Prevent Child
Sexual Abuse
This article
appeared in the December 2001 issue of 'Advance for Nurse
Practioners. It is Vol. 9 Issue 12 Page 52. It was
written by Gretchen Overstolz, a family nurse practitioner
and forensic nurse examiner at Care Centers in Charleston, SC.
It Can Start in Primary Care Settings
Children are bombarded with messages about sex every day.
From peers at school to content on television and radio, it
surrounds them in many forms. Pedophiles who prey on
trusting children are able to enter directly into a child's
home, via the Internet, disguised as other children.
Children are even turned into sexual objects for advertising
campaigns.
Unfortunately, society's over-sexualization has had little
impact on the comfort levels of health care professionals
dealing with children's most disturbing exposure to sex:
child sexual abuse (CSA). In most cases, NPs intervene in
the CSA continuum only after abuse has occurred, when they
provide health care and support. No established CSA
prevention guidelines exist for use in primary care. In
spite of the reported prevalence of CSA, the preparation of
health care providers to work with sexually abused children
has received little attention.1 CSA prevention is rarely
mentioned in the curriculums that train NPs, physicians or
other providers. The availability of information about
family violence in medical and nursing texts is limited.2
Although identifying children who have experienced or are at
high risk for abuse is of great importance, this is rarely
accomplished in the primary care setting.3 It is also
unlikely that identification of children at high risk for
sexual abuse is an effective method of prevention.
Prevention efforts should increase understanding of the risk
and consequences of sexual abuse, incorporate healing for
families who have been touched by CSA, and take into account
the developmental levels of families and their children.
Positive outcomes of prevention intervention are achieved
through a direct, nonaccusatory, noninterrogatory approach
that is sensitive to the patient's cultural background and
personal values.
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.3
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.3
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.4
Additionally, CSA is one of the most frequent modes of
transmission for human immunodeficiency virus and other
sexually transmitted diseases to children.5
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.4 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.6 Female survivors are more
likely to divorce or separate from their husbands than are
non-abused women.7 These women tend to feel less
satisfaction with their relationships, experience greater
discomfort and sensitivity, and have more maladaptive
interpersonal patterns.8 Sexual abuse survivors are more
likely to become involved in abusive relationships than
their nonabused counterparts.9
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.10 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.11 Victims of both physical and
sexual abuse are at increased risk for substance abuse,
particularly at early ages.12
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.13
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.14 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.15 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.14
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.16 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.3,16
Initiating Prevention
Most CSA prevention programs are school-based and
implemented by teachers who have had little preparation for
intervention.18 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.19 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.20 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.17
Our current system of protection efforts negatively affects
all involved.21 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.22 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.23
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.21 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.24 It is foreseeable that this success can translate
to CSA prevention as well.
Prevention
A primary care-based method of prevention should be
realistic and efficient to implement. One way to provide CSA
prevention in a short period of time is by implementing the
intervention in more than one visit. During the first visit,
you can introduce the topic of CSA to the family and provide
information about prevalence data, risks and possible
effects of abuse. Written information may include a parent,
child and family assessment tool, along with comprehensive
information and resources that include information for abuse
recovery and age-specific sexuality education.22 CSA
prevention tends to be most effective during the beginning
stages of family development.25 Therefore, women's health
NPs, CNMs and obstetricians might be the most appropriate
care providers to begin intervention during prenatal visits
and childbirth classes.26
Patients are more likely to comply with suggested activities
and assessment if they are approached in a caring and
respectful manner. Inform patients that no unique traits
separate abusers from nonabusers.27 Although 15% to 20% of
perpetrators are parents, most offenders are more distant
relatives or other acquaintances.
Components of the prevention intervention may include
dismissal of stereotypes and societal elements that
encourage CSA, and healthy parenting skills that improve
children's self-esteem.28 Parents should also have an
understanding of the four preconditions that must be met for
CSA to occur:28
a person must be motivated to abuse a child;
the person must overcome internal inhibitions;
the person must overcome external impediments; and
the person must surmount resistance by the child.
Clinic-based assessment and intervention address external
impediments to abuse and the child's resistance to abuse.
External impediments include parents and other adults who
protect children from abuse. Children's resistance may
include the child, friends and siblings. Physical,
intellectual and emotional factors influence external
impediments and the child's resistance (Table 1).
