Child Sexual Abuse and Mental Disorder

Table of Content

[I] Definitions and Methods
[A] Definition
1. Incidence
2. Child sexual abuse
3. Incest
4. Sexual inappropriate behavior
i.) Non-contact abuse
ii.) Contact abuse
5. Sexual Abusers
6. Issues of Gender
[B] Methods
1. Self report/case studies
2. Psychological scales
3. Referral
4. Drawings and anatomically correct dolls

[II] The Victim
[A] Data on Victims
1. Socio-demographic data
i.) High risk groups
ii.) Day care centers
iii.) Family structure and parenting
2. Psychological Data
i.) Prior victimization
ii.) Blame
iii.) Special issue –
mother-daughter incest
3. Intercultural examples
i.) Canada
ii.) Netherlands
iii.) Zimbabwe
[B] Impact on Mental Health
1. General remarks
i.) Systematic Variation
ii.) Clinical Control Group
iii.) General Complex of Symptoms
2. Anxiety
i.) Sources and Symptoms of anxiety
ii.) Case Story From the Netherlands
iii.) Impact of Parent-Child Relationship
iv.) Psychosomatic Symptoms
3. Post-traumatic stress disorder
i.) Symptoms
ii.) Influence of disclosure on
PTSD Symptomatology
iii.) Psychosomatic Symptoms
iv.) Prior Victimization
4. Depression
i.) General Remarks
ii.) Depression Immediately after
Abuse
iii.) Five Years After the Abuse
iv.) Depression in the Adult Personality
5. Dissociative Identity Disorder (DID)
i.) General Remarks
ii.) Dissociative Identity Disorder
– one single entity?
iii.) Defining Symptoms
iv.) Childhood Experiences
v.) System of Alters
vi.) Treatment
6. Persistence of Impact
i.) Sleeper Variables
ii.) Sexual Disturbance
iii.) Anxiety and Depression
iv.) Substance Abuse and
Physiological Issues
v.) Postsexual Abuse Syndrome?
[C] Associated Problems
1. Child sexual abuse and the legal system
i.) Employment of protective devices
ii.) Expert testimony
iii.) General accuracy of memory
iv.) Delayed disclosure
v.) Suggestibility
vi.) Exception from hearsay rule
2. Evaluation of repressed memories
linked to abuse
i.) Repressed and rediscovered
memories?
ii.) The Influence of Counseling
iii.) Treatment of “Rediscovered”
Memories in the Court
iv.) Judicial Standards for Expert
Witnesses
3. Allegations and families
i.) Categorization schema
ii.) Discovered abuse leads to divorce
iii.) Revelation during divorce
iv.) Divorce prepares ground
v.) False allegations
vi.) Assessment facilitation in divorce
Cases
vii.) Approaches for first time offenders
to maintain family system
viii.) Pretrial diversion program
ix.) Post arraignment diversion program
x.) Pre-legal diversion program
4. Problems in functioning
i.) Dental experiences
ii.) Memory function
5. The Freudian coverup
i.) The Seduction Theory
ii.) Sexual Abuse – only a fantasy?
6. Victim to abuser circle
i.) Incidence of pedophilia in a
community sample
ii.) Multiple abused versus single
time abused victims
iii.) Attitudes toward treatment
[D] Treatment
1. Entering treatment
i.) Filters
ii.) Research on Conflicting Variables
iii.) Obstacles for Adults in Therapy
2. Treatment
i.) Reasons for Group Therapy
ii.) Concrete Procedure

[III] Conclusion

References

[I.] Definition and Methods

[A.] Definition

1. Incidence

This first part of the paper deals with the question of how to define child sexual abuse. Differences in the definitions that impede a comparison of different studies conducted on this topic are examined. Child sexual abuse has long been thought to be rare or at least occurring in small numbers only. In recent decades, however, the incidence of child sexual abuse cases seemed to explode. Probably only the higher number of reported cases is responsible for that phenomenon. The incidence of child sexual abuse probably did not really change. The number of child sexual abuse ranges for females somewhere between 6% to 62% and for males between 3% and 31% (Whetsell-Mitchell, 1995; Finkelhor, 1993). The large difference between these numbers is due mainly to the fact of different definitions in the studies. In the following paragraphs three different elements for which definitions seem necessary are discussed. First the phrase child sexual abuse is to be defined. Second phrases for the sexual inappropriate behavior are examined, and third terms to name the abuser are defined.

