The economic burden of child sexual abuse in the United States

The present study provides an estimate of the U.S. economic impact of child sexual abuse (CSA). Costs of CSA were measured from the societal perspective and include health care costs, productivity losses, child welfare costs, violence/crime costs, special education costs, and suicide death costs. We separately estimated quality-adjusted life year (QALY) losses. For each category, we used the best available secondary data to develop cost per case estimates. All costs were estimated in U.S. dollars and adjusted to the reference year 2015. Estimating 20 new cases of fatal and 40,387 new substantiated cases of nonfatal CSA that occurred in 2015, the lifetime economic burden of CSA is approximately $9.3 billion, the lifetime cost for victims of fatal CSA per female and male victim is on average $1,128,334 and $1,482,933, respectively, and the average lifetime cost for victims of nonfatal CSA is of $282,734 per female victim. For male victims of nonfatal CSA, there was insufficient information on productivity losses, contributing to a lower average estimated lifetime cost of $74,691 per male victim. If we included QALYs, these costs would increase by approximately $40,000 per victim. With the exception of male productivity losses, all estimates were based on robust, replicable incidence-based costing methods. The availability of accurate, up-to-date estimates should contribute to policy analysis, facilitate comparisons with other public health problems, and support future economic evaluations of CSA-specific policy and practice. In particular, we hope the availability of credible and contemporary estimates will support increased attention to primary prevention of CSA.     

The impacts of institutional child sexual abuse: A rapid review of the evidence

While awareness of institutional child sexual abuse has grown in recent years, there remains limited understanding of its occurrence and outcomes as a distinct form of abuse. Drawing on research commissioned by the Australian Royal Commission into Institutional Responses to Child Sexual Abuse, this article presents a rapid review of available evidence on the impacts of institutional abuse on victim/survivors. Literature searches identified 75 sources spanning international peer reviewed work and reports to Government that document or quantify the impacts of mostly historical child sexual abuse occurring in religious, educational, sporting and residential or out-of-home care settings. Consistent with child sexual abuse in other contexts, institutional child sexual abuse is found to be associated with numerous, pervasive and connected impacts upon the psychological, physical, social, educative and economic wellbeing of victims/survivors. Further, institutional child sexual abuse is associated with vicarious trauma at the individual, family and community level, and with impacts to the spiritual wellbeing of victims/survivors of abuse that occurs in religious settings. The identified literature suggests the trauma of institutional child sexual abuse may be exacerbated by the interplay of abuse dynamics in institutional settings, which may reduce or impede circumstances supporting disclosure, belief, support and protection from future harm. Acknowledging the limitations of the present study and the available evidence, this narrative synthesis provides insights into the complex impacts of institutional child sexual abuse.     

Getting evidence into action to tackle institutional child abuse

The Australian Royal Commission into Institutional Responses to Child Sexual Abuse is an example of a government response to survivors’ demands to address the harm they suffered. It is also a major response by a national government to improve child safety in the future. Facing up to child abuse is difficult and in other countries similar inquiries have suffered delays and derailing. This commentary uses an evidence-to-action lens to explore why clear evidence of child sexual abuse may be ignored and side-lined. It argues that where evidence challenges the powerful, is surprising and shocking, or undercuts current institutional and policy arrangements, then that evidence is likely to be ignored, undermined or refuted – all factors which are present in the case of historical institutional child sexual abuse.     

Differences in child sexual abuse cases involving child versus adolescent complainants

While adolescents report the highest rates of sexual abuse victimization, few studies have investigated how child sexual abuse (CSA) cases involving adolescent complainants may differ from cases involving child complainants. The current study draws on 3,430 allegations of CSA in Canada to compare abuse characteristics and judicial outcomes in cases involving adolescent complainants to cases involving child complainants. Adolescent complainants were more likely than child complainants to be abused by a stranger or a person with a community connection to the complainant, while children were more likely than adolescents to be abused by a parent or other relative. Furthermore, compared to child complainants, adolescent complainants were more frequently involved in the most intrusive offenses and their cases were more likely to involve violence. Both groups were most likely to disclose the abuse to a parent, though a greater proportion of children disclosed the abuse to a parent. There were no differences in the delay to disclosure. Accused were equally likely to plead “guilty” and to be convicted in cases involving child and adolescent complainants. However, offenders convicted of the most intrusive offenses received longer probation sentences when the complainant was a child than when the complainant was an adolescent. These findings have implications for ensuring appropriate support and services to adolescent victims of CSA.     

