Clinical Reference Systems: Pediatric Advisor 10.0

Child sexual abuse has been reported up to 80,000 times a year, but the number of unreported instances is far greater. Many children are afraid to tell anyone what has happened and the legal procedure for validating an episode is difficult. It is very important to identify episodes of sexual abuse. The abuse must be stopped and the child given professional help. The long-term emotional and psychological damage of sexual abuse can be devastating.

Child sexual abuse can take place within the family, where the abuser is a parent, stepparent, sibling, or other relative. Or the abuser may be unrelated, such as a friend, neighbor, child care provider, teacher, or random molester. In any case, the sexually abused child develops a variety of distressing feelings and thoughts.

No child is psychologically prepared to cope with repeated sexual stimulation. Even a 2 or 3 year old, who cannot know the sexual activity is wrong, will develop problems resulting from the inability to cope with the overstimulation.

A child of 5 or older who knows and cares for the abuser becomes trapped between affection for or loyalty to the person and the sense that the sexual activities are terribly wrong. If the child tries to break away from the sexual relationship, the abuser may threaten the child with violence or loss of love. When sexual abuse occurs within the family, the child may fear the anger, jealousy, or shame of other family members, or be afraid the family will break up if the secret is told.

A child who is the victim of prolonged sexual abuse usually develops low self-esteem, a feeling of worthlessness, and an abnormal perspective on sexuality. The child may become withdrawn and mistrustful of adults and can become suicidal.

Some children who have been sexually abused have difficulty relating to others except on sexual terms. Some sexually abused children become child abusers themselves or prostitutes, or they may have other serious problems when they reach adulthood.

Often there are no physical signs of child abuse. Sometimes there are signs that only a physician can detect, such as changes in the genital or anal area.

The behavior of sexually abused children may include:

• unusual interest in or avoidance of all things of a sexual nature
• sleep problems or nightmares
• depression or withdrawal from friends or family
• seductiveness
• statements that their bodies are dirty or damaged, or fear that there is something wrong with them in the genital area
• refusal to go to school or delinquency
• secretiveness
• aspects of sexual molestation in drawings, games, fantasies
• unusual aggressiveness
• suicidal behavior
• other severe behavior changes.

Sexual abusers can make a child extremely fearful of telling anyone about the abuse. Only when a special effort has helped the child to feel safe may the child be able to talk freely.

If a child says that he or she has been molested, parents should stress that what happened was not the child's fault. Parents should seek a medical examination and possibly a psychiatric consultation.

These are some preventive measures parents can take:

• Tell children, "If someone tries to touch your body and do things that make you feel funny, say NO to that person and tell me right away."
• Teach children that respect does not mean blind obedience to adults and to authority. Don't tell children to always do everything the teacher or baby-sitter tells them to do.
• Encourage professional prevention programs in the local school system.

Sexually abused children and their families need professional evaluation and treatment as soon as possible to reduce the risk that the child will develop serious problems as an adult. Abused children need help regaining a sense of self-esteem, coping with feelings of guilt about the abuse, and beginning the process of overcoming the trauma.