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Defining CSA
The National Center on Child Abuse and Neglect defines CSA as contacts or interactions between a child and an adult in which the child is being used for the sexual stimulation of the perpetrator or another person. Sexual abuse may also be committed by a person younger than 18 when that person is either significantly older than the victim or when the perpetrator is in a position of power or control over the child.
CSA may include specific acts such as exhibitionism, voyeurism, solicitation, kissing, fondling, oral sex, and intercourse. Particular acts may or may not be considered CSA, depending on culture and family norms (such as nudity). When evaluating cultural influences on CSA, the criterion for determination is harm. Harm is the result of an exploitation of the child's ignorance, trust and obedience. While exploitation of a child through sexual abuse can be pursued without conscience, it cannot be pursued without intent.
Effects of Abuse
The effects of sexual abuse on children can include emotional distress and dysfunction, post-traumatic stress syndrome, behavioral problems, negative interpersonal consequences, and cognitive difficulties and distortions. Additionally, CSA is one of the most frequent modes of transmission for human immunodeficiency virus and other sexually transmitted diseases to children.
Many of the symptoms reported by adult survivors of CSA are merely extensions of those present in child victims. One consequence of CSA, difficulty with interpersonal relationships, can be devastating as the child develops. Emotional distress, problems with trust, and distortion of self-image and the image of others can make satisfying relationships impossible.Because the victimization typically occurs in the context of human relationships, sexual abuse can cause a disruption in the normal processes of learning to trust, acting autonomously and forming stable, secure relationships. Female survivors are more likely to divorce or separate from their husbands than are non-abused women.These women tend to feel less satisfaction with their relationships, experience greater discomfort and sensitivity, and have more maladaptive interpersonal patterns. Sexual abuse survivors are more likely to become involved in abusive relationships than their nonabused counterparts.
Sexual abuse has a tremendous impact on society. One study found that 10% of boys and 68% of girls incarcerated in a single youth correctional facility had been sexually abused. Girls who had been sexually abused reported an earlier age of consensual intercourse than those who were not abused, and were less likely to use contraception. CSA may also increase the risk of adolescent pregnancy by fostering the desire to conceive, although the reason for this relationship is unclear.Victims of both physical and sexual abuse are at increased risk for substance abuse, particularly at early ages.
Boys who are victims of CSA are less likely to report the abuse, more likely to view themselves as responsible for it, and more likely to act out aggressively because of it.Like girls, boys experience guilt and self-blame, low self-esteem and self-image, problems with intimacy, sexual dysfunction, substance abuse and depression and symptoms of post-traumatic stress syndrome. Many sexually abused men attempt to "prove" their masculinity by having multiple female sex partners; sexually, physically or verbally victimizing others (including children); or engaging in dangerous or violent behaviors. They may experience concern about their own sexuality, confusion over gender and sexual identity, and may experience feelings of inadequacy. They may also have a sense of lost power, control and confidence in their manhood.
Finally, the effects of sexual abuse can escalate after disclosure as the child is forced to deal with parental reaction. Disbelief and blaming are common reactions of the nonabusive parent, due in part to denial that occurs naturally during the grieving process. The child also encounters trauma when the family begins dealing with social services and family court. The physical examination for evidence of sexual abuse can be an additional traumatizing event, especially if improperly conducted. The examination has been made less difficult by child victim advocacy agencies, single-episode forensic examinations using specialized viewing instruments with videotaping capabilities, and victim interviews behind two-way mirrors. Faced with this magnitude of trauma, children often recant their assertions.
Initiating Prevention
Most CSA prevention programs are school-based and implemented by teachers who have had little preparation for intervention.The school setting is inappropriate as a sole means of CSA prevention because discussion of sexual issues in school is severely limited. Vague prevention programs are potentially harmful to children. Concepts such as "good touch, bad touch," "private zones" and "bathing suit area" are used instead of specific descriptive terms. They are confusing and lack applicability to all abuse situations.
Programs that are constructed around the concept of child empowerment are based on unproven assumptions: that a child has the capacity to make choices, assume responsibility and maintain sufficient skills to thwart danger. In direct contradiction to these assumptions, the child is given virtually no information about sexuality and norms of sexual behavior, nor are the child's inaccurate beliefs corrected. Another concept frequently used in such programs is "stranger danger." Although this is an important concept for children to learn, it is not very effective in child abuse prevention because in the majority of cases, children are victimized by someone they know and trust.
Our current system of protection efforts negatively affects all involved. With broad, generalized information about the characteristics of victims and perpetrators, health care providers tend to be suspicious of everyone or fail to address CSA unless presented with physical signs and symptoms or valid reports of prior abuse. Vague methods of instruction may indirectly cause parents and others to withhold needed affection from children, fearing that their actions may be misinterpreted. CSA prevention programs often leave children confused and fearful. For example, 20% of preschoolers said they were fearful of parent-child behavior such as tickling, bathing and being tucked in at night after they were exposed to a CSA prevention program.
The ability of a child to conceptualize according to his developmental level has not been consistently considered in planning CSA prevention programs. For example, some children inform parents that they "have the right to say no" to general instructions. One little boy refused to stand to urinate, because he did not want to touch his own penis. These programs are the only sex education that some children ever receive. Although we live in an extremely sexualized society, many parents are unable to address the subject with their children except in vague, cryptic terms that are designed less for the protection of children than for the comfort of parents and other adults.
One reason is that NPs can be effective at providing CSA education is that they have no qualms about discussing highly personal issues. In the area of violence prevention, anticipatory guidance provided in the context of routine health supervision visits can lead to short-term behavioral changes.It is foreseeable that this success can translate to CSA prevention as well.
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