A response to the Royal Commission into institutional responses to child sexual abuse in Australia

Abstract

The final report of the Australian Royal Commission into institutional responses to child sexual abuse comprises 17 volumes, one of which addresses its findings in relation to schools. In this article, I raise two key questions in response to the devastating details of the allegations made by survivors of their abuse: how was any of this possible, and what really does go on in schools? In answer to these questions, I critique both the codes of ethics and conduct authored by the Victorian Institute of Teaching and draw attention to their conceptual inadequacy and terminal ambiguity. I then make a case for renewed research into sociological and historical aspects of schooling in Australia, emphasising a need to gain access to ‘private’, especially boarding, schools. In particular, I argue for a Foucauldian approach to understanding how education in catholic seminaries needs to be better understood in the context of child sexual abuse in Catholic schools.     

Diagnostic agreement when comparing still and video imaging for the medical evaluation of child sexual abuse

Still photo imaging is often used in medical evaluations of child sexual abuse (CSA) but video imaging may be superior. We aimed to compare still images to videos with respect to diagnostic agreement regarding hymenal deep notches and transections in post-pubertal females. Additionally, we evaluated the role of experience and expertise on agreement. We hypothesized that videos would result in improved diagnostic agreement of multiple evaluators as compared to still photos. This was a prospective quasi-experimental study using imaging modality as the quasi-independent variable. The dependent variable was diagnostic agreement of participants regarding presence/absence of findings indicating penetrative trauma on non-acute post-pubertal genital exams. Participants were medical personnel who regularly perform CSA exams. Diagnostic agreement was evaluated utilizing a retrospective selection of videos and still photos obtained directly from the videos. Videos and still photos were embedded into an on-line survey as sixteen cases. One-hundred sixteen participants completed the study. Participant diagnosis was more likely to agree with study center diagnosis when using video (p < 0.01). Use of video resulted in statistically significant changes in diagnosis in four of eight cases. In two cases, the diagnosis of the majority of participants changed from no hymenal transection to transection present. No difference in agreement was found based on experience or expertise. Use of video vs. still images resulted in increased agreement with original examiner and changes in diagnostic impressions in review of CSA exams. Further study is warranted, as video imaging may have significant impacts on diagnosis.     

Religion in child sexual abuse forensic interviews

Religion is an under-studied factor affecting children’s sexual victimization and their willingness to discuss such experiences. In this qualitative study, 39 child forensic interviewers and child advocacy center (CAC) directors in the United States discussed religious influences on children’s sexual abuse experiences, their relationships to CACs, and their disclosures in the forensic setting. Participants reported both harmonious and dissonant interactions between religiously observant children and families on one hand and child advocacy centers on the other. Themes emerged related to abuse in religious contexts and religious justifications for abuse; clergy and religious supports for disclosures as well as suppression of disclosures; and the ways CACS accommodate religious diversity and forge collaborations with clergy. Participants discussed a wide range of religions. Recommendations for practice and research are included.     

An examination of trends in child sexual abuse investigations in Ontario over time

BackgroundChild sexual abuse (CSA) rates have been declining since the 1990s (Dunne et al., 2003; Finkelhor & Jones, 2004, 2012; Jones et al., 2001). Discrepancies in contexts and measures complicate comparing CSA rates across jurisdictions and studies, and there is limited literature about trends in CSA in Canada.ObjectiveUsing data from the Ontario Incidence Study of Reported Child Abuse and Neglect (OIS), the only source of provincially aggregated data in Ontario, Canada, that describes child welfare investigations, this paper provides information on reported and investigated CSA over the past 20 years.Participants and settingThe OIS uses a file review methodology; information is collected directly from investigating child welfare workers.MethodsA sample of child welfare agencies is selected for the study, and data are collected over a three-month period. Weights are applied to produce annual provincial estimates.ResultsThe rates of investigated CSA in Ontario decreased between 1993 and 2013, from 5.20 (95% CI [3.94, 6.47]) to 1.81 (95% CI [0.97, 2.66]) children per 1000. During this time, the rate of all child maltreatment-related investigations doubled, from 21.41 (95% CI [18.38, 24.42]) to 53.32 ([29.61, 77.03]) children per 1000.ConclusionsUnlike other forms of child maltreatment, the incidence of investigated CSA in Ontario declined since 1993. Substantiation rates for CSA investigations decreased more dramatically than the rate of all CSA investigations, which could indicate a true decline in rate or an inability to accurately identify cases of CSA.     

