Child sexual abuse is a problem of epidemic proportions with the potential to result in lifelong physical and mental health consequences for victims. According to the U.S. Department of Health & Human Services (2017), over 57,000 children living in the United States were victims of sexual abuse in 2016. On the basis of retrospective studies of adults, it is clear that this number represents merely the tip of the iceberg, with only about one in 20 victims disclosing in childhood (Kellogg & American Academy of Pediatrics Committee on Child Abuse and Neglect, 2005). As a result, most child sexual abuse victims do not receive timely assessment, intervention, and treatment. Clearly, pediatric healthcare providers must understand the dynamics of child sexual abuse to better identify and protect those at risk for victimization. Several myths exist within the American culture regarding perpetrators of child sexual abuse: Only men sexually abuse children, children are most at risk from a stranger such as "the dirty old man at the park," and sexual abuse occurs only in poor families (Cromer & Goldsmith, 2010). In reality, although men are primarily responsible for sexually abusing children, women are also guilty of sexually abusing children (Williams & Bierie, 2015). Furthermore, sexual abuse occurs in families of all socioeconomic statuses (Davies & Jones, 2013). Carlson, Grassley, Reis, and Davis (2015) found that, in a population of children seen at a Child Advocacy Center, 61% of children were sexually abused by a relative; 38%, by an acquaintance; and only 1%, by strangers. Forensic nurses are at the forefront of caring for victims of sexual abuse and are strong voices in the education of parents, community members, and other healthcare professionals. Armed with a deeper understanding of child sexual abuse perpetrators, forensic nurses are better positioned to educate the public and advocate for children at risk of being sexually abused. In this article, specific types of child sexual abuse perpetration will be explored, and implications for forensic nurses will be discussed.

Characteristics of Child Sexual Abuse Perpetrators

It is important for the forensic nurse to understand that not all men who are sexually attracted to children ever act on that attraction (Bailey, Bernhard, & Hsu, 2016). Although this phenomenon remains unclear, recent research reveals potential influences. Bailey et al. (2016) completed an Internet study of men attracted to children and noted the following characteristics among those who were both sexually attracted to children and who also offended against children. The participants were older in age (56 years or older), repeatedly worked in jobs with children, repeatedly fell in love with children, and struggled not to offend. The number of legal convictions for an individual does not accurately reflect the number of child victims. In a now classic study, Gebhard, Gagnon, and Pomeroy (1967) examined 376 incarcerated sex offenders convicted of sexually abusing a child less than 11 years old. The mean number of sexual convictions ranged from 1.57 to 2.24. After obtaining a federal guarantee of confidentiality, the convicted child molesters admitted to many more victims and sexual acts. Abel and Osborn (1992) utilized the same type of guarantee and reported that 453 pedophiles recruited through outpatient treatment programs admitted to an average of 236 sexual acts and 148 victims per offender.

Studies produce conflicting results regarding the concept of child sexual abuse experience being a risk factor for perpetration as an adult. This "sexually abused-sexual abuser" hypothesis is supported by a number of studies (Hulme & Middleton, 2013; Seto, 2008; Thomas et al., 2013). It is important to note that most of this research was conducted on incarcerated subjects who may overstate their childhood victimization histories to minimize their responsibility for their own offending (Thomas et al., 2013). Most child sexual abuse victims do not grow up to be offenders (Thomas et al., 2013); however, most sexual abuse perpetrators report being sexually abused as children. Simons, Wurtele, and Durham (2008) examined the developmental experiences of child sexual abuse perpetrators. Child sexual abusers reported frequent experiences of child sexual abuse (73%), early exposure to pornography (65% before the age of 10 years), an earlier onset of masturbation (60% before the age of 11 years), as well as sexual activities with animals. Child sexual abusers also reported anxious parental attachments with parents who responded inconsistently to their needs.

A meta-analysis of 89 studies identified characteristics of child sexual abusers in comparison to those who sexually offended against adults, with nonoffenders (Whitaker et al., 2008). Sexual offenders of children and adults were more likely to have a history of abuse (physical or sexual), poorer family functioning, harsher discipline, and poorer attachment or bonding (Whitaker et al., 2008). In general, very few differences were noted between sexual offenders of children and sexual offenders of adults. However, there were substantial differences between sexual offenders of children and nonoffenders across six major categories: family risk factors, externalizing behaviors, internalizing behaviors, social deficits, sexual behaviors, and attitudes/cognitions. When compared with nonoffenders, those who sexually offended against children were much more likely to report a history of sexual abuse, an antisocial personality, difficulty with intimate relationships, experiencing harsh discipline as a child, and loneliness (Whitaker et al., 2008). See Table 1 for a list of characteristics endorsed more frequently in child sexual abusers when compared with nonabusers.