2. Child Sexual Abuse.

A sample of phrases equated with child sexual abuse by different researchers is: sexual victimization, sexual exploitation, sexual assault, sexual misuse, child molestation, sexual maltreatment, and child rape (Whetsell-Mitchell, 1995). Discussion about child sexual abuse becomes even more difficult when different fields are taken into account. The legal and the social welfare system have quite different ideas of child sexual abuse, and these ideas are different from the psychological ideas as well. Some features are more ambiguous than others are. For instance, it is more likely for different people to agree that child sexual abuse has happened when one or the other form of penetration was involved. It becomes more difficult when behavior is examined that might be perfectly normal in one family, while abusive in another family. This depends on the family’s idea and practice of nudity. While one family thinks it inappropriate to be naked in front of the child another family might find this perfectly normal. Thus, if one of the parents would approach his or her naked child during bathing, it would be normal in family two but not in the first one. This is largely related to the environment in which the child grew up. One feature that indicates sexual abusive behavior is sexual gratification for the involved adult.

3. Incest

In family environments incest is often mentioned. This form of child sexual abuse is broadened by Whetsell-Mitchell’s (1995) definition, which takes into account relationships other than parent-child relationships. In this definition persons who derive authority through ongoing emotional bonding with the involved child commit incest when they engage in sexually inappropriate behaviors with the child. This form of child sexual abuse is held secret; on the other side a form of child sexual abuse is found that inflicts sexual behavior on children for the sake of money. These commercial based acts are called sexual exploitation and involve children sold for prostitution as well as taking pictures of children in sexual activities and to sell them.

4. Sexually Inappropriate Behavior

Whetsell-Mitchell (1995) distinguishes between two main forms of sexually abusive behavior. The first one is called non-contact sexual abuse; the second was termed contact sexual abuse.

i.) Non-contact abuse. For non-contact sexual abuse, sexual comments, exhibitionism, voyeurism, and pornography are listed in Whetsell-Mitchell (1995). Sexual comments include any statements made to a child that are of a sexual nature. This includes obscene phone calls or telling children how much they elicit sexual desire in the abuser. Exhibitionism is the showing of one’s genitals to a child. This can occur in the context of taking showers or public bathing facilities. In the context of families, however, it is hard to identify an abusive situation with respect to the different degree of nudity some families have. Another abusive behavior, which is difficult to identify, is voyeurism as long as it occurs within the family context. It involves an adult observing a child as he/ she undresses, or takes a bath. Sometimes in a family or day-care facility it might very well be appropriate to engage in “voyeurism” for the safety of the children. The distinctive characteristic is once more the sexual gratification for the adult. If such a gratification occurs, the behavior has to be labeled as abusive.

Pornography is the presentation of films that reveal explicit sexual behavior between adults and adults, adults and children, or children and children. This is often used by abusers as a desensitization process (Whetsell-Mitchell, 1995). Such pornographic films make children believe it would be alright to engage in sexual behavior with adults. Consequently, this form of non-contact sexual abuse might lead to contact sexual abuse.

ii.) Contact abuse. Contact sexual abuse includes a number of behaviors that are only sometimes easier to identify as abusive than the non-contact abuse. Kissing is the first of the contact sexual abuse behaviors listed in Whetsell-Mitchell (1995), not ordinary kisses but kissing of other parts of the child’s body such as breasts, vagina, or penis, and kisses that involve the contact of the adult’s tongue and the child’s mouth (“French-kiss”) are included by this definition. Handling or fondling involves touches and caresses of the child’s body with the intention of sexual gratification for the adult. Fellatio or cunnilingus is a child forced to have oral-genital contact with an adult or when an adult has oral-genital contact with the child. Vaginal or anal intercourse occurs even if the adult does not use his penis to penetrate the child’s vagina or penis but uses fingers or other objects. It also involves behaviors that require the child to penetrate the adult in one way or the other.

