Ritualistic child sexual abuse in post-conflict Eastern DRC: Factors associated with the phenomenon and implications for social work.

Ritualistic child sexual abuse (RCSA) is a critical and under-recognised form of child maltreatment prevailing in developing countries. In the Democratic Republic of Congo (DRC), children from specific communities suffer complex forms of RCSA perpetrated with extreme brutality by various individuals and groups of conspirators. Although the DRC has achieved significant milestones towards combatting war-related sexual abuse of women and children, disturbing forms of RCSA, notably child kidnapping, rape, child defilement for fetish and superstitious beliefs, child sexual exploitation, and cult-based child marriage persist and affect many victims. This study examines the factors associated with the resurgence of RCSA in post-conflict eastern DRC. The article also discusses the implications of such forms of abuse for social work practice and education in a post-war context.

[Recognizing signs of sexual abuse]. / Signalen van seksueel misbruik herkennen.

Sexual abuse is very common. In the Netherlands 42% of women and 13% of men aged over 25 years have experienced unacceptable sexual behaviour. Most victims do not seek professional help nor do they report the abuse to the police, and most of the victims who do seek medical help do not mention the abuse. Doctors often do not recognize the signs of sexual abuse. Most victims of rape have symptoms that may develop into posttraumatic stress disorder (PTSD) if they persist for more than 4 weeks, such as sleep problems or panic attacks. Victims of sexual abuse also more often develop a psychiatric disorder or medically unexplained symptoms (MUS). Doctors should ask about sexual abuse in cases of MUS or unexplained mental problems. The complications of abuse can be treated with eye movement desensitization and reprocessing (EMDR) or cognitive processing therapy (CPT).

Testing and Treatment After Adolescent Sexual Assault in Pediatric Emergency Departments.

OBJECTIVE: To examine rates of recommended of testing and prophylaxis for chlamydia, gonorrhea, and pregnancy in adolescents diagnosed with sexual assault across pediatric emergency departments (EDs) and to determine whether specialized sexual assault pathways and teams are associated with performance of recommended testing and prophylaxis. METHODS: In this retrospective study of 12- to 18-year-old adolescents diagnosed with sexual assault at 38 EDs in the Pediatric Hospital Information System database from 2004 to 2013, information regarding routine practice for sexual assault evaluations and presence and year of initiation of specialized ED sexual assault pathways and teams was collected via survey. We examined across-hospital variation and identified patient- and hospital-level factors associated with testing and prophylaxis using logistic regression models, accounting for clustering by hospital. RESULTS: Among 12,687 included cases, 93% were female, 79% were <16 years old, 34% were non-Hispanic white, 38% were non-Hispanic black, 21% were Hispanic, and 52% had public insurance. Overall, 44% of adolescents received recommended testing (chlamydia, gonorrhea, pregnancy) and 35% received recommended prophylaxis (chlamydia, gonorrhea, emergency contraception). Across EDs, unadjusted rates of testing ranged from 6% to 89%, and prophylaxis ranged from 0% to 57%. Presence of a specialized sexual assault pathway was associated with increased rates of prophylaxis even after adjusting for case-mix and temporal trends (odds ratio 1.46, 95% confidence interval 1.15 to 1.86). CONCLUSIONS: Evaluation and treatment of adolescent sexual assault victims varied widely across pediatric EDs. Adolescents cared for in EDs with specialized sexual assault pathways were more likely to receive recommended prophylaxis.

