confidence.
- Sexual interaction: The perpetrator introduces sexual activities into the relationship with the child; the perpetrator often begins with noncontact types of activities and, over time, progresses to more invasive forms of contact activities.
- Secrecy: The perpetrator attempts to maintain access to the child and to avoid disclosure of the abuse by coercing the child to keep the activities hidden. Coercion to keep the secret can be explicit (eg, threatening the child or the child’s family’s safety) or it can be implicit (eg, manipulation of the child’s trust to create a fear of losing the “friendship” or “attention” should the truth become known to others).
- Disclosure: Sexual abuse can become known to others either accidentally, when a symptom from the maltreatment or a third party witnessing the abuse leads to an evaluation, or can be purposeful, as when the child reveals the abuse that is taking place and seeks help.
- Suppression: The tumult that occurs after the disclosure prompts the people in the child’s caregiving environment to think that they are unable to support the child; thus, these people exert pressure on the child to recant what the child has told in order to go back to the perceived “stable” situation that existed prior to the disclosure.
Sexual abuse typically presents as a pattern of maltreatment that occurs over time. Children or their families usually know the perpetrators, because they often are either relatives or acquaintances.
Traumagenic dynamics model
- Traumatic sexualization: The child’s sexual feelings and attitudes are shaped in a developmentally inappropriate and interpersonally dysfunctional manner. The child learns that sexual behavior may lead to rewards, attention, or privileges. Traumatic sexualization may also occur when the child’s sexual anatomy is given distorted importance and meaning.
- Betrayal: The child learns that a trusted individual has caused him or her harm, misrepresented moral standards, or failed to protect him or her properly.
- Powerlessness: This is a process of disempowerment in which the child’s sense of self-efficacy and will are consistently thwarted by the perpetrator’s coercion and manipulation. The child manifests symptoms of fear, anxiety, and impaired coping.
- Stigmatization: The child’s self-image incorporates negative connotations and is associated with words such as bad, awful, shameful, and guilty. This stigmatization is consistent with the “damaged goods” mentality originally described by Sgroi et al (1982), in which the child feels deviant and not as whole as he or she felt prior to the abuse.
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