Families' and Victims' Characteristics Influencing Child Sexual Abuse

Child sexual abuse is considered an important national public health problem that must be addressed with a sense of urgency [1]. Unfortunately, many incidents of child sexual abuse go unreported [2]. Therefore, US Department of Health and Human Services (USDHHS) reported that actual rates of sexual abuse are thought to be much higher than those recorded in official records [3]. The most informative official sources of data are those that provide the number of reported or substantiated cases of child sexual abuse in the US and all over the world. Significantly, though, these data have been severely criticized as underreporting the incidence of child sexual abuse. There is a large discrepancy between official data and prevalence estimates based on retrospective studies, which always report higher rates. The World Health Organization (WHO) estimates one in five women and one in thirteen men report having been sexually abused as a child every year in the world community [4]. These astounding numbers suggest that sexual abuse is an unfortunate part of the lives of many children in communities all over the world. The United States Department of Health and Human Services (USDHHS) reported that in 2010 alone, 63,527 American children were reported having been sexually abused [5]. Oftentimes, unreported cases of sexual abuse can be identified by researching familial characteristics and reported health histories, and through assessing and treating individuals who manifest psychological despair and/or abuse of alcohol and drugs [6]. Families’ and children’s characteristics play important roles in disclosing and treating sexually abused cases [7].


Introduction
Child sexual abuse is considered an important national public health problem that must be addressed with a sense of urgency [1]. Unfortunately, many incidents of child sexual abuse go unreported [2]. Therefore, US Department of Health and Human Services (USD-HHS) reported that actual rates of sexual abuse are thought to be much higher than those recorded in official records [3]. The most informative official sources of data are those that provide the number of reported or substantiated cases of child sexual abuse in the US and all over the world. Significantly, though, these data have been severely criticized as underreporting the incidence of child sexual abuse. There is a large discrepancy between official data and prevalence estimates based on retrospective studies, which always report higher rates. The World Health Organization (WHO) estimates one in five women and one in thirteen men report having been sexually abused as a child every year in the world community [4]. These astounding numbers suggest that sexual abuse is an unfortunate part of the lives of many children in communities all over the world. The United States Department of Health and Human Services (USDHHS) reported that in 2010 alone, 63,527 American children were reported having been sexually abused [5]. Oftentimes, unreported cases of sexual abuse can be identified by researching familial characteristics and reported health histories, and through assessing and treating individuals who manifest psychological despair and/or abuse of alcohol and drugs [6]. Families' and children's characteristics play important roles in disclosing and treating sexually abused cases [7]. This trend is believed to have been in existence for decades [8,9]. Some children may lack adequate supervision and parental support. Nevertheless, any person who experienced sexual abuse in childhood, regardless of his/her demographic profile, tends to manifest insecure family relationships, fears, and unresolved traumas. This mix of emotions and thoughts may negatively impact the victim's life and his/her potential for positive personal growth and development because the family-related traumas extend into adulthood and are often transmitted from one generation to the next [1,10,11]. In order to detect and treat the abused children, it is important for the health care providers to have a holistic view of the problem, including being sensitive to the child-victims' and their families' characteristics which may influence on the reporting on child sexual abuse [12,13].
This article will survey the existing scholarship literature review of child-victims' and their family's characteristics. Research is needed that include demographics and characteristics of both child-victims and their families. It may be possible to provide a clearer picture of child sexual abuse. This could help to detect vulnerable children who are at risk for this horrific experience. As a result, this article may help in early detection and prompt intervention for the sexually abused children and families.

Demographic Characteristics
Family socio-demographics Priebe and Svedin found that sexually abused children were less likely to live with both parents and more likely to live in families of low socioeconomic status [14]. In a similar study, Bernard-Bonnin, Hébert, Daignault, and Allard-Dansereau compared 67 girls with a history of child sexual abuse to 67 girls without a history of child sexual abuse [15]. They found that girls who had experienced child sexual abuse were less likely to have parents with higher education and socioeconomic levels than the control group. Ramírez, Pinzón-Rondón, and Botero interviewed 1,089 mothers in order to identify maternal risk factors for child sexual abuse. Low income and education were risk factors; and older and non-employed mothers were less willing to report child sexual abuse [16]. Poor communication between parent and child increased the chances late disclosure on sexual abuse incidents. Laaksonen et al. suggested that family problems such as biological parents' alcohol abuse, substance abuse, and lack of supervision increased the risk of child sexual abuse [17]. Finkelhor, Turner, Ormrod, and Hamby added that low socioeconomic status, low educational attainment, and unemployment negatively influence parents' ability to protect and care for their children, which, in turn, negatively influences child rearing and increases psychological damage from child sexual abuse [18].

Victim's gender differences
The relationship between gender and outcome may depend on characteristics of the children and the consequences being measured. However, findings concerning the relationships between gender of the victim and frequency of child sexual abuse have been mixed [19]. Kinner argues that, because boys are physically stronger and tend to protect themselves more than girls, young female victims are more likely to be forced than are male victims [20,21]. Male perpetrators are more able to use their physical strength to control and limit the child-victims' resistance, in order to satisfy their attachment needs and intimacy desires, which fail to be satisfied through normal relationships [22]. Ranney et al. hypothesized that boys might be more reluctant to report the sexual abuse. Boys may have fears related to their identities as males or the possibilities of being labeled as homosexual or other types of sexual deviants [23]. Therefore, sexually abused male child-victims are perhaps under-reported. For female child-victim, Gibson and Leitenberg conducted a survey of 106 women with a history of child sexual abuse [24]. They reported high prevalence of unwanted sexual activities: 45% experienced force, 7% experienced threats of physical force, and 48% were given drugs or alcohol before sexual intercourse. All of the female victims in the study reported powerlessness as the main psychological problem that they experienced.

