1. Sexual Abuse of Children & Adolescents Dr. Alan Krohn Clinical Psychologist, Psychoanalyst Adjunct Clinical Associate Professor of Psychiatry University of Michigan Medical School, USA Dr. Elizabeth G. Finigan Family Primary Care Physician Veterans Administration Hospital, Rochester, New York, USA

2. Definition of Child Sexual Abuse  Adult or older adolescent uses child for sexual stimulation  Indecent exposure of genitals to child  Displaying pornography to child  Pressuring child to engage in sexual activity – regardless of outcome  Actual contact or viewing child’s genitals (except for medical exams)

3. Incidence and Prevalence in North America  15-25% of female population  5-15% of male population  abusers: 30% relatives of child 60% friends and acquaintances 10% strangers

4. Incidence  Men commit 75-85% of abuse  Women commit 14-20% against boys  Women commit 6% against girls

5.  Identify patients abused  Direct-presented by child or adult  Indirectly revealed: child appears frightened, needs to keep secrets  Adults interfere with private interview of child  What is not abuse?’

6.  Doctors at times avoid recognizing sexual abuse  Explore subject of abuse carefully  Problem of not asking about abuse

7.  Do not try to talk child out of abuse report: like family denying, assaults child’s reality testing, leads to dissociation

8.  Child’s irrational guilt  Child’s fear of the effects of report of abuse  Guilt over confused feelings of terror, physical excitement and need for attachment  CHILDREN CANNOT CONSENT TO SEXUAL ACTIVITY.

9.  Psychological effects Guilt Overwhelmed/trauma Fear of injury Repetitive memories Distraction in school Need to repeat abuse Hypersexuality Pathological defenses

10.  Further psychological effects Problems with adult sexual functioning and pleasure Tendency to form abusive relationships in women and abusing relationships in men Problems with ownership of own body Reality testing problems Cognitive problems

11.  Further psychological effects Problems with basic trust Self-esteem

12.  Therapy-interventions  Change abusive situation—social services involved if necessary  Family approach to problem  If necessary, removal of child from home

13. Therapeutic Framework  Follow patient’s communications  Follow patient’s pace to avoid retraumatization  Maintain respectful boundaries  Be non-judgemental

14.  Forming helping relationship Be ready for distrust Maintain clear boundaries Pushing too hard for details can be re- traumatizing Just talking helpful In some children resolution can take some time

15.  Talking to child Not child’s fault—explained irrational guilt Talk at child’s pace about problem Explain repetitive thoughts Work with emotional numbing

16.  Identifying emotions Problem of attachment to abusive person  Explain why child needs to repeat abuse (in some cases)  Work with emotional numbing  Repetition as problematic effort at mastery  Depression and low self esteem as expressions of guilt