Professionals conservatively use child sexual abuse prevalence estimates of 20% in women and 5-10% in men. A classic prevalence study of New England male and female college students done by Finkelhor (1984), which used a definition that included both contact and noncontact abuse with older perpetrators and children younger than 17 years, revealed that 19.2% of female students (1 in 5 women) and 9% of male students (1 in 10 men) reported sexual misuse during their childhoods. These figures are believed to be conservative estimates; other studies using different methodologies support using these figures as reasonable prevalence estimates. Analysis by various experts of 16 prevalence studies of nonclinical North American samples supports setting the upper end of prevalence figures at about 17% for women and 8% for men.
According to the US Federal Government’s official report, Child Maltreatment 2006, approximately 905,000 children were determined to be victims of child abuse; the overall child maltreatment rate was 12.1 cases per 1,000 children. Of these, about 8.8%, or close to 80,000, represented cases of sexual abuse that were substantiated by child protective services (CPS) for a child sexual abuse rate of 1.1 cases per 1,000 children. Overall, in 2006, the 905,000 substantiated cases emerged from approximately 3.3 million reports of alleged child abuse and neglect, involving about 6 million children. In addition to the 8.8% of substantiated cases of sexual abuse, an additional 16% were substantiated for physical abuse, and 64.1% were substantiated for child neglect.
In 2009, release of the Fourth National Incidence Study of Child Abuse and Neglect (NIS-4) is expected and eagerly awaited. The NIS-4 was mandated by the Keeping children and Families Safe Act of 2003 (P.L. 108-36) and aims to estimate the most current national incidence, severity and demographic distribution of child abuse and neglect in the United States. The NIS-4 will collect data from a nationally representative sample of 122 counties.
Prior to the NIS-4’s release, older data remain available from the previously congressionally mandated Third National Incidence Study of Child Abuse and Neglect (NIS-3). In 1993, this study reported an estimated sexual abuse incidence rate of 3.2 cases per 1000 children (or a total of 217,000);7 this represented 29% of the total number of children known to have been abused. NIS-3 used a definition that subsumed a range of behaviors, including intrusion, genital molestation, exposure, inappropriate fondling, and unspecified sexual molestation.
At present, the NIS-3 is the single most comprehensive source of information about the current incidence of child abuse and neglect in the United States and is based on a nationally representative sample. At best, the incidence is an underestimate; however, the cases counted are only those occurrences known to professionals and do not include incidents of sexual abuse that have not been disclosed. With sexual abuse, the number of undisclosed incidents is believed to be large due to the stigma and criminal behavior involved.
The 1993 NIS-3 incidence figure of 3.2 cases per 1000 children represents a statistically significant (68%) increase from the 1986 Second National Incidence Study of Child Abuse and Neglect (NIS-2) incidence of 1.9 per 1000 children. In part, this difference is due to increased recognition of sexual abuse in the pediatric population. Finkelhor and Jones (2008) at the Crimes Against Children Research Center have been tracking the trends in child maltreatment statistics collected by the Federal Government and have found a national decline in the incidence of both physical and sexual abuse that began in the middle the 1990s and continues through the early 2000s. However, no decline was found in the rate of child neglect. Specifically, child sexual abuse substantiations have seen a 53% downward trend from the peak annual incidence observed in 1992 From2005-2006,substantiated child sexual abuse cases declined 5%.
Finkelhor and Jones have explored the potential reasons for the decline in child sexual abuse cases and have focused on factors that may be impacting the actual incidence as well as factors that may be influencing the reporting and investigation of reported cases, which may then downstream impact the number of substantiated cases
Optimistically, prevention efforts, incarceration, and treatment of perpetrators (along with other societal factors) may actually be decreasing the number of children who are harmed by sexual abuse. On the other hand, more pessimistically, fears of lawsuits and retribution, higher thresholds set for investigation and substantiation, and changes in policies and procedures may be changing the numbers but not impacting the actual amount of children under abuse.
No consensus has been reached about what may be causing the steady decline; Finkelhor and Jones draw attention to the idea that factors such as increasing economic prosperity, increasing numbers of agents of social intervention, and increasing availability of highly effective psychiatric medications may very well be leading to a decline in incidence with a resultant decline in substantiations.
Numerous psychological and medical consequences have been described as associated with sexual abuse. Psychological disorders are reported as having an increased incidence in those who have been abused sexually and include depression, eating disorders, anxiety disorders, substance abuse, somatization, posttraumatic stress disorder (PTSD), dissociative disorders, psychosexual dysfunction in adulthood, and numerous interpersonal problems, including difficulties with issues of control, anger, shame, trust, dependency, and vulnerability.