Frottage occurs when an adult rubs himself/ herself against the child’s body, again with the idea of sexual gratification. Pornography is contact sexual abuse when it requires children to engage in sexual behavior in front of a camera or paying clients. All these situations have in common that the child is robbed of his or her own body control. Force is not necessarily involved (Whestsell-Mitchel, 1995). Persuasion or the feeling of duty can be used, depending on different relationships between the adult and the child. Always a lack of consent is involved as well. This might be obvious in situations of rapes by strangers. However, there are situations when the abuser might argue plausibly that the child did want to engage in a particular not painful behavior with the adult. This is rejected because the child has no complete understanding of the act he or she gives consent to. The child also has not really the power to refuse participation. He or she never has a real choice on his or her participation. Grooming processes might take place for months before the adult engages in an attempt at sexual behavior with the child. In this grooming process the adult systematically discovers what the child likes and dislikes and uses this knowledge to win the child over. Once engaging in the actual abusive behavior, the adult might use this knowledge to force the child to continue the sexual encounters (Whetsell-Mitchell).

5. Sexual Abusers

Names for abusers of children include offender, abuser, molester, perpetrator, rapist, child assaulter, intra-familial abuser, extra-familial abuser, and pedophile (Whetsell-Mitchell, 1995). Particularly the terms "intra-familial abuser" and "extra-familial abuser" distinguish two discrete populations of sexual abusers. This distinction has become necessary since different effects are expected from abuse within the child’s family system or from outside this system. Similar abusive acts from outside the family system are usually easier to deal with, when discovered. When the abuse happens within the family system, penalty for the offender is usually guilt provoking in the child. Such dynamic occurs for instance when the father has to go to jail because of the child’s disclosure of sexual abuse. Children have a hard time realizing that the abusers have to go to jail for their crimes against them.

6. Issues of Gender

Child sexual abuse was researched mainly in female victims during the first decades of research on this topic. Male victims were regarded to be rare and suffering of less severe forms of consequent harm resulting from child sexual abuse (Genuis, Thomilison and Bagley, 1991). In the review conducted by Genuis et al., definition of sexual abuse was pointed out to be one of the major problems in conducting comparable research on male victims. Rape was not possible until anal penetration was considered as rape as well as vaginal penetration, leaving male victims outside of legal processes. Genuis et al. also criticizes the concept of non-contact sexual abuse because of its difficulties in operationalization. Therefore they define child sexual abuse as every unwanted sexual contact with a child. The status child derives from legal definitions and therefore is bound to the age. This definition was adopted particularly because earlier definitions stressed an arbitrary (most commonly 5 years) age difference between victim and abuser. This was done to eliminate sexual play among adolescents from child sexual abuse. However, this age difference is regarded as arbitrary and leaves out abuse committed by adolescents. The number of such abuses seems high enough to worry the researcher. This broad definition is also somewhat more likely to include male victims, than a narrower definition is.

[B.] Methods

The methods used to assess child sexual abuse are as different as the problems posed by this phenomenon are. Out of 42 studies that were used in this literature review, 18 studies actually assessed child sexual abuse on adults, adolescents or children. The remaining 24 studies deal with other problems, such as therapy aspects, legal programs, or meta-analyses of other studies. The used methods in the 18 studies can be categorized in four approaches. Self-report and case studies, psychological scales, telephone surveys and referrals from other treatments or legal institutions were used by the investigators to determine whether a child was sexually abused and thus in the sample of sexually abused children.

1. Self-report/case studies

When the assessment of child sexual abuse was part of the study, five out of the 18 studies used self-report measures to assess either symptoms or the dichotomy abused or not abused. Three of these five studies fit into the very same category, since they were conducted in the context of elusive phenomena such as multiple personality disorder. For these three studies the form of an interview was adopted to free clients from restraints in their narration. A stricter format would have limited the qualitative data in these studies. Thus, all these studies were conducted as case studies with the intention to give a comprehensive review of onset, mediator variables and possible consequences of these phenomena. A fourth study (Hays & Stanley, 1996) quantified the essentially qualitative information by using category systems to cluster certain symptoms. Their study about influence of child sexual abuse on quality of dental experience relied in two regards on self-report measures. The first self-report measure was the statement whether they were victims of child sexual abuse or not. The second self-report measure was the narration about dental experiences. Thus, the finally found link between these two phenomena might very well be heightened by using the same method for the two correlated variables.

