Introduction
Reported incidents of child sexual abuse are markedly on the rise. What is especially shocking is the fact that these reports represent only a small portion of actual occurrences of sexual abuse. Incest affects individuals and families regardless of class, income, profession, religion or race. The statistics are truly alarming. It is currently estimated that one-third of all children are sexually abused before the age of 18. This includes 40% of all females and 30% of all males. The vast majority of these reports involve very young children, below age seven.

Every year in this country, two million children are brutally beaten or sexually abused. 340,000 new cases were reported in 1989 (U.S. Advisory Board, April, 1991). Of these abused children, 3,000 to 5,000 die every year. In New York State alone, 200 bodies of sexually and physically abused children are found each year and not even identified. These are the ultimate victims.

Children who are neglected or sexually abused are known to have lower IQs and an increased risk of depression, suicide and drug problems. Abused children are 53% more likely to be arrested as juveniles, and 38% more likely to be arrested for a violent crime. During preschool years, abused children are more likely to get angry, refuse direction from teachers, and lack enthusiasm. By the time they reach grade school, they are more prone to being easily distracted, lacking in self-control, and not well-liked by peers. ^l

Myths
There are many commonly held beliefs about sexual abuse. One is that abusers are always men. In fact, reports of female perpetrators are on the rise, involving both male and female victims. At least 5% of abusers are known to be women. Another myth is that the abuser is usually a stranger. More than 70% of abusers are immediate family members or someone very close to the family. Remember – bad guys don’t always look bad; they’re often the people we love. A third myth is that the abuser is always hated. Often the victim loves and protects the perpetrator. Some children feel "special" about the abuse. It may be the only attention or physical contact they’re getting. Because of this, some survivors even into adulthood will deal with the abuse by minimizing it. Thus, they make the abuser and the events "OK", to make it feel like they’re okay. An additional myth is that only females are sexually abused. In fact, 30% of all male children are molested in some way, compared to 40% of females.

Occurrence of Abuse
If you are one of the survivors, you are acutely aware that these numbers represent much more than statistics. They represent the pain and anguish and shattered dreams of so many individuals. You are also aware, if you are a survivor, that it’s often not the mysterious stranger in a trench coat who commits this type of crime. Typically it’s a friend, a parent, someone you love and trust – and it often happens at home. The effects of this kind of brutal betrayal are shattering and may last a lifetime.

Specialists in the addiction field (alcohol, drugs and eating disorders) estimate that up to 90 percent of their patients have a known history of some form of abuse. Recent studies (Calam, 1989²; Blume, 1989³) point out that substance abuse, including "food abuse," is a frequent aftermath of early sexual abuse. Current studies (Koopmans, 1990⁴) demonstrate that the vast majority of children and adolescents who attempt suicide have a history of sexual abuse as well. However, many individuals are resistant to seeking treatment for sexual abuse. This is especially true for males and adolescents. Men are often extremely reluctant to admit to any history of abuse and often fail to identify it as such. Many survivors are in denial of the effects of early abuse and may fail to see any connection with later tendencies toward ongoing abusive relationships, feelings of self-loathing, inability to trust, or problems with intimacy. Some patients denigrate themselves further, claiming that their abuse could not have been "as bad" as that of other victims. All abuse is bad.

Defining Sexual Abuse
The diversity of examples and case histories may lead one to ask, "What is sexual abuse?" There are many definitions. One of the most succinct is provided by the Incest Survivors Resource Network.⁵ They state "the erotic use of a child, whether physically or emotionally, is sexual exploitation in the fullest meaning of the term, even if no bodily contact is ever made." This last point – "no bodily contact" – is crucial. A parent who exposes a child to intercourse or deviant sexual behaviors or pornographic materials is abusing that child. New York State law now clarifies that such abuse is a crime. The law defines a sexually abused child as one whose parent or person legally responsible for the child’s care, commits, allows to be committed, permits or encourages a sex offense against the child, including prostitution, incest, obscene sexual performance or sexual conduct.