Victims' age differences
The histories of children younger than 15 years were different from those of adolescents 15 to 17 years old. For example, women who experienced child sexual abuse as younger victims reported genital touching, attempted penile-vaginal intercourse, and completed penilevaginal intercourse by the perpetrator. However, the adolescent victims experienced a greater range of activities: genital touching, oral sex, vaginal penetration with an object or finger, vaginal intercourse, anal penetration with a finger, and anal intercourse [24]. Furthermore, Modelli, Galvão, and Pratesi reported that boys are at higher risk for sexual abuse when they are below the age of 6.5 years [25].

Victim's Ethnic Differences
Victims' ethnicity and culture may influence the childhood experience of sexual abuse [26]. In a study of 142 college students, Lauterbach, Somer, Dell, and Vondeylen found that 30.9% of American students had a history of child sexual abuse; however, only 4.1% of Israeli students reported child sexual abuse [27]. In another study of 94 African American and Latino adults, Sciolla et al. asked child-victims of sexual abuse to reflect on their experiences in later life [28]. They found that African Americans described more externalizing behaviors such as anger and physical aggression; however, Latino respondents reported more internalizing behaviors such as depression and isolation. In contrast, in a survey of 1,698 young adults (ages 19-20), Trent, Clum, and Roche found no behavioral differences based on ethnicity when describing their findings about victims of child sexual abuse [29].

Family protection
Parental perceptions of sexual abuse may differ depending on their own characteristics as well as those of their children. Pullins and Jones found that parents paid more attention to behavioral and physical symptoms in preadolescent children than in adolescents; physical and sexual symptoms in adolescents may have been disregarded because parent thought their children may be sexually active [1,30]. Family members/ caregivers play an important role in supporting and protecting their children. Afifi and Macmillan studied family environment and child abuse [31]. They concluded that families with sexual abuse histories were considered less cohesive and had fewer or no household rules, and there was a general lack of mutual responsibility among household members regarding the protection of their children. Families in which child abuse occurs are also more likely to have ill-defined boundaries and a lack of limit-setting [1]. In addition, family members with sexual abuse histories were less likely to encourage personal and independent growth and development. For instance, Möhler et al. reported that mothers with a history of child physical or sexual abuse themselves were more likely to abuse their children [32]. These mothers may also react negatively to their children's disclosure of sexual abuse and not support them [33].

Response to the child-victim disclosure
Sometimes inappropriate familial responses to child sexual abuse can delay a victim's disclosure. For females, the perpetrator is often a friend of the family or the mother's sexual partner [6], and in this case, the child risks losing support from the mother by disclosing. The family's response to the child's sexual abuse may be influenced by the family's perceptions of their children's credibility or by the family's emotional connection to the perpetrator. That is to say, if the family does not perceive this act as being a realistic possibility, they may interpret the report as an indicator of the child's disrespect for elders or as an attempt to disrupt the family by untruthfully reporting sexual abuse. In these instances, the child will probably not receive support from the adults in the family and his/her sense of trust will deteriorate even further [34].
Victims of child sexual abuse tend to have fewer problems if their parents believe their disclosure and support them in the long process that is required to overcome the resulting psychological and emotional trauma [33]. For instance, family reaction to the victim of child sexual abuse determines his/her experience of externalizing and internalizing behavioral problems. It is generally recognized that adults with a history of child sexual abuse manifest behaviors that are consistent with clinical descriptions of early abuse experiences [35]. For instance, in their sample of 122 women with a history of child sexual abuse, Jonzon and Lindblad found that the majority of victims had had a close relationship with the perpetrator, were abused before the age of 6, and had sexual contact with penetration [36]. In addition, these victims were sexually abused a few times a month. The previous study explains how the relationship of the family and the child to the perpetrator can heavily influence the disclosure of sexual abuse of young children [37]. For instance, the child-victim's fear, guilt, and shame may prevent him/her from reporting the sexual assault [38]. Furthermore, in cases of intrafamilial sexual abuse, the child experiences negative caregiver reactions such as being deprived of physical and emotional care that he/she has become accustomed to receiving when he/she discloses the sexual abuse activities of a family member. In addition, many times the family member may reprimand the abused child, protect the perpetrator, and place the abused child in a position of family scapegoat by other members. These responses often hinder the children from reporting the abuse [39] and the child experience sexual abuse for a longer duration and suffers more severe physical and mental damage [40].

Conclusion
In sum, a theoretical review on child sexual abuse provides guidelines for health care providers who are challenged to be more sensitive to the child-victims' such as gender, age, and ethnicity as well as their families' characteristics such as socio-demographics, protection and response to their sexually abused children. Underreported cases are in a bad need for early detection and treatment. This theoretical information presents a continuous dialogue about children who experienced sexual abuse and identify the social environment which may influence the occurrence of child sexual abuse. This theoretical overview also provides preliminary information about the important role of parents/families to protect their children.

Recommendations
Given the literature review on the child-victim' and family' characteristics influencing child sexual abuse, including demographic and personal features, the findings from this study indicate the need for the intensification of efforts that address the prevention, early detection, and prompt intervention for these children. Parents and caregivers should be sensitive to their young children's vulnerability. Children will require that family, friends, and health care providers be more diligent about keeping these young children and youth safe and out of harm's way. In addition, involving the general public though increasing their awareness about child sexual abuse could help to decrease the incidence of this devastating experience. Policymakers and practitioners to redouble their efforts to protect child victims. Child protective services should ensure the child-victim's safety in order to prevent revictimization [41].
Finally, the researchers recommend the further studies be done to determine the emotional, psychological, and physical impact that child sexual abuse, and the specific therapeutic approaches that provide the best treatment outcomes [42,43].