A case study was also used in Green’s (1996) study on the consequences of child sexual abuse on mental health. This, however was used for illustration purposes only, otherwise the article is a short literature review on the pathogenesis of child sexual abuse rather than an empirical study.

2. Psychological scales

Psychological scales, in essence questionnaires, were used in only two studies out of the 18 studies with direct assessment. This reflects the fields methodological problems. A questionnaire might be more reliable and less suggestive than an interview measure but it hardly ever can include the multiplicity of symptoms and mediator variables that affect the course of child sexual abuse. McGraw and Smith (1992) used their psychological scales assessment in a very intensive form. They did not only ask victims via questionnaires but also had questionnaires for other people involved in the course of the reported case of child sexual abuse. The questionnaire was built up from very different domains and subscales. Another psychological scale was used in a telephone interview with 2,000 children. Although the label “telephone interview” suggests a more open form of questioning, in this study a prepared questionnaire was read on the phone and the answers were on scales rather than open ended format.

3. Referral

The vast majority of studies relied on referral from other institutions when determining abuse or symptoms of abuse. Such other institutions were legal institutions such as court cases or police reports, others were referrals from crisis or treatment centers. Referred from these institutions the existence of the abuse was not questioned any longer and the participants were included in the samples.

4. Drawings and anatomically correct dolls

Both of these measures were not found in any of the studies for this paper. Since for this paper only the most recent literature was reviewed considerable doubt about the use of these two measures in empirical research arises. Both measures are intended to give children the opportunity to express their experiences since often the children are unable to articulate them. In such cases the use of dolls was often favored. The child could point out what happened and show it on the doll. However, Dunn (1995) rejects their value for empirical research. The use of these methods is not reliable enough and might trigger fantastic stories of children. Essentially, the children are ready to point out whatever the therapist wants them to point out. Although there is little doubt about an occurring event itself, the fragments of the memory might often be fantastically connected by using such methods. The child is reconstructing his or her memory and suggestive hints from dolls or drawings might shift the balance from true story to imagined features of the story until the true element cannot be discovered any longer.

[II.] The Victim

[A.] Data on Victims

1. Socio-demographic variables

The most important result of studies conducted to find certain social environmental variables that distinguish between abuse of children or not is the non-existence of such variables (Finkelhor, 1993). Child sexual abuse is found in every segment of the population regardless of race, education, profession, age, parental relationship and other factors. Thus, no factor can be used to exclude child sexual abuse. With this result in mind, studies were conducted to find out about children who are at a particular high risk.

i.) High risk groups. The first socio-demographic variable that indicates a larger risk to be victimized is gender. Although former beliefs about the proportion between male and female victims have been found vastly distorted, boys are at somewhat smaller risk for child sexual abuse than girls are. The mean ratio across eight epidemiological studies was 1 to 2.5 for boys to girls. Thus, about 30 % of victims are males (Finkelhor, 1993).

A second variable that increases the risk for victimization is the age of children. At the age of 10 occurs a vast increase in cases. Another increase in risk is found at age 6-7 (Finkelhor, 1993). It is important, however, to remember that also at other ages, even among the very young, child sexual abuse cannot be excluded. Children under age 6 constitute about 10 % in retrospective studies. However, this might be a problem of undercount, for a majority of cases might be lost from these retrospective studies.

Another variable that is often associated with the incidence of child sexual abuse is social class. It is often argued that members of higher, particularly more educated, classes have a lower incidence of child sexual abuse. However, this is only true for reported cases, not for the incidence itself. The likelihood to report cases in lower social classes is higher than the likelihood to report child sexual abuse in higher socio-economic classes. From this situation the stereotype is strengthened again. If fewer cases are reported in higher social classes, a lower incidence rate is perceived. This distorted perception might decrease the likelihood to report cases in higher classes because they would not fit the typical schema. The typical schema however was constructed and is not a matter of facts.

