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Sexual Abuse and Assault in Children and Teens: Time to Prioritize Prevention

      See Related Article p. 329
      In this issue, Finkelhor et al. extend their previous epidemiologic studies of sexual abuse and assault of children using data from three national phone surveys and focusing on information obtained from 15- to 17-year-old adolescents [
      • Finkelhor D.
      • Shattuck A.
      • Turner H.A.
      • Hamby S.L.
      The lifetime prevalence of child sexual abuse and sexual assault assessed in late adolescence.
      ]. The authors aimed to provide an estimate of the lifetime prevalence of childhood sexual abuse and assault and to include adolescents through the age of 17 years. Similar studies have examined childhood sexual abuse and assault by questioning adults about their childhood experiences which may have occurred years before. This study questioned 15-, 16-, and 17-year olds about their experiences of sexual abuse and assault to decrease recall bias and to capture a snapshot of the experiences of older teens. The questions about sexual victimization common to the three surveys included reports of a “grown-up” familiar to the teen forcing sexual touching or sex, a “grown-up” stranger forcing sexual touching or sex, a known other child or teen forcing sexual acts or sex (including siblings), and attempts of sexual acts by anyone even if none occurred.
      In this editorial, we highlight four key points of the article, remind clinicians who care for children and adolescents of the importance of these study findings and implications for practice, and issue a call to action for the prevention of childhood sexual abuse and assault.
      The first key point of Finkelhor et al. is that clear definitions are important. Incidence and prevalence studies often combine sexual abuse and assault [
      • Finkelhor D.
      • Shattuck A.
      • Turner H.A.
      • Hamby S.L.
      The lifetime prevalence of child sexual abuse and sexual assault assessed in late adolescence.
      ]. The article refers to this phenomenon as a “terminological ambiguity.” Sexual abuse often refers to sexual acts by adult caregivers in the family; by adults in the caregiving role, such as a coach; or by older children in the family, such as an older sibling or cousin. In contrast, the term sexual assault is often reserved for sexual acts by strangers or by the same-age peers. The risk factors, prevention efforts, and treatment strategies may differ between these two phenomena, but the statistics for each are often combined, making understanding the true occurrence of each difficult or impossible. The authors provided clear definitions and reported the overall results and the results by types of perpetrators (adult or juvenile, male or female, and family, acquaintance, or stranger). Overall, the authors found that one in four girls and one in twenty boys experienced sexual abuse or assault in their lifetimes. When just sexual abuse by an adult was examined, the lifetime prevalence was one in nine girls and 1 in 53 boys. Juvenile offenders committed well over half of the total abuse and assault episodes of female or male children. When citing data or using rates of abuse and/or assault to shape guidelines for clinical care, public policy, or funding, it is important to understand the difference between assault and abuse and specifically what the data represent.
      The second key point relates to the relationship between the child and the perpetrator of the sexual abuse or assault. Strangers were the least commonly reported perpetrator; most commonly, the acts were by an acquaintance of the child. These data challenge the public's perception of child sexual abuse or assault as being perpetrated by strangers. Educational programs need to focus on helping children and teens to protect themselves from people they know [

      Children's Trust Fund, S.C. The stranger you know...; 2014. Available at: http://www.ct.gov/ctf/cwp/view.asp?a=1786&q=293148. Accessed June 11, 2014.