TABLE 1 Characteristics of Child Sexual Abuse Perpetrators

Emotional congruence with children (ECWC) is frequently cited as a psychological risk factor for sexually abusing children (McPhail, Hermann, & Nunes, 2013). ECWC is an exaggerated affective and cognitive affiliation with children, which includes emotional attachment and dependency needs that can be better met by interacting with children than adults. Such individuals may seek relationships with children because social interactions with adults are uncomfortable and unfulfilling. Relationships with children relieve feelings of social and emotional loneliness. Some aspects of ECWC may be normal, healthy, and present in nonoffending individuals, however, not to the degree found in adults who sexually abuse children. It is interesting to note that ECWC is higher in extrafamilial offenders of children than in intrafamilial offenders and is high in pedophiles but not in nonpedophilic offenders (McPhail et al., 2013). ECWC is predictive of recidivism in offending behavior. Adults, especially nonfamily members, who like to spend a lot of alone time with children and seek relationships with children more than adults are at an increased risk for sexual abuse perpetration and also to reoffend after treatment (McPhail et al., 2013).

Family members perpetrate nearly two thirds of child sexual abuse, with fathers and stepfathers being the most common abusers. Intrafamilial child sexual abusers when compared with extrafamilial abusers show significantly lower atypical sexual interests (pedophilia, hebephilia, other paraphilias, and excessive sexual preoccupation) and antisocial tendencies (criminal history, juvenile delinquency, impulsivity, substance use, and psychopathology) (Seto, Babchishin, Pullman, & McPhail, 2015). Intrafamilial child abusers are less likely to report ECWC but more likely to have experienced sexual abuse, neglect, and poor parent-child attachment (Seto et al., 2015). It is not uncommon for family members who sexually abuse children to also have sexual relationships with adults.

Sex offenders are often classified as "child" or "adult" offenders. However, several studies have found that many sexual offenders change victim type, committing sexual offenses against a wide variety of victims (Kleban, Chesin, Jeglic, & Mercado, 2013). This concept is referred to as crossover sexual offending. Kleban et al. (2013) examined the records of 789 incarcerated sex offenders and found that offenders remain relatively stable regarding the gender of their victims but less so with the age of and relationship to their victims. Less than one fourth (17%) of sex offenders had victims of both genders (Kleban et al., 2013). Yet, nearly half (48%) varied in their relationships to their victims (family member, acquaintance, and stranger), and 40% offended against victims from different age groups (child, adolescent, and adult). Clearly, sexual offenders show significant crossover in their choice of victims, and it is difficult to eliminate potential victims based on past patterns of offending. Children are at a potential risk from all known sex offenders, not only those known to have previously sexually abused a child.

Pedophilia

Pedophilic disorder is a psychiatric diagnosis that is defined as a persistent sexual attraction to prepubertal children (generally less than the age of 13 years) as shown by one's sexual fantasies, urges, thoughts, arousal patterns, or behaviors (American Psychiatric Association, 2013). Diagnostic criteria for pedophilic disorder also necessitates specification whether the individual is the exclusive type (attracted only to children) or the nonexclusive type (attracted to adults and children); whether the individual is sexually attracted to boys, girls, or both; and whether sexual urges are limited to incest. Some experts further distinguish between pedophilia and hebephilia-the sexual attraction to pubescent children who exhibit signs of secondary sexual development but who are not yet sexually mature or have met the legal age of consent (Seto, 2009). Hebephiles tend to pursue reciprocal sexual relationships with children, are more opportunistic when engaging in sexual acts, and generally have better social functioning than pedophiles (Danni & Hampe, 2000).

Pedophilia is often equated with acts of child sexual abuse; however, it is important to differentiate pedophilic disorder from illegal acts of child sexual abuse. A diagnosis of pedophilic disorder requires that individuals have sexual urges or arousing fantasies about children that cause marked distress or interpersonal difficulty-with or without actual acts of child sexual abuse. Although pedophilia does increase the risk of the individual engaging in acts of child sexual abuse, not every person with pedophilic disorder has abused children; in fact, only about half of all people who sexually abuse children have been found to meet the diagnostic criteria for pedophilia (Tenbergen et al., 2015).

Miller (2013) describes three main typologies of individuals who sexually abuse children:

1. the "situational child sex molester" who engages in sex with adults or children and simply sees children as targets of opportunity;

2. the "preferential child molester" who imagines a special relationship with each of the children he or she has sex with, often grooming them over time; and

3. the "sadistic pedophile" who enjoys engaging in acts of sexual violence with children, often resulting in their death (pp. 507-508).

Pedophilic individuals are further categorized by whether they are heterosexual, homosexual, or bisexual in their attraction to children. A common misconception is that homosexuality is correlated with child sexual abuse. Anywhere from 9% to 40% of pedophiles are attracted to children of the same gender, but homosexual adults are no more likely to sexually abuse children than heterosexual adults (Hall & Hall, 2007).