The conclusions for socio-economic status are also warranted for racial differences in child sexual abuse incidence numbers. If studies found any higher risks associated with black subgroups, it was possible to trace this higher risk back to the influence of socio-economic status. However, few such results were found. Even in reported cases generally there is no difference between whites and blacks (Finkelhor, 1993). Thus, it becomes more important to look at different situations than subgroups to identify high-risk situations for children. For many parents child sexual abuse is still connected to the stereotype of the child rapist as a stranger. Thus, prevention is considered successful when children are warned not to talk to any strangers, neither to accompany them anywhere. This stereotype neglects the fact that only about 10 – 15% of sexual crimes committed against children are committed by strangers (Whetsell-Mitchell, 1995). The closer environment, relatives, acquaintances, and social institutions include a much higher risk for children.

ii.) Day care centers. One of the institutions that became suspicious during the last decades is the day care center. The risk for children to be abused in day care centers, however, is lower than in the own home (Kelley, Brant, & Waterman, 1993). The more severe impact on children abused in day care centers compared with those abused in the own home justifies the increased perceived risk for children in day care centers. This results from a variety of variables connected to abuse in day care centers. Multiple perpetrators, ritual abuse, penetration, pornography, and forcing children to act sexually upon other children increase the impact on children. Particularly the latter variable is used to create an ambiguity in the victims’ feelings. Besides the feeling of being a victim, they experience a feeling of guilt for abusing other children. This is particularly severe since children are more empathetic for other children at the same age. By hurting them the way they have been hurt, they experience a severe form of guilt, which prevents them from disclosing their own abuse. To decrease a disclosure’s credibility, perpetrators used certain strategies. One such strategy was to suggest to the child the use of objects in way they cannot be used without causing severe harm. For instance, children were forced to bend over, a knife was shown and the abuser explained he would insert the knife in the child’s rectum. Then another object, invisible for the child, was inserted. When the child discloses the abuse and states that a knife was inserted in his or her body, the absence of injuries makes the statement suspect and undermines the credibility of other testimonies. The use of other threats is also targeted to decrease the probability for disclosure in children. Threats are often targeted not only toward the single child but also towards his/ her family. The threat is often pictured in every detail and sometimes little animals are killed in front of the children’s eyes to make the threat more convincing. Physical abuse is often included and the use of drugs is also common to make children less resistant against the adult’s activities.

Different from child sexual abuse in other settings is also the higher relative number of abusive women. About 40% of offenders in day care facilities are women (Kelley, Brant, & Waterman, 1993). This fact should not be surprising when the high number of female employees is considered. Also the number of offenders in a single case is higher than in family settings. Children were abused by 2.8 offenders on the average (range 1 to 8) in a study by Faller (cited in Kelley, Brant, & Waterman), and by an average of 3.4 offenders (range 1 to 17) in a study by Kelley (cited in Kelley, Brant, & Waterman). Thus, day care centers do not put children at higher risk for child sexual abuse compared to family settings. However, if abuse happens it is likely to be of more severe impact on children, if it happens in day care centers, due to the features mentioned above.

iii.) Family structure and parenting. The most important factor when the influence of family structure on risk distribution is studied is the presence of a stepfather in the children’s household. Russel (cited in Finkelhor, 1993) found a seven times higher risk for girls to be abused when a stepfather is living in the same household compared with girls that grew up with both natural parents. In general, children without natural parents are placed at higher risk, although the presence of both natural parents cannot be seen as a disconfirming fact in the diagnosis of child sexual abuse. Parenting, particularly the use of severe forms of punishment or permanent conflicts between the parents also put children at a somewhat greater risk. Two processes seem to play an important role when parenting is regarded. Poor parenting, characterized by punitive parents and strong conflicts in the mutual household, is accompanied by less monitoring of the child’s activities and is also connected to emotional neglect of children (Finkelhor, 1993). Both variables increase the vulnerability of children to child sexual abuse. Less monitoring increases the chance of other people entering the children’s life without control of the parents. Emotional neglect makes the child more susceptible for the “grooming” process of child abusers. Particularly at the second point we should be aware again of the fact that abusers usually are not strangers. A close acquaintance or a relative is much more likely to abuse children. If parenting is difficult for the parents, they might be glad to place their child with friends or relatives. Abusers might be particularly aware of such occasions and offer their help “altruistically”.

Generally, intra-familial and extra-familial abuse does not differ in the outcome for the child, as long as the intra-familial abuse is not committed by one of the parents (Beitchman, Zucker, Hood, DaCosta, Akaman, Cassavia, 1992). Parental abuse, however, seems to cause a greater betrayal and loss of trust. On the other side, the abuse by parents might already indicate a highly disturbed family environment and hereby decrease the amount of available resources for the child.

