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Evaluation, Diagnosis, and Outcomes of Child Sexual Abuse

Jessica Smith

 Penn State College of Medicine

March 2002


  1. Definition: “Sexual abuse of children refers to sexual behavior between a child and an adult or between two children when one of them is significantly older or uses coercion. The perpetrator and the victim may be of the same sex of the opposite sex.     The sexual behaviors include touching breasts, buttocks, and genitals whether the victim is dressed or undressed; exhibitionism; fellatio; cunnilingus; and penetration of the vagina or anus with sexual organs or with objects. Pornographic photography is usually included in the definition of sexual abuse. It is important to consider developmental factors in assessing whether sexual behaviors between two children is abusive or normative.”5
  2. Epidemiology1:
    • Women: 16.8% , Men: 7.9%
    • Number of substantiated or indicated cases has decreased by 41% in the time period of 1992 to 2000.
  3. Risk Factors4:
    • Age: incidence of child sexual abuse increases with age
      • 0-3 y/o: 10% of victims
      • 4-7 y/o: 28.4% of victims
      • 8-11 y/o: 25% of victims
      • 12 and older: 35.9% of victims
    • Gender:
      • 2.5-3:1 female predominance
      • 25% of victims are male
    • Disabilities:
      • Risk increased for those with physical disabilities, especially those that impair the child’s perceived credibility: blindness, deafness, and mental retardation
      • Gender effect: boys are over represented among sexually abused children when compared to sexually abused children without disabilities
    • Family Constellation:
      • Absence of one or both parents is a risk factor
      • Presence of stepfather in home doubles the risk for girls
      • Parental impairments are also associated with increased risk
    • Socioeconomic status:
      • More important for physical abuse and neglect
      • Much less impact on child sexual abuse
    • Race and Ethnicity:
      • May influence symptom expression
      • Do not seem to be risk factors for child sexual abuse
  4. Evaluation
    • No gold standard3
    • Interview:
      • Assumed to be more reliable and more valid3
      • Time consuming3
      • Guidelines6:
        • Establish a rapport
        • Truth telling
        • Reduce the number of times interviewed
        • Make the environment comfortable
        • Obtain accurate history including development, cognitive assessment, history of prior abuse or traumas, medical history, behavioral changes, parent’s abuse as children, family attitude toward sex and modesty
        • Interview both parents when abuse is intrafamilial
        • Consider false allegations
        • Assess credibility of child
        • Dolls are not necessarily reliable and anatomical correctness is not necessary
        • Children’s drawings are helpful
    • Questionnaire3:
      • Helpful in large populations because less time consuming
      • Some are too detailed because they are meant as a substitute for an interview
    • Medical examination2 :
      • Relied on too much for diagnosing sexual abuse
      • History is the single most diagnostic feature for sexual abuse
      • Only 4% of children referred for medical evaluation have abnormal examinations
  5. Outcomes4 : Psychiatric disorders, dysfunctional behaviors, neurobiological dysregulation
    • Depression and dysthymia
      • 3-5 times more common in women with a history of child sexual abuse
      • Gender differences disappear for depression when controlled for a history of child sexual abuse
      • Altered clinical presentation- reversed neurovegetative signs such as increased appetite, weight gain, and hypersomnia
    • Sexualized behaviors
      • Increased arrest rate for sex crimes and prostitution irrespective of gender
      • Sexually abused adolescents are at increased risk for earlier pregnancy
      • Child sexual abuse is a predictor of HIV risk related behaviors
    • Neurobiological effects
      • Deleterious effects on the hypothalamic-pituitary-adrenal axis, the sympathetic nervous system and possibly the immune system
      • Sexually abused females demonstrate increased morning cortisol levels and decreased evening basal levels of cortisol
      • Sexually abused females had increased 24 hour urinary catecholamine levels
    • Borderline personality disorder, somatization disorder, substance abuse disorder, PTSD, dissociative identity disorder, and bulimia nervosa
  6. Principles of Psychopathology in child sexual abuse4
    • Twin studies- in twins discordant for child sexual abuse, affected twins had significantly higher rates of major depression, attempted suicide, conduct disorder, alcohol dependence, nicotine dependence, social anxiety, rape after age 18 and divorce
    • Basic clinical features that link different clinical outcomes associated with child sexual abuse
      • Affect regulation
      • Impulse control
      • Somatization
      • Sense of self
      • Cognitive distortions
      • Socialization problems
  7. DSM-IV Diagnosis4
    • Individually based on symptoms
    • Disorder of extreme stress not otherwise specified (DESNOS)
  8. Treatment4
    • Asymptomatic children
      • 40% of sexually abused children present with few or no symptoms
      • ‘sleeper effects’: 10-20% will deteriorate over the next 12 to 18 months
      • Need to be evaluated for additional risk factors
    • Symptomatic children
      • 62.8% qualify for at least one psychiatric diagnosis
      • 29.5% qualify for 2 or more psychiatric diagnoses
      • Cognitive behavioral therapy is affective for some symptoms of child sexual abuse
      • Appropriately treat for psychiatric diagnoses


  1. Gorey, K. and Donald Leslie. (1997). “The prevalence of child sexual abuse: Integrative review adjustment for potential response and measurement biases.” Child Abuse and Neglect. Vol. 21(4): 391-398.
  2. Heger, A., Ticson, L., Velasquez, O., and Bernier, R. (2002). “Children referred for possible sexual abuse: medical findings in 2384 children.” Child Abuse and Neglect. Vol. 26: 645-659.
  3. Kooiman, C.G., Ouwehand, A.W., and ter Kuile, M.M. (2002). “The sexual abuse questionnaire (SPAQ): A screening instrument for adults to assess past and current experiences of abuse. Child Abuse and Neglect. Vol. 26: 939-953.
  4. Putnam, Frank W. (2003) “Ten year research update review: child sexual abuse.” J. Am. Acad. Child Adolesc. Psychiatry. Vol. 42(3): 269-278.
  5. “Practice Parameters for the forensic evaluation of children and adolescents who may have been physically or sexually abused.” AACAP Partial text.
  6. “Guidelines for: The clinical evaluation of child and adolescent sexual abuse.” (2001).
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