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, asserts that use of pornography depicting prepubertal children is a useful diagnostic indicator of a pedophilic disorder (American Psychiatric Association, 2013). However, the extent of this correlation is not clear. There is evidence that more than half of child pornography consumers have had no physical contact with children (Seto, Cantor, & Blanchard, 2006). Therefore, although an individual's consumption of child pornography may be a reliable indicator of a pedophilic disorder, it is not necessarily a reliable predictor of future child sexual abuse offending.

Nonpedophilic Child Sexual Abusers

Pedophilia refers to deviant sexual interest in prepubescent children that may or may not lead to the sexual abuse of a child, whereas child sexual abuse refers to the perpetration of at least one sexual offense against a child that may or may not be committed by a pedophile (Sigre-Leiros, Carvalho, & Nobre, 2015). Approximately 40%-50% of those who sexually abuse children are not pedophiles, as they are not preferentially attracted to children (Eastvold, Suchy, & Strassberg, 2011). Nonpedophilic child sexual abusers are primarily sexually attracted to and have sex with adults but also sexually offend against children. They are much less sexually focused on children than pedophiles (Schiffer & Vonlaufen, 2011). Nonpedophilic child abusers tend to have difficulties with impulse control and sexually abuse children based on circumstances such as the availability of child victims, disinhibition after substance abuse, or difficulty connecting with an adult sexual partner (Schiffer & Vonlaufen, 2011). Nonpedophilic abusers rarely plan sexual abuse; rather, they offend impulsively when circumstances allow. Nonpedophilic abusers are less likely to reoffend against a child when compared with pedophiles (Strassberg, Eastvold, Wilson Kenney, & Suchy, 2012). Nonpedophilic abusers also have fewer victims than pedophiles and tend to be more responsive to treatment (Seto, 2008).

Strassberg et al. (2012) found nonpedophilic child sexual abusers to show more psychopathology than pedophiles. Perhaps, the psychopathology explains why an adult without an intrinsic sexual desire for children would chose to sexually abuse a child. Strassberg et al. hypothesized that people who possess sociopathic qualities, such as self-centeredness, impulsivity, lack of empathy for others, manipulativeness, and lack of conscience, are more likely to commit a variety of antisocial acts, including the sexual abuse of children. Nonpedophilic abusers do not exhibit elevated ECWC; their motivation for sexually abusing a child is not to meet their own emotional and/or social needs (McPhail et al., 2013).

Adolescent Perpetrators

Adolescents under the age of 18 years commit approximately 20% of all sexual assaults and as high as 40% of sexual offenses against children (Barbaree & Marshall, 2006). Data from the National Incident Reporting System present the following key adolescent perpetrator statistics: Adolescents who commit sex offenses against other children are more likely than adult sex offenders to offend in groups and at schools, and have more male victims and younger victims. The number of youth accused of a sex offense increases sharply at the age of 12 years and plateaus after the age of 14 years. Approximately 16% of juvenile sex offenders are younger than 12 years old, and female juveniles make up about 7% of juvenile sex offenders (Finkelhor, Ormrod, & Chaffin, 2009).

Keelan and Fremouw (2013) conducted a critical review of juvenile sex offender literature and reported that the prototypical juvenile sex offender is a White male juvenile who offends against female and male family members, has been diagnosed with depression/anxiety, and has a history of being sexually abused (especially if the victims are male). In contrast, the prototypical juvenile sex offender who sexually offends against adolescent peers is more likely to be a Black male juvenile who offends against female acquaintances and strangers, uses force to commit offenses, and comes from a family with poor supervision (Keelan & Fremouw, 2013). Adolescent sex offenders show less recidivism than adult offenders. About 8%-14% of adolescent sex offenders will offend again (Caldwell, 2010). Hence, most adolescent sexual perpetrators do not go on to become adults who commit sexual offenses.

In general, adolescent sexual perpetrators are more similar to other adolescents who commit nonsexual crimes than they are to adult sexual offenders. Seto and Lalumiere (2010) performed a meta-analysis of studies comparing adolescent sex offenders with adolescent nonsex offenders. The results showed that the two groups did not differ in terms of family dynamics, general psychopathology, early conduct and social problems, and attitudes/beliefs toward women and sexual offending. However, adolescent sex offenders did have less extensive criminal histories, fewer delinquent peers, and less substance abuse. In addition, investigators found that adolescent sex offenders may be more likely to have a personal history of physical, sexual, and/or emotional abuse and they may also be more likely to have had early exposure to sex, pornography, atypical sexual interests, and sexual violence within the family (Seto & Lalumiere, 2010).