2. Psychological Data

Besides looking at some typical background variables for child sexual abuse that are related to the child’s psychological dynamic, prior victimization is also regarded as a psychological status of the victimized child rather than a socio-demographic variable.

i.) Prior victimization. Not to include this variable in the socio-demographic section might be controversial. However, since prior victimization is certainly connected to psychological impact on children, its treatment in this chapter seems justified.

Literature on prior victimization concentrates strongly on the relationship between first victimization in childhood and a second victimization in the adult’s life. The possibility of a second victimization as a child is generally neglected (Boney-McCoy, Finkelhor, 1995). Another question Boney-McCoy and Finkelhor were trying to answer was the possibility of other prior victimization than child sexual abuse for a second victimization in childhood. For instance are children who experienced physical abuse at greater risk for later child sexual abuse. For Finkelhor (1993) the connection between punitive parenting and child sexual abuse was already mentioned. However, there the temporal relationship was not evaluated. Boney-McCoy and Finkelhor conducted a telephone survey with 2,000 participants (1,042 boys and 958 girls). Children were classified as either having experienced sexual abuse in the past year or not. In the sexually abused sample, 132 children (72% female, 28% males) were found and were classified as attempted abuse (51%), serious non-contact abuse (19%), and contact abuse (30%). The results suggest serious impacts of prior victimization. Both, prior sexual abuse and prior physical assault by a family member were significantly different between prior victimized and prior non-victimized children. Thirty-nine percent of those children who experienced prior sexual abuse were also sexually abused during the past year. Of those children who experienced prior physical assault by a family member 19% were sexually abused during the last year. In comparison, only 5% of those children without prior sexual assault and only 6% of those without prior physical assault by family members experienced sexual abuse during the last year. Prior physical assault by a non-family member and prior attempted kidnapping were also accompanied by increased risk for victimization during the last year.

Of particular interest is the figure for prior victimization of another family member of the child’s family. This characteristic distinguished between children abused in the last year and those not abused in the last year. Of those children, who had one family member who already experienced victimization prior to the last year, 17% were sexually abused in the last year. From those children who did not have such family members, only 4% were sexually abused during the last year. This study, however, is interesting from another point of view as well. The interviewers spoke to 132 children who were abused during the last year. They also spoke to family members of these children. Since a high percentage of abused children are abused by their own parents, they probably also spoke to such parents as well. Maybe they even spoke to children who disclosed their experiences for the first time. However, no potential steps are mentioned to help these children in any way. After the telephone survey was over, the research project was closed and the children were out there. They were alone again, and had no way to know how their life would go on.

ii.) Blame. The attribution of blame is regarded as one very characteristic element of child sexual abuse. Children, it is said, often blame themselves for the events that occurred in the past. The abuse is not seen as something inflicted from outside, but rather stimulated by some unidentifiable behavior from the child. Thus, children suffer from severe problems with adaptation in adult life. The reasoning behind this notion is very straightforward. The children attribute blame to themselves, because the abusers, often parents or other close persons, have a “good” and trusting relationship with the child. Thus, the child, developmentally unable to distinguish good an bad characteristics in one person, is not able to override the good sides, care giving, protection from the outside world and others, with the attribution of blame.

Since there is often times no other person involved in the abuse besides the abuser and the child, there also is no possibility for the children to direct their blame on somebody else (we will see a qualification of that notion later). This straightforward thinking, however, is challenged by studies that show a lower or no self-blame of children for the abusive event. Such a study was conducted by Hunter, Goodwin, and Wilson (1992). They were able to show that children are much less likely to blame themselves for the events than it is commonly believed. The discrepancy with former notions on this topic might have derived from studies that employed adult populations rather than children, from recent abusive situations. Hunter et al. examined the self-blame of children, adolescents, and adults. The study researched not only self-blame but also molester blame, which might be perceived as the complement of self-blame. The more likely children are to blame themselves, the less likely they should be to blame the molester. The three age groups (children, adolescents, and adults) in Hunter et al.’s study were also divided by gender, and the data were analyzed for several other factors as well. These factors, as well as attribution of blame were assessed with a 250-item questionnaire that was administered to the subjects. Self-blame correlated significantly with the number of months that passed between the abusive event and the disclosure for males and females combined (r =.27). Thus, victims were more likely to blame themselves the longer the event was not disclosed to others. This fact confounds with the age of the victims. By mere logic, assessed children did not have the occasion to withhold their disclosure for such a long time as an adult subject had. Thus, age of subjects might have played a mediating role in this relationship. However, subject’s age, when assessment took place, did not correlate significantly with the rating on self-blame (r =.07).