The use of telemedicine in child sexual abuse evaluations

OBJECTIVE: To describe the advantages, disadvantages and current status of child abuse consultations conducted through telemedicine networks. METHOD: The results of a telephone survey of seven statewide telemedicine networks are reported and discussed with respect to goals, funding, technical support and expertise, infrastructure, and extent of use. Quality assurance and liability issues concerning telemedicine child abuse consultations are also reviewed. RESULTS: The goals of telemedicine networks in child abuse are to provide (1) expertise to less experienced clinicians primarily in rural areas; (2) a method for peer review and quality assurance to build consensus of opinions particularly in sexual abuse cases; and (3) support for professionals involved in an emotionally burdensome area of pediatrics. Problems encountered by existing networks include: (1) funding for equipment and reimbursement for consultation; (2) consistent technical support: (3) clinician lack of technical expertise, knowledge, or motivation; and (4) lack of network infrastructure. Legal considerations include licensure exemptions for consulting across state lines, potential for malpractice, patient confidentiality and security of images forwarded over modem lines, and liability of the equipment, consulting site, and the consultant in criminal proceedings. CONCLUSIONS: Telemedicine consultations offer a unique opportunity to raise the standard of care in child abuse evaluations, but success depends on clinician motivation, appropriate infrastructure, and ongoing funding and technical support.     

Perceptions of caregivers and adolescents of the use of telemedicine for the child sexual abuse examination

BackgroundChildhood sexual abuse is a common cause of morbidity and mortality. All victims should receive a timely comprehensive medical exam. Currently there is a critical shortage of child abuse pediatricians who can complete the comprehensive child sexual abuse examination. Telemedicine has emerged as an innovative way to provide subspecialty care to this population. Despite the growing popularity of telemedicine, no literature exists describing patient and caregiver perceptions of telemedicine for this sensitive exam.ObjectiveTo explore caregiver and adolescent perspectives of the use of telemedicine for the child sexual abuse examination and discover factors that drive satisfaction with the technology.Participants and SettingCaregivers and adolescents who presented for a child sexual abuse medical evaluation at our county’s child advocacy center.MethodsWe completed semi structured interviews of 17 caregivers and 10 adolescents. Guided by the Technology Acceptance Model interviews assessed perceptions about: general feelings with the exam, prior use of technology, feelings about telemedicine, and role of the medical team. Interviews were audio-recorded, transcribed, coded and analyzed using content analysis with constant comparative coding. Recruitment ended when thematic saturation was reached.ResultsThere was an overwhelming positive response to telemedicine. Participants reported having a good experience with telemedicine regardless of severity of sexual abuse or prior experience with technology. Behaviors that helped patients and caregivers feel comfortable included a clear explanation from the medical team and professionalism demonstrated by those using the telemedicine system.ConclusionTelemedicine was widely accepted by adolescents and caregivers when used for the child sexual abuse examination.     

The unusual suspects: Female versus male accused in child sexual abuse cases

When women encounter the criminal justice system, it is typically as victims rather than as offenders. Consequently, there is limited empirical research on women who have sexually offended against children, but there is a clinically-significant group of victims who have experienced female-perpetrated child sexual abuse (CSA). In a database of 4237 CSA cases that were heard in criminal courts between 1986 and 2012, we found 70 cases that involved female accused. We compared female-accused cases against a randomly selected sample of 70 male-accused cases from the same database. We investigated associations between gender of the accused and characteristics of the victim, offense, and criminal proceeding. Several important differences between female- and male-accused cases were found: proportionally more male complainants were in female-accused cases; female-accused offenses were longer in duration; and despite offenses being similarly intrusive, female perpetrators received shorter sentences. This research indicates that there are potentially unique pathways to abuse for women and men, and unique experiences in the criminal justice system. Although female perpetrators are involved in a small proportion of CSA offenses, the cases that we describe herein are important to consider when developing appropriate support and intervention programs for offenders and victims of CSA.     

Neuroticism as a risk factor for child abuse in victims of childhood sexual abuse

Findings on the relationship of experienced sexual abuse and abuse behavior in adulthood are ambiguous. However, associations between experienced abuse and neuroticism as well as between neuroticism and active child abuse have been reported repeatedly. In our study, we compared pedosexual child abusers with consumers of internet child pornography and control subjects with adult-sexual preference with regard to traumatic childhood experience (Childhood Trauma Questionnaire, CTQ), personality traits (NEO – Personality Inventory – Revised, NEO-PI-R), and sexual abnormalities (Multiphasic Sex Inventory, MSI). In an initial analysis, sexual abuse experienced in childhood was not directly linked to sexual abuse behavior in adulthood. However, this relationship was mediated by neuroticism. In a second step, the CTQ scales were conflated and, using a structural equation model, direct links between the overall level of abuse experienced in childhood (generally high CTQ levels) and sexual abuse behavior in adulthood revealed again the mediation by neurotic personality. We conclude that the overall level of abuse experienced in childhood in general, and less sexual abuse experience in particular, modulates the tendency for child sexual abuse behavior in adulthood. Data suggest that, depending on the resilience of an individual, abuse experience during childhood increases the likelihood of developing neurotic personality traits in later life, which are in turn considered to increase the risk of child sexual abuse in child sex offenders.     

