Child sexual abuse is a global public health problem: where is Australia?

In this article, we argue that a public health approach to child sexual abuse (CSA) is needed in Australia. We outline the high prevalence rates of CSA and the costs of child abuse, followed by the emotional effects and potential physiological consequences of CSA. We argue that the prevalence of CSA combined with its far-reaching implications clearly establish its status as a public health problem. We then outline the current Australian approach to CSA and the inadequacies of such strategies. We suggest what is needed for Australia to take preventative action on this serious social and public health problem.

**********

Child sexual abuse (CSA) represents a truly reprehensible act and is one of the few crimes that consistently incite public outrage. Consequently, sexual offences have at times dominated penal agenda, with the more punitive responses politically being considered as somehow more likely to resolve public concern and deter would-be offenders. Whilst tougher sentences and mandatory reporting may satisfy the demands of the general public, we know that such strategies do little, if anything, to prevent child sexual abuse (Harries & Clare, 2002). We therefore argue that child sexual abuse should not just be thought of as a crime, but as a serious social and public health issue requiring urgent attention and preventative action.

A preventative approach to CSA is of utmost importance and considerable value given the immense personal cost to victims, and the great social and economic costs to the wider community. Such costs are not only related to the services needed for victims and offenders, but also the huge array of associated problems that are likely to emerge as a result of child sexual abuse. Mercy (1999) has stated clearly why sexual abuse should be viewed as a general public health problem:

    Imagine a childhood disease that affects one in  five girls and one in seven boys before they    reach 18 ... a disease  that can cause dramatic    mood swings, erratic behaviour, and even  severe  
   conduct disorders among those exposed; a    disease that breeds  distrust of adults and undermines    the possibility of experiencing  normal    sexual relationships; a disease that can have    profound  implications for an individual's future    health by increasing the  risk of problems such as    substance abuse, sexually transmitted  diseases,  
   and suicidal behaviour ...; a disease that replicates    itself by  causing some of its victims to    expose future generations to its  debilitating    effects. Imagine what we, as a society, would do  if  such a disease existed. We would spare no    expense. We would invest  heavily in basic and    applied research. We would devise systems to  identify those affected and provide services to    treat them. We would  develop and broadly    implement prevention campaigns to protect our  children. Wouldn't we? Such a disease does    exist--it's  called child sexual abuse (p. 317). 

Prevalence of Child Sexual Abuse

Literature on CSA describes highly varied prevalence rates. According to the Australian Bureau of Statistics (2003), the sexual assault victimisation rate (based on reported crime) increased from 71 to 92 per 100,000 persons between 1994 and 2003. For sexual assault, males aged 14 years and under had the highest victimisation rate (89 per 100,000 population) of any male age group and their rate was nearly three times that of the general male population. For females, the highest sexual assault victimisation rate was for the 10-19 year age group (497 per 100,000 population), over three times the rate for the general female population.

Generally, reported crime is considered to be a poor indicator of the true rates of offending. Research on a sample of randomly selected Australian women revealed that 20% of participants had experienced CSA. Of those women 71% were aged less than 12 years at the time and, overall, only 10% of CSA cases were ever reported (Fleming, 1997). Andrews, Gould and Corry (2002b) report on the overall findings of seven studies done on child sexual abuse in Australia. They found that the adjusted prevalence estimates were 5.1% for males and 27.5% for females. The onset of abuse occurred at a mean age of 10 years, with most cases starting before the age of 12 years. In the vast majority of cases the offender was known to the child (75%), with 40% of cases involving an offender who was a family member.

Dunne, Purdie, Cook, Boyle and Najman (2003) found different victimisation rates for males compared to other studies. Through a telephone-based survey of randomly selected males (n = 876) and females (n = 908), the researchers found that for non-penetrative CSA, 15.9% of males were abused and 33.6% of females. With regard to penetrative CSA, 4% of males were abused compared to 12% of females. In reference to the different prevalence rates for males and females, Spataro, Moss and Wells (2001) argue that there are a number of reasons for this disparity, such as differences in definitions of CSA, the methods by which abuse has been assessed, and the characteristics of research samples. They further suggest that male CSA is under-reported due to factors that perpetuate non-disclosure, specifically, the socialisation of males within a culture where independence, sexual prowess and self-reliance are valued, whilst vulnerability, fear, dependency and homosexuality are considered as weaknesses and likely to lead to rejection and denigration.

Overall, these results highlight the alarmingly high rates at which CSA is potentially occurring, and the alarmingly low rates at which it is coming to the attention of justice agencies.

Costs of Child Abuse

In terms of the cost of child abuse (including CSA), an extensive study by Keatsdale Pty. Ltd. (2003) identified four main types of costs. They are the human cost of those abused (including pain and suffering, suicide and medical costs associated with injury and disability); long-term human and social costs (including juvenile delinquency, adult criminality, homelessness, substance abuse and intergenerational transmission of abuse); the cost of public intervention (including child protection services and criminal justice system costs); and the cost of community contributions. Based on conservative estimates of annual rates of child abuse and neglect, they estimated the annual cost of child abuse in Australia for one financial year at A$4.03b.

Effects of Child Sexual Abuse

The majority of research on the effects of CSA has concentrated on the emotional and behavioural outcomes. Johnson (2004), based on an extensive literature review, produced a table listing many of the emotional and behavioural consequences of CSA. These included anxiety, depression, posttraumatic stress disorder, and suicide or suicide attempt. The causal pathways linking CSA to these health outcomes are complex, with issues such as poverty and other forms of abuse often co-occurring (Johnson, 2004) and many of these factors displaying bi-directional relationships. For instance, depression has been studied as both an effect and cause of social difficulties (Nettle, 2004). Recent genetic and …