When the data in Hunter et al.’s (1992) study were broken down by gender, the relationship between delay of disclosure and self-blame remained almost stable for females (r =.24), while the males did no longer achieve a significant correlation between the two variables (Hunter et al.). However, another variable that showed a relationship with self-blame is the perceived level of force (r =.38). The more force was involved in the abuse the more likely children were to blame themselves. At first glance, this finding seems to be unclear. It should be easier for a child to blame a forced intercourse on the offender than a more “gentler” event of fondling. However strong this logic appeals to us, children might rather see a relationship between forced sexual abuse and physical abuse. Physical abuse is often confounded with sexual abuse and might derive from the same source of disrespect for the child’s life and his or her rights. Yet physical abuse is more often connected to actions committed by the child, however unjustified the consequent punishments are. Thus, the child perceives a certain sequence. (1) An action is committed by the child, and (2) the parental response follows consequently. The use of force in sexual abuse might activate that chain and lead to attributions of blame on the child. This is consistent with the finding that the correlation between self-blame and perceived level of force was not found for females. Only male victims, who are more likely to suffer from physical abuse, showed the significant relationship.

As one might expect the blame on the molester was complementary to this pattern. The delay of disclosure was negatively correlated with molester blame (r =-.22); this was visible only for females (r =-.27). The younger the victims the more likely they were to blame the molester (Hunter et al., 1992). Thus, the common notion that children blame rather themselves than their molester seems unjustified. Rather, the opposite was the case. This, however, was true only for the male subjects and not for females. Males also were more likely to put more blame on the molester the older the molester was and the more force was used in the abuse.

iii.) Special issue – mother-daughter incest. In a case study of three adult victims of mother-daughter incest, Ogilvie and Daniluk (1995) reported common themes that are of psychological importance for the experience of children. Several such common topics were identified over the three cases. As far as methodological reasons were concerned, several points were made before engaging in a more detailed description of the study. First of all, the assessment technique was an unstructured interview. The authors adopted this method to “avoid imposition of interviewer bias and assumptions and to encourage discussion of only the material that was personally meaningful to each woman” (p. 73). However, since Rosenthal’s research, it is at least doubted whether such a method is able to deal with interviewer biases, particularly since the researchers were searching for common themes in the experiences of the abused women. On the positive side, however, Ogilvie and Daniluk reported the cases of three women, who seemed to be representative for the larger population of mother-daughter incest victims. Common themes in the cases of all the women were (1) shame and stigmatization, (2) profound sense of betrayal, (3) experience of self-blame and (4) identification with and differentiation from the mother.

Stigmatization was found in Ogilvie and Daniluk’s (1995) sample as a very characteristic problem. This is certainly due to the special construction of their abuse. Two taboos are combined together in this form of abuse. The first of these taboos is the mother as protector. This notion is almost as old as mankind is and is supported by a wide range of animal behavior we are aware of. Thus, whenever a mother violates this assumption, we react with deep emotions. In mother-daughter incest, another taboo makes it virtually impossible to talk freely about this form of abuse. Homosexuality among women, although in politically correct views it is acknowledged as freedom of the individual, is not regarded positively among certain groups of people. Together the occurrence leads to major problems for victims. They feel out of the ordinary. In days, when child sexual abuse is painful reality, mother-daughter incest seems to threaten our last firmly held beliefs. Thus, to be not believed leaves the victims with a feeling of unworthiness. The sense of betrayal victims feel, derives mainly from the break of trust. While the abuse by males often elicit rage in the victims against their mothers for not protecting them, this rage hardly ever occurs in victims of mothers (Ogilvie, & Daniluk, 1995). One of the girls in the case study wished to die, instead of living through the incestuous events.