Sexuall cognitions in victims of chilhood and adolescence/adulthood sexual abuse

This study explored the relationship between 1) child sexual abuse (CSA), adolescent/adult sexual abuse (AASA), and both (CSA+AASA), and 2) the frequency of positive and negative sexual cognitions according to their content -intimate, exploratory, dominance, submission, and impersonal- in men and women. We also analyzed the severity of the sexual contact of individuals who had experienced AASA. We assessed a Spanish sample of 228 men and 333 women, aged between 18 and 50 years old. In the sample, 341 individuals reported having experienced some type of sexual victimization (victims group), while 220 individuals reported no victimization (non-victims group). Overall, sexual victims reported a higher frequency of positive sexual cognitions compared to non-victims, particularly when they had experienced CSA+AASA and the severity of the sexual contact was greater. Men and women who had experienced abuse reported a higher frequency of exploratory cognitions (p < .01). Male victims reported more cognitions of submission (p < .01), whereas female victims reported more cognitions of dominance (p < .05), which indicates lack of congruence with traditional gender roles. Finally, only intimate cognitions (p < .001) were experienced as negative by male victims. We discuss the relevance of the findings for therapeutic interventions with sexual abuse victims (AU)

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South asian immigrant women who have survived child sexual abuse: resilience and healing.

The current study is a phenomenological examination of the resilience strategies of South Asian immigrant women in the United States who survived child sexual abuse. Semistructured interviews (N = 5) and a focus group (N = 8) were analyzed to gain a deep structural understanding of participants' experiences of child sexual abuse and resilience. Findings included four subthemes of South Asian context (strict gender socialization, maintenance of family image, influence of ethnic identity, acculturative stressors) and five subthemes of resilience strategies (use of silence, sense of hope, South Asian social support, social advocacy, intentional self-care). Research and practice implications are discussed.

Pediatric sexual abuse: emergency department evaluation and management.

Pediatric sexual abuse is an overwhelming problem in the United States. It is estimated that 25% of females and 16% of males in the United States are sexually abused before the age of 18. The emergency department (ED) is frequently the point of entry for care of sexually abused children and adolescents. Personnel from the ED are usually the first "reporters" of sexual abuse, propelling these issues into the medicolegal system. Therefore, it is critical for ED practitioners to have the knowledge and skill set required to provide thorough, comprehensive care for this patient population. The ED holds a powerful position in the multidisciplinary approach to pediatric sexual abuse, involving social workers, child protective services, and law enforcement. This article presents the essential information required to assume a leadership role in the medical management of the sexually abused child/adolescent in the ED, including mandatory reporting, triage, assessment, treatment, and follow-up.

Expert judgment in cases of alleged child sexual abuse: clinicians' sensitivity to suggestive influences, pre-existing beliefs and base rate estimates.

Clinicians' expertise in child sexual abuse (CSA) cases was explored by giving a questionnaire covering clinical experience, self-evaluated expertise, beliefs and attitudes about CSA and a trial material concerning CSA to 320 child mental health professionals. In the material the suggestiveness of the interview with the child was varied and one condition did not contain any interview transcript. Participants were sensitive to the presence of leading questions but not to the presence of other suggestive techniques and not to the possibility that suggestive techniques could have been used when no interview transcripts were included. Experience only affected sensitivity to leading questions. Strong attitudes and beliefs lessened the sensitivity to leading questions and made participants more prone to wanting the case to be prosecuted when other suggestive influences than leading questions were present. Practical implications of the results will be discussed.

Health care utilization and costs associated with childhood abuse.

