Childhood Sexual Abuse (CSA)

The definition of childhood sexual abuse (CSA) from Estimating a Child Sexual Abuse Prevalence Rate for Practitioners: A Review of Child Sexual Abuse Prevalence Studies is described as follows:

Any sexual act between an adult and a minor or between two minors when one exerts power over the other. Child sexual abuse includes forcing, coercing or persuading a child to engage in any type of sexual act. This includes sexual contact as well as non-contact acts such as exhibitionism, exposure to pornography, voyeurism and communicating in a sexual manner by phone or internet with a child is inappropriately exposing or subjecting the child to sexual contact, activity, or behavior. Sexual abuse includes oral, anal, genital, buttock, and breast contact. It also includes the use of objects for vaginal or anal penetration, fondling, or sexual stimulation. This sexual activity may be with a boy or a girl and is done for the benefit of the offender. In addition, exploitation of a child for pornographic purposes, making a child available to others as a child prostitute, and stimulating a child with inappropriate solicitation, exhibitionism, and erotic material are also forms of sexual abuse. All sexual activity between an adult and a child is sexual abuse. Sexual touching between children can also be sexual abuse. Sexual abuse between children is often defined as when there is a significant age difference (usually 3 or more years) between the children, or if the children are very different developmentally or size-wise. Sexual abuse does not have to involve penetration, force, pain, or even touching. If an adult engages in any sexual behavior (looking, showing, or touching) with a child to meet the adult’s interest or sexual needs, it is sexual abuse (Townsend & Rheingold, 2013, p. 26).

In 2013, there were 60,956 CSA cases reported (US Department of Health & Human Services, 2015). In the article Estimating a Child Sexual Abuse Prevalence Rate for Practitioners: A Review of Child Sexual Abuse Prevalence Studies, six studies were examined to suggest an overall full-childhood sexual abuse prevalence rate of 7.5% – 11.7%. These studies suggest the child sexual abuse prevalence rate for girls is 10.7% to 17.4% and the rate for boys is 3.8% to 4.6% (Townsend & Rheingold, 2013). The study’s subjects were adolescents between the ages of 14 and 17 (Townsend & Rheingold, 2013). However, adolescents providing data for a study have not yet experienced a full childhood in which they might have been abused, which may be a limitation or an under-reporting. This could mean that child self-report studies that collect and report data from a wide array of ages understate prevalence rates (Planty, Berzofsky, Krebs, Langton & Smiley‐McDonald, 2013).

Most recent estimates indicate that in the United States, as high as 33% of women and as high as 16% of men experience some form of CSA (Barth, Bermetz, Heim, Trelle & Tonia, 2013). In the same article with the above-mentioned definition of CSA, it provides the following statistics:

Statistically, 1 in every 4 girls and 1 in every 6 boys are sexually abused. While 1 in 5 children are sexually solicited while on the Internet. Almost 70% of all reported sexual assaults occur to children aged 17 and under, this includes adults reporting past sexual abuse. The average age of these reported sexual assaults is 9 years old. This does not include the 85% of child sexual abuse victims that never report their abuse. Nearly 50% of all victims of forcible sodomy, sexual assault with an object, and forcible fondling are children under 12. Greater than 90% of abusers are people whom the victim knows, loves and trusts. 30-40% of these victims are sexually abused by a family member, and 50% are abused by someone outside of their family by someone they know and trust. About 70% of child sex offenders have between 1 and 9 victims with at least 20% of offenders having 10 to 40 victims. An average serial child molester may have up to 400 victims in his/her lifetime. Girls who report childhood rape are 3 times more likely to become pregnant before the age of 18. An estimated 60% of teens’ first pregnancies are preceded by experiences of molestation, rape, or attempted rape. Childhood sexual abuse victims are also more likely to be more promiscuous, more than 75% of teenage prostitutes have been sexually abused during their childhood. There are an estimated 42 million survivors of childhood sexual abuse in America today (Townsend & Rheingold, 2013, p. 13).

The Diagnostic and Statistical Manual of Mental Disorders, 5th edition, also known as the DSM–V (American Psychiatric Association, 2013) is the most widely accepted diagnosis and criteria manual used by clinicians and researchers for the classification of mental disorders. In the DSM-V (2013, p. 715), there is a section entitled Other Conditions that May be a Focus of Clinical Attention. The CSA diagnosis is: V61.21: Sexual Abuse of Child (American Psychiatric Association, 2013, p. 718). The criteria includes that it is not due to a mental disorder and that the abused child is a victim of non-parental sexual abuse (American Psychiatric Association, 2013, p. 718). The 10th revision of the International Statistical Classification of Diseases and Related Health Problems is also known as the ICD-10 (2016). It contains the codes for mental and behavioral health, as well as other medical codes for billing purposes. The ICD-10 code for V61.21 Sexual Abuse of Child is Z69.020 (World Health Organization, 2016).