Self-blame is combined with the self-doubt raised through the lack of confidence victims receive from others. The wish that all the abuse did not really happen comes too easily and the hope to repress all the memories is very powerful. Along with that notion, the belief to be unlovable, flawed, deserving, and unworthy characterize the emotional situation of these children. The identification and differentiation from their mothers pose another problem for them. Abused and betrayed, these women often break contact with the abuser and thus never have the opportunity to face the abuser with the allegations of their deeds. To be as different from their mothers as possible is another common desire for these women, and often related to the fear to become abusive to their own children. The abused – abuser cycle is vivid in the minds of these victims and the threat to let their children experience, what they had to experience, handicaps their family life in their adult years.

3. Intercultural Examples

In this chapter I will deal with the occurrence of child sexual abuse in different cultures. I will not be able to cover extensively the form or the consequences of child sexual abuse in other cultures. Rather I will confine my work to problem recognition, the notion that child sexual abuse is a phenomenon that exists despite cultural and federal borders.

i.) Canada . The existence of child sexual abuse in the USA is of no doubt anymore, and thus the occurrence of child sexual abuse in the neighbor countries is not surprising. Canada is particularly aware of the problem, and as studies show, the Canadian health officials are on the edge of declaring child sexual abuse a phenomenon that affects Canada as strongly as it affects the USA. In former years, Canadian health officials often cautioned against the notion that they might have the same problems as the USA and in particular that the prevalence rate is not lower than the one in the USA. Nonetheless, at least one group of researchers (Genuis, Thomlison, & Bagley, 1991) interprets other study findings as indications for a decline in the prevalence rate of child sexual abuse. They consider the rapid improvement made over the past few decades of such impact that the occurrence of child sexual abuse is on the way back. Prevention programs and better education seems to be their major argument to support their notion of improvement. However, so far only one recent study (Bagley, 1990; as cited in Genuis et al.) found declining numbers of child sexual abuse. Whether these numbers are due to expectations or reflect real changes in society remains to be proven. Wolfe and Birt (1995), from the children’s hospital in Ontario, report no decline in numbers and impact on children. They found the same problems for abused children in the recent years than problems were found in earlier studies. Post-traumatic stress disorder and problems in sexual behavior are still the major areas of symptoms for abused children and the number of children in their workplace shows no decline either.

ii.) Netherlands. The farther away from the USA, the more unlikely people are to believe in serious events of child sexual abuse. Such serious events as group abuse, ritual abuse and the existence of selling children for sexual pleasure are not believed to occur outside of the USA. A prime example for this notion is conveyed in the study conducted by Jonker and Jonker-Bakker (1991). They studied the occurrence of ritual child sexual abuse in the Netherlands. The investigation led them to an event of unexpected size. Over 100 children were abused in Oude Pekela, a small town in the Netherlands, in ways that are outside of any understandable sexual behaviors. Such behavior included throwing knives and stones at the tied children, the killing of children by other children, and the permanent threat of losing their lives in the face of these events. The reaction of many people in that town after the disclosure was resistance to believe in the reality of these events. Children were called liars and were expected not to tell the stories again.

Even official statements reflect the widespread notion that something like that could not happen in the Netherlands. “Just because it happen in the States, doesn’t mean that it happens here” (Jonker, & Jonker-Bakker, 1991, p. 194) was the statement of the public prosecutor in this case. How destructive this statement for the credibility of the children was can be easily imagined. Once more the negative example is the USA, and all other countries believe in less serious events only. However, at least in the Western cultures the extent of child sexual abuse seems to be on the same level everywhere regardless whether the country is called USA or Netherlands.

iii.) Zimbabwe. But child sexual abuse does not stop at the backyard of the industrialized countries in the Western hemisphere. A report from researcher in Zimbabwe showed that the problem is as prominent in this country as it is here (Meursing, Vos, Coutinho, & Moyo, 1995). In their sample of 54 child sexual abuse victims (only one male victim) they reported an additional problem that is probably prevalent in most of the African countries and some South Asian countries as well. The child abuse was not disclosed because of behavioral problems with the child but rather because of the health status of the abused children. Half of the children were detected because they had sexually transmitted diseases, particularly HIV. If one considers the impact of this fact for the children, they are doomed to death because of the sexual gratification of their abuser, which were adult men in all the cases. Besides the impact of child sexual abuse and all its negative sequelae, these children will die from the consequences of their abuse. Family, other health and court problems seem to aggravate these problems and contribute additionally to a poor outcome expectation of the abused victims.

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