BACKGROUND: Physical and sexual childhood abuse is associated with poor health across the lifespan. However, the association between these types of abuse and actual health care use and costs over the long run has not been documented. OBJECTIVE: To examine long-term health care utilization and costs associated with physical, sexual, or both physical and sexual childhood abuse. DESIGN: Retrospective cohort. PARTICIPANTS: Three thousand three hundred thirty-three women (mean age, 47 years) randomly selected from the membership files of a large integrated health care delivery system. MEASUREMENTS: Automated annual health care utilization and costs were assembled over an average of 7.4 years for women with physical only, sexual only, or both physical and sexual childhood abuse (as reported in a telephone survey), and for women without these abuse histories (reference group). RESULTS: Significantly higher annual health care use and costs were observed for women with a child abuse history compared to women without comparable abuse histories. The most pronounced use and costs were observed for women with a history of both physical and sexual child abuse. Women with both abuse types had higher annual mental health (relative risk [RR] = 2.07; 95% confidence interval [95%CI] = 1.67-2.57); emergency department (RR = 1.86; 95%CI = 1.47-2.35); hospital outpatient (RR = 1.35 = 95%CI = 1.10-1.65); pharmacy (incident rate ratio [IRR] = 1.57; 95%CI = 1.33-1.86); primary care (IRR = 1.41; 95%CI = 1.28-1.56); and specialty care use (IRR = 1.32; 95%CI = 1.13-1.54). Total adjusted annual health care costs were 36% higher for women with both abuse types, 22% higher for women with physical abuse only, and 16% higher for women with sexual abuse only. CONCLUSIONS: Child abuse is associated with long-term elevated health care use and costs, particularly for women who suffer both physical and sexual abuse.

The effect of childhood sexual abuse on adolescent pregnancy: an integrative research review.

PURPOSE: This study aims to describe the current research literature on the relationship of childhood sexual abuse and adolescent pregnancy and highlight the potential cross-cutting risk factors. DESIGN AND METHODS: Thirteen articles were identified as the basis of this review using Cooper's methodology (1998) for synthesizing research. Articles were categorized according to the levels of evidence proposed by Melnyk and Fineout-Overholt (2005). RESULTS: The majority of the studies identified a relationship between childhood sexual abuse and adolescent pregnancy (n=9). Cross-cutting risk factors included female gender, younger age, substance use/abuse, family constellation, parent-child conflict, and mother disengagement. PRACTICE IMPLICATIONS: Strategies for nurses to identify pregnant and parenting adolescents who have been sexually victimized are important for early intervention. Resiliency factors of young people who report positive outcomes are highlighted.

A community program to fight child abuse: the Fort Wayne Children's Foundation and Kids' Law.

This paper offers a brief review of child abuse in the United States and describes an example of a community program in Fort Wayne, Ind, to stop and reverse the adverse effects of child abuse. This commentary aims to offer resources, raise awareness, and stimulate research into child abuse incidence, type, and prevention.

Relationship between drug abuse and intimate partner violence: a longitudinal study among women receiving methadone.

OBJECTIVES: We examined whether frequent drug use increases the likelihood of subsequent sexual or physical intimate partner violence (IPV) and whether IPV increases the likelihood of subsequent frequent drug use. METHODS: A random sample of 416 women on methadone was assessed at baseline (wave 1) and at 6 months (wave 2), and 12 months (wave 3) following the initial assessment. Propensity score matching and multiple logistic regression were employed. RESULTS: Women who reported frequent crack use at wave 2 were more likely than non-drug using women to report IPV at wave 3 (odds ratio [OR]=4.4; 95% confidence interval [CI]=2.1, 9.1; P<.01), and frequent marijuana users at wave 2 were more likely than non-drug users to report IPV at wave 3 (OR=4.5; 95% CI=2.4, 8.4; P<.01). In addition, women who reported IPV at wave 2 were more likely than women who did not report IPV to indicate frequent heroin use at wave 3 (OR=2.7; 95% CI=1.1, 6.5; P=.04). CONCLUSIONS: Our findings suggest that the relationship between frequent drug use and IPV is bidirectional and varies by type of drug.

The efficacy of an integrated risk reduction intervention for HIV-positive women with child sexual abuse histories.