In the October 2013 issue of the American Journal of Psychiatry, Teicher and Samson (2013) reviewed the psychiatric literature on sexual abuse, neglect, and other forms of psychological abuse on the diagnoses of anxiety disorders, depression, and other disorders in children and adults. Those children who had been abused or neglected had the most severe forms of the disorders studied, according to Teicher and Samson (2013). Those who had psychiatric disorders and had been abused had measurable changes in their brains, while those with disorders but no history of abuse had no brain changes (Teicher & Samson, 2013). Those with a history of abuse and a psychiatric disorder often responded to different treatments than those with a psychiatric disorder without a history of abuse (Stuart & Kaplan, 2014).

Researchers have found high rates of post-traumatic stress disorder (PTSD) in sexual abuse victims (Karakurt & Silver, 2014). Dissociation, which disrupts consciousness in areas of memory and perception, is another problem associated with adults who have suffered CSA in childhood. Higher dissociative scores were associated with those who were sexually abused in childhood (Apgar, 1999). Children who face the horrors of sexual abuse experience the ultimate sense of betrayal, as they are dependent on others (Karakurt, 2014). In a quantitative study it was found that adolescents in treatment centers show high levels of psychological distress after disclosure of sexual abuse (Brabant, Hébert, and Chagnon, 2013). Studies show that children continue to experience the trauma from the abuse, including symptoms of anxiety, suicidality, and post-traumatic stress disorder (PTSD), involving physical health problems, and risky sexual behaviors (Walsh, Fortier, & DiLillo, 2010; Maniglio, 2009; Zink, Klesges, Stevens, & Decker, 2009). In the book The Courage to Heal (Bass & Davis, 1994), the self-love that victims tried to nurture so carefully seems out of reach, almost unattainable, and after experiencing this childhood trauma it may be difficult. After experiencing this childhood trauma, it may be difficult to love oneself.

Survivors of CSA are left feeling powerless, alone, and not worthy of protection or love, and feeling that something is wrong with them (Bass & Davis, 1994). One such survivor said: “Survivors were programmed to self-destruct. You learned to put yourself down so effectively that the abusers don’t even have to be around any more to do it” (Bass & Davis, 2004, p. 202). Some feel they should be perfect, or that nothing is ever good enough, and others do not even try, feeling that they will never be good enough (Bass & David, 2004). It is difficult to change some of these internalized messages and negative thinking experienced from sexual abuse at an early age, especially when one is learning to develop initiative and trust (Finkelhor & Brown, 1986; Karakurt & Silver, 2014). Cheasty, Clare, & Collins (1998), studied the effects of childhood sexual abuse on adult depression in a case-controlled study. Results showed that out of 237 women interviewed, 132 were depressed and 37% of the depressed women had been sexually molested prior to age 16 (Cheasty et al., 1998). All of those who were severely molested, defined as including penetration or attempted penetration, were depressed (Cheasty et al., 1998).

CSA has been linked to subsequent sexual victimization in adulthood (Allor & McElvaney, 2010). In the quantitative research study Adverse Childhood Experiences and Sexual Victimization in Adulthood (Ports, Ford, & Merrick, 2016), it was found that CSA was a significant risk factor for sexual re-victimization in adulthood. Among a nationally representative sample of children and youth, 6% of the total sample reported having experienced a sexual offense and 1.4% experienced a sexual assault in the last year (Finkelhor, Turner, Shattuk, & Hamby, 2015). Rates were highest for girls aged 14–17 years, of whom 16.4% experienced a sexual offense and 4.6% experienced a sexual assault in the last year (Finkelhor et al., 2015).

Another dynamic of CSA that has a harmful influence on survivors is the feeling of powerlessness. Powerlessness in this context can be defined as a disturbance of a child’s body against the child’s will (Karakurt & Silver, 2014). The last dynamic related to sexual abuse is stigmatization. Stigmatization can be described as abuse-specific shame and self-blame (Finkelhor & Browne, 1986). It is linked with negative feelings and guilt, as well as a concept of the self as bad and responsible for the abuse (Finkelhor & Browne, 1986). Guilt is frequently observed among sexual abuse victims; many survivors feel guilty and blame themselves for the abuse (Levenkron, S., & Levenkron, 2007). Another event increasing the victim’s sense of guilt occurs when the offender must separate from his or her family after the disclosure (Karakurt & Silver, 2014).