Credibility assessment in child sexual abuse investigations: A descriptive analysis

A major challenge in cases of child sexual abuse (CSA) is determining the credibility of children's reports. Consequently cases may be misclassified as false or deemed ‘no judgment possible’. Based on a large national sample of reports of CSA made in Israel in 2014, the study examines child and event characteristics contributing to the probability that reports of abuse would be judged credible. National data files of all children aged 3–14, who were referred for investigation following suspected victimization of sexual abuse, and had disclosed sexual abuse, were analyzed. Cases were classified as either ‘credible’ or ‘no judgment possible’. The probability of reaching a ‘credible’ judgment was examined in relation to characteristics of the child (age, gender, cognitive delay, marital status of the parents,) and of the abusive event (abuse severity, frequency, perpetrator–victim relationship, perpetrator's use of grooming, and perpetrator's use of coercion), controlling for investigator's identity at the cluster level of the analysis. Of 1563 cases analyzed, 57.9% were assessed as credible. The most powerful predictors of a credible judgment were older age and absence of a cognitive delay. Reports of children to married parents, who experienced a single abusive event that involved perpetrator's use of grooming, were also more likely to be judged as credible. Rates of credible judgments found are lower than expected suggesting under-identification of truthful reports of CSA. In particular, those cases of severe and multiple abuse involving younger and cognitively delayed children are the ones with the lowest chances of being assessed as credible.     

Child maltreatment re-offending in families served by the United States Air Force Family Advocacy Program

The current study examined child maltreatment re-offending in United States Air Force (USAF) families. In a clinical database containing 24,999 child maltreatment incidents perpetrated by 15,042 offenders between the years 1997 and 2013, 13% of offenders maltreated a child on more than one date (i.e., they re-offended). We explored several offender demographic characteristics associated with who re-offended and found that civilians re-offended at a similar rate as active duty members, males re-offended at a similar rate as females, and younger offenders were more likely to re-offend than older offenders. We also explored incident characteristics associated with who re-offended: Re-offending was more likely if the initial maltreatment was neglect or emotional abuse and re-offenders were likely to perpetrate subsequent maltreatment that was the same type and severity as their initial incident. The current data indicate that young offenders and offenders of neglect and emotional maltreatment are the greatest risk of re-offending. These offender and incident characteristics could be used by the USAF to guide their efforts to reduce re-offending.     

The characteristics of reports to the police of child sexual abuse and the likelihood of cases proceeding to prosecution after delays in reporting

Delays in disclosing and reporting child sexual abuse to the police are common, particularly among males and those who have been abused by clergy and others in a position of trust. This study, commissioned by the Royal Commission into Institutional Responses to Child Sexual Abuse, examined the patterns of timely and delayed reporting of sexual offences against children, and the likelihood of legal action commencing. De-identified unit record data for all sexual offences against children reported to the police over 20 years were obtained from official crime statistics agencies in two Australian states. While there were similarities between the two states in terms of the influence of public inquiries on reporting numbers over this period, and in the factors associated with delayed reporting, there were substantial differences in the likelihood of legal action being taken in cases reported by a child or adult complainants. In one state, legal action was more likely with increasing delay, until the delays extended to 10–20 years, after which the likelihood of legal action decreased. In the other state, the pattern was quite different – reports of sexual assault were somewhat more likely to result in legal action with immediate reporting. The least likely to proceed were cases involving young children in more recent years; long delays into adulthood were not necessarily adverse for prosecution.     

Removing the child--prosecuting the offender in cases of sexual abuse: evidence from the national reporting system for child abuse and neglect

Sexual abuse has come to public attention so rapidly and is such a difficult problem to deal with that many observers are concerned that the quality of child protective intervention in these cases has been haphazard and indiscriminate. This article analyzes data on all 6,096 cases of child sexual abuse which were "officially reported" in 1978 to see what kinds of intervention were made. The data show that foster placement occurred in more cases of sexual abuse than physical abuse, and was concentrated among cases of older children who reported their own victimization. Criminal action was taken almost five times more often in cases of sexual abuse than in cases of physical abuse, and occurred more often among cases which were directly reported to police and involved offenders with prior criminal records. Black families and poorer families did not seem to be the objects of obvious discrimination in the disposition of these cases.     