Child sexual abuse (CSA) is associated with HIV risk behaviors [Bensley, L., Van Eenwyk, J., and Simmons, K. W., 2003.] and more prevalent among women living with HIV than in the general population [Koenig, L. J., and Clark, H., 2004]. This randomized Phase~I clinical trial tested the impact of a culturally congruent psychoeducational intervention designed to reduce sexual risks and increase HIV medication adherence for HIV-positive women with CSA histories. An ethnically diverse sample of 147 women were randomized to two conditions: an 11-session Enhanced Sexual Health Intervention (ESHI) or an attention control. Results based on "intent to treat'' analyses of pre-post changes are reported here. Additional analyses explored whether the observed effects might depend on "intervention dose,'' i.e., number of sessions attended. Women in the ESHI condition reported greater sexual risk reduction than women in the control condition. Although there were no differences between women in the ESHI and control groups on medication adherence, women in the ESHI condition who attended 8 or more sessions reported greater medication adherence at posttest than control women. The findings provide initial support for this culturally and gender-congruent psychoeducational intervention for HIV-positive women with CSA, and highlight the importance of addressing the effects of CSA on sexual risk reduction and medication adherence in preventive interventions for women.

Residential psychiatric treatment of emotionally disturbed deaf youth.

A survey of the literature on emotional disturbance in deaf youth is followed by presentation of data on a sample of 58 deaf children and adolescents who were patients at the Tampa Bay Academy, a residential treatment facility serving both hearing and deaf youth with serious psychological disturbances. These 58 patients were compared to a hearing sample of 168 patients on key variables such as admitting symptoms, diagnoses, substance abuse, aggressive and assaultive behaviors, and sexual abuse. A startling and significant finding was that all of the deaf children admitted at age 12 years or younger had strong or confirmed indications of sexual abuse. Deaf adolescents had an 85% rate of strong or confirmed indications of sexual abuse. A list and brief description of residential care facilities serving deaf youth in the United States and Canada is reviewed. Only 8 were found that provided specialized services to deaf youth. Of those 8, only the National Deaf Academy, Mount Dora, FL, provided exclusive mental health and residential care to deaf persons.

Women and traumatic events.

Posttraumatic stress disorder (PTSD) gained the status of a psychiatric disorder in 1980, although the syndrome had already been recognized widely for many years. PTSD is distinguished by alternations between reexperiencing of the traumatic event that triggered the PTSD in the first place and avoidance and numbing. Increased arousal (e.g., exaggerated startle reaction) also forms part of the diagnosis. Although the majority of trauma victims recover spontaneously, more than 30% develop persistent PTSD symptoms, with women being twice as likely as men to suffer PTSD. To date, the most studied psychosocial treatments for PTSD are the cognitive-behavioral interventions. Exposure therapy (systematic exposure to the traumatic memory in a safe environment) has been demonstrated to be quite effective with adult women who were sexually or nonsexually assaulted in adulthood as well as with women who were sexually abused in childhood. Supportive counseling does not appear as effective as exposure therapy, but is better than no therapy.

Childhood experiences and adult behavior in a group of women with pain accounted for by psychological factors and a group recovered from major depression.

OBJECTIVE: In this study twenty-four women with pain accounted for by psychological factors (DSM-IV, 307.80) and twenty-four with major depression diagnosed according to DSM-III-R were compared to study the relationship between pain and depression. METHOD: They were examined by a semi-structured, tape-recorded interview to study their childhood experiences and adult behavior. The interviews were rated by two independent and blind raters. Interrater correlation (Cohen-Kappa) varied between good and close agreement. RESULTS: Of childhood experiences, "brutality between parents," "brutality toward child," and "sexual abuse" were often found in both groups and were more strongly represented in these than in comparison groups of former studies. As adults, the pain group had experienced more serious illness (p = 0.037) and surgery (p = 0.014). The depression group more often had a history of depression (15/24 vs. 4/24; p = 0.001). The pain group spoke negatively of its physicians (p = 0.001), was more hostile during the interview (p = 0.041), was less convinced of the benefit of the hospital stay (p = 0.029), felt less self-responsible, and was more pessimistic (p = 0.013). The pain patients also provoked negative emotions in the raters, whereas the latter's reaction to the depression group was compassion and interest (p = 0.0005) (Pearson's chi2 and Fisher's exact tests). CONCLUSIONS: The results show that negative childhood experiences are prominent and similar in patients with pain accounted for by psychological factors and in patients after major depression. Adult behavior, however, is very different.