Through CSA prevention intervention, potential offenders may
gain insight, thereby achieving freedom of choice in their
actions. Adults who experienced CSA may be free to act
against internalized feelings and learned behaviors. They
may comprehend the inappropriateness of their childhood
sexual experiences, acquire empathy for prospective victims
(and themselves), and realize that future abuse is not
likely to go unnoticed, nor will it be tolerated.28
Assessment
To focus on the external impediments to CSA and resistance
by the child, assess the factors that influence their
occurrence (Table 2). Patients and families should be
allowed to decide whether or not to share the information
gained from assessment.
Parents who have been victims of abuse may not be protective
of their children, able to foster self-esteem, or able to
communicate comfortably with their children. For this
reason, parenting classes or videotaped parenting
instruction should be made available, and you or another
trained provider should provide brief follow-up discussions.
Remain culturally sensitive with regard to the assessment.
For example, if a parent reveals that it was acceptable in
his childhood home for sisters and brothers to bathe
together, do not express an opinion. Instead, gather
information about the ages of children, whether or not
children felt they were allowed adequate privacy, etc. You
may want to discuss with the parent feelings related to
childhood experiences, and how such experiences may affect
parenting practices.
Children with disabilities must be given special
consideration. Basic theoretical assumptions about child
development and intellectual capacity for understanding do
not always apply. There may be an inherent lack of
self-esteem that cannot be corrected or prevented by
parental interventions. Additionally, these children may not
have the physical ability to remove themselves from
situations in which abuse may occur.
Another issue to be raised during assessment is current
family functioning. Poverty, the absence of one or both
parents, physical or emotional incapacitation of the mother,
spousal abuse, and drug and alcohol dependence are often
present in families of children who are abused.3 Other
commonalties among families who have experienced CSA include
rigid family belief systems, a dysfunctional parental
coalition, parental neglect and emotional unavailability.31
Family functioning affects both external inhibitions and a
child's ability to resist sexual advances.
Parental Protection
External inhibitions include situational circumstances that
do not allow abuse to occur. Provide parents with
information about the general patterns of offenders (Table
3). Urge them not to leave children who are unable to
understand and practice CSA prevention concepts with anyone
they do not feel completely comfortable with.
Parents should also carefully assess day care settings. It
is appropriate, although uncomfortable, for parents to
discuss CSA with others who may be caring for their
children. This should be suggested in all situations, but
may be particularly important for single mothers who date,
since stepfathers and boyfriends are among the most common
perpetrators.
You can model prevention measures by pointing out that
health care providers should only examine children's
genitals when their parents are in the room. Encourage
comfortable discussion between parents and children by
acting as a mediator. Also discuss with children and parents
concepts such as safety plans, and cite examples of
situations that parents should specifically monitor (public
restrooms, malls, parks and playgrounds, and extracurricular
events).
Child Self-Protection
A child is more likely to resist CSA if he has an
understanding of what needs to be resisted, has an ability
to use descriptive language in a report of abuse, and feels
comfortable reporting to parents or other adults. In
addition, a child must have the self-confidence and
self-esteem to resist the perpetrator.3
Sexuality instruction should be congruent with a child's
level of understanding and the family's level of development
(Table 4). Written materials for age-appropriate sex
education are available (Table 5). These brochures include
parental instructions, which can increase comfort and assist
parents in providing meaningful information to their
children.
A child's level of self-esteem is a major influence on
whether a child can protect himself, and poor self-esteem
may be a result of dysfunctional family relations. By
observing children for signs of poor self-esteem, increased
assessment about family risk factors can be established and
addressed. If parents express concern about their child's
self-esteem, don't take it lightly. Although schools may not
be the most appropriate settings for teach CSA prevention
skills, they can be good environments for encouraging
self-esteem and teaching social problem-solving skills.
Finally, societal elements that increase the acceptance of
CSA should be addressed. Encourage parents to teach and
model for their children appropriate behaviors related to
sexuality and acceptable treatment of themselves and others.
Selectivity in viewing, reading and listening materials
should be promoted for both children and parents. This is
not to say that anything dealing with sex should be avoided,
but exploitive materials should not be tolerated.
Assess for Risk
If you suspect abuse, work to ensure that the suspicion is
investigated and that the child's risk is assessed. In most
cases, providers who specialize in child abuse examinations
or forensic pediatricians best make this assessment.
Evidence must be well-documented, and the findings must be
interpreted properly. If there is no forensic pediatrician
in your area, seek training in forensics through
organizations such as the International Association of
Forensic Nurses. v
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