      ].
      A third and related key point is that most of the sexual abuse or assault reported through the age of 17 did not include penetration. Many state statutes include more stringent penalties for penetration versus genital touching, which may contribute to the perception that penetration is somehow more “wrong” than other sexual contact or touching. One longitudinal study of outcomes of sexual abuse found an increased rate of psychopathology in survivors of any type of sexual abuse or assault, with a tendency toward even higher rates in those who had experienced penetration as part of the abuse [
      • Cutajar M.C.
      • Mullen P.E.
      • Ogloff J.R.
      • et al.
      Psychopathology in a large cohort of sexually abused children followed up to 43 years.
      ]. It is important to recognize that all forms of child abuse and neglect have been linked to poor medical and psychiatric health outcomes; the biologic and epigenetic bases of the outcomes are being uncovered and are beginning to be applied to public policy development [
      • Jaffee S.R.
      • Christian C.W.
      Social Policy Report: The biological embedding of child abuse and neglect: Implications for policy and practice, in Social Policy Report.
      ]. Penetration should not be viewed as the sole marker of severity of abuse or predictor of long-term outcomes for the survivors.
      Finally, separating the survey responses by teens of different ages highlighted the important differences in the experiences of older adolescents. The rates of abuse by all types of perpetrators rose steadily among the 15-, 16-, and 17-year olds. In 15-year-old females, 16.8% reported sexual abuse or assault in their lifetime; the number of 17-year-old girls reporting sexual abuse or assault was much higher at 26.6%. These data indicate that a significant amount of the sexual abuse and assault experienced by girls occurs between the ages of 15 and 17 years. The mid- to late-teen years are a time when many adolescents are gaining independence: sleepovers at friends' homes, taking a first job, initiating dating, and starting to drive a car. These data indicate that these ages may also be the time that such young people are especially vulnerable to unwanted sexual acts by peers and adults. Prevention programs for adolescents should focus on strategies both to help teenagers avoid vulnerable or dangerous situations and how to exit such situations.
      These data have important implications for clinicians who care for children and adolescents. Pediatric clinicians often use the HEEEADSSS acronym to assess important aspects of the lives of teens that impact overall health and safety, including Home, Education/Employment, Eating, Activities, Drugs, Sexuality, Suicide or Depression, and Safety from Injury and Violence [
      • Goldenring J.M.
      • Rosen D.S.
      Getting into adolescent heads: An essential update.
      ]. The results of Finkelhor support and underscore the importance of the sexuality, suicide, and safety section and its use at health maintenance visits, especially during later adolescence. Clinicians need to be both willing to ask and comfortable hearing from teens about sexual abuse and assault. Clinicians also must know when to report to child protective services and how to access trauma-focused therapy for those teens who do report sexual abuse or assault.
      Although the identification of these young people who have experienced sexual abuse or assault is important, as in all of pediatrics, prevention is the best medicine. The fact that 25% of females self-identify as lifetime victims of childhood sexual abuse and/or assault is chilling. An inherited trait present in 25% of a population would be considered a normal variant. Will physicians, parents, lawmakers, and society allow sexual abuse and assault to be “normal”? The results of this study are a plea to take notice of what is happening to children and teens and to prioritize prevention through school education, teen programs, and parenting awareness campaigns. There are educational programs aimed at preventing teens from offending on each other by teaching respect and boundaries and appropriate sexual behaviors [
      • Wolfe D.A.
      • Crooks C.
      • Jaffe P.
      • et al.
      A school-based program to prevent adolescent dating violence: A cluster randomized trial.
      ,
      • Wolfe D.A.
      • Crooks C.
      • Chiodo D.
      • et al.
      Observations of adolescent peer resistance skills following a classroom-based healthy relationship program: A post-intervention comparison.
      ,
      • Wolfe D.A.
      • Wekerle C.
      • Scott K.
      • et al.
      Dating violence prevention with at-risk youth: A controlled outcome evaluation.
      ], but there must be a renewed focus on implementing such programs and on developing other strategies to prevent the sexual abuse and assault of young people.

      References

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        • Shattuck A.
        • Turner H.A.
        • Hamby S.L.
        The lifetime prevalence of child sexual abuse and sexual assault assessed in late adolescence.
        J Adolesc Health. 2014; 55: 329-333
      1. Children's Trust Fund, S.C. The stranger you know...; 2014. Available at: http://www.ct.gov/ctf/cwp/view.asp?a=1786&q=293148. Accessed June 11, 2014.

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        • Mullen P.E.
        • Ogloff J.R.
        • et al.
        Psychopathology in a large cohort of sexually abused children followed up to 43 years.
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        • Jaffee S.R.
        • Christian C.W.
        Social Policy Report: The biological embedding of child abuse and neglect: Implications for policy and practice, in Social Policy Report.
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        Getting into adolescent heads: An essential update.
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        A school-based program to prevent adolescent dating violence: A cluster randomized trial.
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        • Chiodo D.
        • et al.
        Observations of adolescent peer resistance skills following a classroom-based healthy relationship program: A post-intervention comparison.
        Prev Sci. 2012; 13: 196-205
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