Regional cerebral blood flow during script-driven imagery in childhood sexual abuse-related PTSD: A PET investigation.

OBJECTIVE: The purpose of this study was to determine whether anterior limbic and paralimbic regions of the brain are differentially activated during the recollection and imagery of traumatic events in trauma-exposed individuals with and without posttraumatic stress disorder (PTSD). METHOD: Positron emission tomography (PET) was used to measure normalized regional cerebral blood flow (CBF) in 16 women with histories of childhood sexual abuse: eight with current PTSD and eight without current PTSD. In separate script-driven imagery conditions, participants recalled and imagined traumatic and neutral autobiographical events. Psychophysiologic responses and subjective ratings of emotional state were measured for each condition. RESULTS: In the traumatic condition versus the neutral control conditions, both groups exhibited regional CBF increases in orbitofrontal cortex and anterior temporal poles; however, these increases were greater in the PTSD group than in the comparison group. The comparison group exhibited regional CBF increases in insular cortex and anterior cingulate gyrus; increases in anterior cingulate gyrus were greater in the comparison group than in the PTSD group. Regional CBF decreases in bilateral anterior frontal regions were greater in the PTSD group than in the comparison group, and only the PTSD group exhibited regional CBF decreases in left inferior frontal gyrus. CONCLUSIONS: The recollection and imagery of traumatic events versus neutral events was accompanied by regional CBF increases in anterior paralimbic regions of the brain in trauma-exposed individuals with and without PTSD. However, the PTSD group had greater increases in orbitofrontal cortex and anterior temporal pole, whereas the comparison group had greater increases in anterior cingulate gyrus.

Effects of ritual abuse: the results of three surveys in The Netherlands.

OBJECTIVE: We decided to document the behavior of 87 children involved in multiple victim/multiple perpetrator sexual abuse by developing and administering surveys to families. Data gathered at 2 1/2 years (1990) and 7 years (1994) after the disclosures indicated the behavioral status of the children at different developmental stages. This data was compared to clinical information available prior to the abuse, and initial survey data rendered at 6 weeks after disclosure (Jonker & Jonker-Bakker, 1991). The objective was to document the behavior of the victims during the healing process. METHODOLOGY: A questionnaire was sent to the parents of 87 children who were abused in 1987. The parents returned the completed questionnaire, and were interviewed in our clinic. RESULTS: Data from the 1990 and 1994 surveys indicate that 39% of the children involved, who lived in supportive family environments, had changed as a result of the abuse. They exhibited behavior within acceptable, normal guidelines for childhood development. In 1994, 7% of the children involved showed signs of more severe behavioral disorders. CONCLUSIONS: The findings indicate that physical and behavioral signs apparent in the 1990 and 1994 surveys were not recognized at the time the abuse occurred. Many of the children exhibit normal, acceptable behavior at the time of the most recent survey (1994).

Child sexual abuse in Matabeleland, Zimbabwe.

The extent, nature, causes and consequences of child sexual abuse in Matabeleland. Zimbabwe, are explored by an intersectoral working group consisting of health, legal and AIDS prevention workers who were struck in the course of their work by the regularity with which they saw sexually abused children infected with HIV and STDs. Methods used in this study are record review, focus group discussions, structured and in-depth interviews. Child sexual abuse cases form between 40-60% of the rape cases brought to the attention of hospitals, police and court and many more are believed to remain unreported. Half of the sexual abuse in children is detected through STDs and some have HIV. The majority of offenders are mature men known to the child. Factors influencing child sexual abuse are male dominance in society, men's professed inability to control sexual desire, and magic beliefs. Victims are traumatized by the abuse itself as well as by subsequent problems in family, health and in court. Since child sexual abuse may endanger the life and well-being of the child, it is a serious problem that requires urgent action.