Sexual abuse in the extreme includes ritual and cult abuse. Ritual abuse involves a specific rite or form in which the abuse is encapsulated. Cult abuse embraces a "religious" or spiritual belief system, usually Satanic. Cults may consist of individual "dabblers" or small, isolated groups. They may also include generations within families or whole segments of communities. They operate by destroying all bonding for their victims, and surrounding the child with total unpredictability or powerlessness. Drugs or trickery may be employed…sometimes even murder.

Defining Incest
Incest was traditionally defined as sex between close relatives. But incest is, above all, abuse; abuse by the very person(s) entrusted with the child’s care. Incest is "any use of a minor child to meet the sexual or sexual/emotional needs of one or more persons whose authority is derived through ongoing emotional bonding with that child."⁶

Incest is especially common in alcoholic families, where judgment and boundaries are impaired. If the perpetrator always commits the act while under the influence of alcohol or some other substance, (s)he may have no memory of the events. Victims also may or may not remember. The trauma may be so severe that part or all of the abuse is blocked from conscious memory. This may continue for many years until something triggers a "flashback," although the effects of the abuse, emotionally or behaviorally, continue all along. The protective role of such blocking must be explained to patients who may, in fact, experience increasing flashbacks as treatment continues.

My own growing awareness of this led to the start of the Survivors’ Group Program at South Oaks Hospital in July, 1988. I began with five women patients. Within a year and a half, I was easily able to expand the groups and the program to include six times that many patients from the hospital – men and women, adolescents and adults. This grew into a full-scale Sexual Abuse Recovery Program with inpatient, outpatient, and aftercare components. It was the first unit of its kind on the East Coast, and was unique for Long Island, despite the pervasiveness of individuals with life problems stemming from a background of abuse. Survivors are everywhere.

Reporting Sexual Abuse
Health professionals are legally obligated by New York State to report suspected child abuse when there exists reasonable cause to suspect. Absolute certainty is not required. The professional may be civilly or criminally liable if no report is made and is provided legal immunity for making the report. The call is made to the New York State Central Register of Child Abuse (1-800-342-3720). Anyone may call this number to report suspected abuse.

Identifying Abused Children
No child is psychologically prepared to deal with ongoing or intensive sexual stimulation. Even very young children, two or three years old, may sense that the sexual activity is "wrong," but they are unable to stop it. Children are frequently threatened that if they tell anyone, they will be killed or sent away, or their puppy will be killed; or their whole family will breakup.

Children subjected to sexual over-stimulation, with or without threats, will develop problems. Those older than five years of age become caught between loyalty to or dependence on the perpetrator, and shame at doing something "wrong." Over time, the child develops low self-esteem, feelings of being worthless or "dirty," and an abnormal view of sexuality. How do you recognize such children? There are many signs:

• Withdrawal and mistrust of adults
  
• Suicidality
  
• Difficulty relating to others except in sexual or seductive ways
  
• Unusual interest in or avoidance of all things sexual or physical
  
• Sleep problems, nightmares, fears of going to bed
  
• Frequent accidents or self-injurious behaviors
  
• Refusal to go to school, or to the doctor, or home
  
• Secretiveness or unusual aggressiveness
  
• Sexual components to drawings and games
  
• Neurotic reactions (obsessions, compulsiveness, phobias)
  
• Habit disorders (biting, rocking)
  
• Wears long sleeves in hot weather (to hide bruises?)
  
• Unusual sexual knowledge or behavior
  
• Prostitution
  
• Forcing sexual acts on other children
  
• Extreme fear of being touched
  
• Unwillingness to submit to physical examination

Specific physical indicators of recent sexual abuse include:

• Difficulty in walking or sitting
  
• Torn, stained or bloody clothing
  
• Pain or itching in genital area
  
• Bruises or bleeding in genital area or mouth
  
• Pregnancy or sexually transmitted diseases, especially in preteens
  
• Repeated urinary infections or genital blockages

Identifying Adults Abused As Children
The effects of early sexual abuse last well into adulthood, affecting relationships, work, family, and life in general. Individual symptomatology tends to fall into four areas: ⁷

1. Damaged goods: Low self-esteem, depression, self-destructiveness (suicide and self-mutilation), guilt, shame, self-blame, constant search for approval and nurturance.
   
   
2. Betrayal: Impaired ability to trust, blurred boundaries and role confusion, rage and grief, difficulty forming relationships.
   