Perpetrators and context of child sexual abuse in Kenya

Child sexual abuse (CSA) interventions draw from a better understanding of the context of CSA. A survey on violence before age 18 was conducted among respondents aged 13–17 and 18–24 years. Among females (13–17), the key perpetrators of unwanted sexual touching (UST) were friends/classmates (27.0%) and among males, intimate partners (IP) (35.9%). The first incident of UST among females occurred while traveling on foot (33.0%) and among males, in the respondent's home (29.1%). Among females (13–17), the key perpetrators of unwanted attempted sex (UAS) were relatives (28.9%) and among males, friends/classmates (31.0%). Among females, UAS occurred mainly while traveling on foot (42.2%) and among males, in school (40.8%). Among females and males (18–24 years), the main perpetrators of UST were IP (32.1% and 43.9%) and the first incident occurred mainly in school (24.9% and 26.0%), respectively. The main perpetrators of UAS among females and males (18–24 years) were IP (33.3% and 40.6%, respectively). Among females, UAS occurred while traveling on foot (32.7%), and among males, in the respondent's home (38.8%); UAS occurred mostly in the evening (females 60.7%; males 41.4%) or afternoon (females 27.8%; males 37.9%). Among females (18–24 years), the main perpetrators of pressured/forced sex were IP and the first incidents occurred in the perpetrator's home. Prevention interventions need to consider perpetrators and context of CSA to increase their effectiveness. In Kenya, effective CSA prevention interventions that target intimate relationships among young people, the home and school settings are needed.     

The sexual abuse of Afro-American and White-American women in childhood

This study examined the prevalence of child sexual abuse in a multi-stage stratified probability sample of Afro-American and white-American women, 18 to 36 years of age, in Los Angeles County. The sample ranged in demographic characteristics by age, marital status, education and the presence of children. Of the total sample of 248 women, 154 (62%) reported at least one incident of sexual abuse prior to age 18, with 57% of Afro-American women and 67% of white-American women having been abused. Sexual abuse before the age of 18 appears to be of equal concern for both ethnic groups, although similarities and differences in the circumstances under which abuse incidents occurred were subtle and deserve attention. The need for identifying contemporary factors that contribute to the prevalence of abuse over the past 40 years is stressed.     

Narrative fragmentation in child sexual abuse: The role of age and post-traumatic stress disorder

The present study aimed to assess the effects of age and PTSD on the narrative fragmentation in memories for child sexual abuse. Lexical complexity, cohesion and coherence were analyzed within a group of 86 allegations of children (M = 10 years; SD = 3.7; range: 4–17) who were victims of sexual abuse. Results illustrated that age played an important role in establishing narrative coherence and predicted the level of orientation, the sequence of events and the level of evaluation of the event. Instead, PTSD was related to narrative coherence and cohesion. Therefore, in children, the narrative fragmentation could be an effective diagnostic tool for understanding the effects of PTSD. Moreover in a legal setting the traumatic effects of PTSD on the narrative coherence and cohesion could be significant indices in the evaluation of child testimony.     

Gendered pathways from child sexual abuse to sexual aggression victimization and perpetration in adolescence and young adulthood

This study aimed to examine the pathways from child sexual abuse to sexual assault victimization and perpetration in adolescence and early adulthood, considering risky sexual behavior and lowered sexual self-esteem as mediator variables. In a two-wave longitudinal study with 2251 college students in Germany, male and female participants provided reports of sexual aggression victimization and perpetration since age 14 (T1) and again a year later (T2), covering the last 12 months. In addition, child sexual abuse (CSA; before the age of 14), risky sexual behavior, and sexual self-esteem were assessed at T1, and risky sexual behavior and sexual-self-esteem were assessed again at T2. Experience of CSA was significantly associated with greater likelihood of sexual aggression victimization and perpetration, lower sexual self-esteem, and more risky sexual behavior in both gender groups at T1 and was directly related to victimization at T2 among male participants. In both gender groups, CSA indirectly contributed to a higher probability of sexual victimization at T2 via its impact on victimization T1. In males, the indirect path from CSA to T2 perpetration via T1 perpetration was also significant. Through its negative impact on sexual self-esteem, CSA indirectly increased the probability of sexual victimization among women and the probability of sexual aggression perpetration among men. Risky sexual behavior mediated the pathway from CSA to sexual victimization at T2 for men and women and the pathway from CSA to sexual aggression perpetration for women. The findings contribute to the understanding of gendered effects of CSA on revictimization and the victim-to-perpetrator cycle.