PTSD and its relationship to sexual abuse have received considerable professional attention. The diagnosis of PTSD in the context of sexual abuse requires the occurrence of maltreatment and (1) frequent reexperiences of the event via intrusive thoughts and/or nightmares; (2) avoidance behavior and a sense of numbness toward common events; and (3) increased arousal symptoms, such as jumpiness, sleep disturbance, and/or poor concentration. Note that no universal short-term or long-term impact of sexual abuse has been identified, and the presence or absence of various symptoms or conditions does not indicate nor disprove the occurrence of sexual abuse.
Medical sequelae of sexual abuse include numerous medical conditions, including functional GI disorders (eg, irritable bowel syndrome, dyspepsia, chronic abdominal pain), gynecologic disorders (eg, chronic pelvic pain, genital or anal tears), and various forms of somatization involving neurologic conditions and pain syndromes. Additionally, children may contract STDs via sexual abuse, and postpubertal females may become pregnant.
In groundbreaking work, Felitti et al have explored the connection of exposure to childhood abuse and household dysfunction to subsequent health risks and the development of illness in adulthood in a series of studies referred to as the Adverse Childhood Experiences (ACE) studie s. Of 13,494 adults who completed a standard medical evaluation in 1995 and 1996, 9,508 completed a survey questionnaire that asked about their own childhood abuse and exposure to household dysfunction; the investigators then made correlations to risk factors and disease conditions.
In order to assess exposure to child abuse and neglect, the ACE questionnaire asked about categories of child maltreatment, specifically psychological, physical, and sexual abuse. When asking about sexual abuse, the questionnaire asked the patients if an adult or person at least 5 years older then had ever (1) touched or fondled them in a sexual way; (2) made them touch the adults or older person’s body in a sexual way; (3) attempted oral, anal, or vaginal intercourse with them; or (4) actually had oral, anal, or vaginal intercourse with them. In order to assess exposure to household dysfunction the ACE questionnaire asked questions by category of dysfunction, such as having a household member who had problems with substance abuse (eg, problem drinker, drug user), mental illness (eg, psychiatric problem), or criminal behavior (eg, incarceration) and having a mother who was treated violently.
In addition to the questionnaire information, the standardized medical examination of the adult assess risk factors and actual disease conditions. The risk factors included smoking, severe obesity, physical inactivity, depressed mood, suicide attempts, alcoholism, any drug abuse, a high lifetime number of sexual partners, and a history of STDs. The disease conditions included ischemic heart disease, cancer, stroke, chronic bronchitis, emphysema, diabetes, hepatitis, and skeletal fractures. Once all of the data were collected and analyzed, Felitti et al reported that the most prevalent ACE was substance abuse (25.6%), the least prevalent ACE was criminal behavior (3.4%), and the prevalence of sexual abuse was 22%. In total, 52% of the respondents to the questionnaire had one or more exposure, and 6.2% of respondents had 4 or more exposures. The following were findings in respondents who experienced 4 or more ACEs compared with those who had none:
- Risk of alcoholism, drug abuse, depression, and suicide attempt increased 4-12 fold
- Rates of smoking, poor self-rated health, and high number of sexual partners and STDs increased 2-4 fold
- Physical inactivity and severe obesity increased 1.4-1.6 fold
The major finding of the ACE studies was a graded relationship between the number of exposures to maltreatment and household dysfunction during childhood to the presence in later life of multiple risk factors and several disease conditions associated with death in adulthood. graphically depicts the hypothesized connection between ACEs and later risk-taking behaviors and the development of life-threatening conditions.
No race differences emerged from the 1993 NIS-3 data. This initially may be surprising due to the disproportionate overrepresentation of children of color who are involved with the child welfare system. NIS-3 data were consistent with the 1986 NIS-2 findings, which also failed to demonstrate any evidence of disproportionate victimization in relationship to children’s race. Finkelhor has concluded that race, ethnicity, and social class do not appear to be associated with risk of child sexual maltreatment.
Gender differences are noted in the reported incidence of sexual abuse. In the NIS-3, a statistically significant difference was noted, with girls experiencing sexual abuse at more than 3 times the rate of boys (4.9 per 1000 girls compared with 1.6 per 1000 boys). Child Maltreatment 2006 did not separately report the number of sexual abuse cases by gender. However, Douglas and Finkelhor have conducted extensive studies on child sexual abuse incidence rate trends; they conclude that the overwh lming majority of rigorous studies report a higher incidence of sexual abuse among girls, with females typically representing 78-89% of cases.
Age differences are observed in the reported incidence rates of sexual abuse for children aged 0-2 years (incidence is 1 per 1000) compared with children aged 12-14 years (incidence is 2.6 per 1000) and children aged 15-17 years (incidence is 2.7 per 1000). Incidence rates of sexual abuse in children aged 3-11 years widely varied and made the statistical comparisons unreliable. Of the approximately 78,000 children for whom age data are reported in Child Maltreatment 2006, the age breakdown shows that 6% of children who were sexually abused were younger than 4 years, 22% were aged 4-7 years, 23% were aged 8-11 years, and 47% were aged 12 years or older.
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