   
3. Helplessness: Anxiety, fear, tendency towards re-victimization, panic attacks.
   
   
4. Isolation: Sense of being different, stigmatized, lack of supports, poor peer relations.

Adult incest survivors may demonstrate some of the following symptoms:

• Fear of the dark, fear of sleeping alone, nightmares, night terrors
  
• Difficulty with swallowing, gagging
  
• Poor body image, poor self-image in general
  
• Wearing excessive clothing
  
• Addictions, compulsive behaviors, obsessions
  
• Self-abuse, skin-carving (also addictive),
  
• Suicidality
  
• Phobias, panic attacks, anxiety disorders, startle response
  
• Difficulties with anger/rage
  
• Splitting/ de-personalization, shutdown under stress
  
• Issues with trust, intimacy, relationships
  
• Issues with boundaries, control, abandonment
  
• Pattern of re-victimization, not able to say "no"
  
• Blocking of memories, especially between age one and 12
  
• Feeling crazy, different, marked
  
• Denial, flashbacks
  
• Sexual issues and extremes
  
• Multiple personalities
  
• Signs of post traumatic stress disorder

Certain issues appear repeatedly. For example, victims typically blame themselves for the abuse, even if they were two or three years old at the time of the event. Guilt and shame are expressed, along with intense feelings of rage.⁸

If the rape or molestation was committed by an individual of the same sex (i.e., a man abusing a boy), questions regarding sexual orientation tend to arise in the patient ("I must be gay; after all, a man raped me!"). Female victims will frequently develop sexually promiscuous lifestyles in an effort to "conquer" the situation and bring it under their control. In other instances individuals will largely withdraw from any social or sexual interactions in order to avoid the feared stimuli, and turn toward extremely isolated lives.

The connection that is made for victims between sex and pain (love and humiliation, closeness and betrayal) is a particularly disastrous one. Frequently patients will express and/or demonstrate the belief that the only way to be loved or cared for is if they are also being abused ("I knew if I didn’t let him keep beating me, I’d always be alone"). Often, in the extreme, physical and sexual abuse are even viewed as a normal part of everyday life. Healthy boundaries do not exist for these individuals, and therefore, healthy relationships are impossible. Victims will actually respond to feelings of loneliness or sadness by abusing themselves (e.g., self-mutilation) if the "significant other" is not available to do so.

One of the more difficult issues that arise is the recollection, by some individuals, of experiencing a certain amount of physical pleasure during a molestation or incest. This adds enormously to the sense of being at fault and "dirty." Thus, one of the aims of treatment is to educate survivors as to normal physiological responsiveness. The realization that their feelings are/were normal helps tremendously toward alleviating the sense of shame.

Even when individuals have spoken of their abuse prior to group treatment, any pleasurable aspects have typically been denied. The opportunity to relate to others who have shared these feelings, as well as the experience, is part of the healing power of this form of therapy. The sense of isolation, of being "different from the whole world," quickly begins to subside. It is only in revealing the secrets and dealing with the pain that survivors of sexual abuse can and do go on with their lives.

References

1. Incest Survivors’ Resource Network, International. (1990). Manual. N.Y. Yearly Meeting, Hicksville, NY.

2. Calam, R.M., (1989) Sexual experience and eating problems in female undergraduates. International Journal of Eating Disorders, 8, 391-399.

3. Blume, E. Sue, (1989). Secret Survivors: Uncovering incest and its aftereffects. John Wiley & Sons, NJ.

4. Koopmans, M., (1990). Yeshiva University/Einstein College. Personal Communication.

5. Op. Cit., Incest Survivors Resource Network.

6. Heiman, M., (1988). Untangling incestuous bonds: The treatment of sibling incest. In M. Kahn & K. Lewis (Eds.), Siblings in Therapy, Norton & Co., N.Y.

7. Ibid.

8. Hartman, M., Finn, S.E., & Leon, G.R., (1987). Sexual abuse experiences in a clinical population: Comparisons of familial and non-familial abuse. Psychotherapy, 24, 154-159.

copyright © 1998 by The American Academy of Experts in Traumatic Stress, Inc.

© Copyright 1998-2005. All rights reserved. Contact: Last edited: 01/02/03.