Sexual victimization

In the present issue of Acta Paediatrica, findings from a Swiss study of sexual victimization in adolescent girls are reported by Tschumper et al. (1). According to the study, almost one out of five respondents had been victims of sexual abuse. Sexual victimization is an important aspect of adolescent community medicine. Research in this field is well warranted. However, the very high prevalence found by Tschumper and colleagues requires some comment. It is well known, and is also pointed out by the authors, that prevalences of sexual abuse vary considerably between different studies. The subject has been penetrated in a literature review by Kreyberg Normann et al. (2), who found a variation in prevalences ranging from 4 to 67%. One important explanation, according to the authors, lies in the choice of definition. The authors are critical of wide and all-embracing definitions, which may serve to conceal the true numbers of severely victimized children. Without proper criteria, the children most in need of help may go unnoticed. According to Kreyberg Normann et al. (2), a definition of serious sexual abuse ought to exclude incidents not involving physical contact. In particular, verbal indecencies and exhibitionism are inappropriate criteria of sexual abuse, being rather common experiences among adolescents (this may, of course, vary between different countries). In the authors’ opinion, a definition making it unnatural not to have been sexually abused is clinically of little value, though it may be of legal and scientific interest. It is concluded that the prevalence of repeated, serious sexual abuse of children in the Nordic countries is about 5%. Could it thus be stated that sexual events without physical contact ought to be defined as harmless, and those involving physical contact as harmful? The answer is no. The degree of harm is clearly a matter of personal feelings. On the other hand, all sexually abusive acts cannot be considered equally harmful in principle. Therefore, some further distinctions have to be made between generally harmful and less harmful sexual incidents, with or without physical contact. Consider, for instance, on the one hand, a child who is exposed to repeated and humiliating exhibitionism by a parent within the family. Even if there is no physical contact, such a child must be regarded as sexually victimized. His or her situation clearly differs from that of a child occasionally sighting an exhibitionist in the street. Consider, on the other hand, a girl who is physically molested by an unknown man on a crowded bus. Some may be frightened or upset by the experience, while others may find it insignificant, although it does in fact involve physical contact. Consequently, the matter is more complicated than just a question of physical contact. Kreyberg Normann and colleagues (2) make further comments on the age limits included in definitions. Since the days of Kinsey, many researchers have adopted an age criterion, saying that the perpetrator has to be .5 y older than the victim. In fact, however, it may not be unusual for an 18or 19-y-old girl to have a boyfriend aged 24 or 25. In a Finnish survey of sexual and physical abuse in a population of 15and 16-y-olds, Sariola (3) found that about half of the girls’ experiences were with boyfriends. Such cases, according to Sariola, should not be included in a definition of sexual abuse. It may indeed be questioned whether sexual experiences with a boy or a girl friend should be referred to as abusive, provided they are not experienced as negative and do not involve violence or coercion. Perhaps, then, it would be recommendable to include in a definition of sexual abuse the criteria referred to by Snyder and colleagues (4), saying that the child is exploited for the gratification of another, that the activities are incompatible with the child’s developmental level and position in the family, and that the child is not capable of giving informed consent, e.g. because of differences in power. With such criteria, repeated exhibitionism in the family would count as sexual abuse even if no physical contact occurred. Nevertheless, molestation in a crowd, even involving physical contact, could perhaps be excluded. Positive experiences with a boyor a girlfriend would not be considered abusive, and so forth. There seems, consequently, to be a need for a stricter definition of sexual abuse, where regard is paid both to the forms of abuse and to whether physical contact was present or not. Age limits should not be set too high. Whether there was just one incident, or whether the pattern of abuse was repeated over a longer period, would be other relevant aspects of a definition, as would the relationship between victim and perpetrator. Was the perpetrator a family member or an unknown? Was there any possibility of escape for the victim, or not? A further point should be made. As regards sexual victimization, there seems to be consensus about the deleterious consequences of the abuse. This holds true for professional groups, as well as for foster parents and for parents from the general population (4–6). There is no similarly strong consensus about the effects of physical Acta Pædiatr 87: 130–1. 1998