Female Child Sexual Abusers

There exists an erroneous perception that female sexual offenders are rare and that, when they do abuse, the consequences are harmless or less harmful to the child than abuse committed by male sexual offenders (Mellor & Deering, 2010; Muskens, Bogaerts, van Casteren, & Labrijn, 2011; Stemple, Flores, & Meyer, 2017). The true prevalence of sexual abuse perpetrated by women is difficult to determine. Sexual abuse by women may go unidentified because of societal and cultural stereotypes of female behavior. Women are often the primary caregivers of young children, and acts of sexual abuse can be disguised as normal caregiving behaviors. As a result, sexual abuse by women may be underreported. Multiple studies have indicated that women are identified as perpetrators in 40%-55% of all sexual abuse reports (Tsopelas, Tsetsou, & Douzenis, 2011). However, only about 1% of sexual offenders in American prisons are female (U.S. Department of Justice, 2007).

McLeod (2015) explored patterns in female perpetration of child sexual abuse. See Table 2 for characteristics of female child sexual abuse perpetrators. Female perpetrators tend to sexually abuse younger children and also have a wider distribution in ages of child victims when compared with male perpetrators. Women exhibit a preference for same sex victims. McLeod states that women are 4.5 times more likely than men to offend against their own biological children. Women are also more likely to sexually abuse their adopted children or other children for whom they are caregiving. Unlike male perpetrators, female perpetrators of child sexual abuse rarely coerce others into being accomplices (Tsopelas et al., 2011).

TABLE 2 Female Sex Offenders

Women who sexually abuse children are very likely to have also experienced significant maltreatment as children (Tsopelas et al., 2011), in particular, sexual, physical, and/or emotional abuse, oftentimes invasive and repeated. Home life for female perpetrators was often chaotic in childhood. As adults, female perpetrators often experience low self-esteem, frequently coupled with a variety of psychopathologies including depression, suicidal ideation, and substance abuse/dependency. Matthews, Matthews, and Speltz (1991) discuss a classic typology of female sexual abuse perpetrators:

1. Teacher/lovers who are usually involved with adolescent and/or preadolescent boys: They are in love with the boys and want to teach them about sex.

2. Male coerced offenders who may later abuse independently: These individuals are typically extremely dependent and submissive.

3. Offenders who have been sexually abused themselves and who subsequently sexually abuse their own children.

The recidivism rate for female sexual offenders once they have been adjudicated is low, between 1% and 3% (Cortoni, Hanson, & Coaches, 2010). Most are never convicted of another crime, and if they are, it is rare to be a sexual offense against a child.

Perpetrator Treatment

Society in general is cynical about sex offender treatment and its ability to reduce the risk of recidivism. However, several treatment modalities exist that have been shown to reduce the recidivism of child sexual offenders. Three primary treatment modalities have been well studied: cognitive behavioral therapy (CBT), multisystemic therapy (MST), and surgical or pharmacologic treatments.

CBT-based treatment targets attitudes, beliefs, and behaviors that increase an individual's likelihood of offending against children and uses therapeutic techniques to teach individuals how to recognize and respond to triggers (Seto, 2009). MST is a family-based approach that is particularly effective with adolescent sex offenders. MST interventions focus on empowering offenders and their families with skills and resources to target specific family risk factors for sexual delinquency, with the goal of interrupting the sexual assault cycle (Henggeler, 2012). Therapy for sex offenders can also include surgical or pharmacologic treatments. Surgical treatment refers to mechanical castration, whereas pharmacologic treatment refers to chemical castration with hormonal agents. Both medical approaches are aimed at reducing the physical drive to act on sexual impulses. It should be emphasized that the goal of any treatment for individuals with pedophilic disorder is prevention rather than an attempt to alter the individual's sexual orientation. Instead, treatments are focused on increasing the individual's ability to manage sexual arousal and abstain from acting on sexual urges (Seto, 2009).

Kim, Benekos, and Merlo (2016) performed a synthesis of 11 meta-analyses of sex offender treatments designed to reduce recidivism. Research focused on extant sex offender therapies including CBT, MST, and medical treatment. All meta-analyses in the review found a significant reduction in recidivism, and importantly, the five most recent meta-analyses concluded that that sex offender treatments are effective and significantly reduce recidivism by 22% (Kim et al., 2016). The review further determined that sex offender treatments are more successful with adolescents than adults and that the most effective treatment for adolescent offenders is a combination of CBT and MST. This may be attributable to the fact that adolescent behaviors are more malleable than adults and therefore more responsive to treatment (Miller, 2013). Conversely, the review concluded that surgical castration and hormonal medications were more effective than psychological treatments in adults; however, ethical considerations may preclude their use (Kim et al., 2016). Therefore, CBT-focused treatments designed to reduce sexual recidivism remain the principle approach with adult sex offenders.

Implications for Forensic Nursing

Child sexual abuse is a serious problem with the potential for lifelong psychological and/or physical consequences for victims. Forensic nurses are at the forefront of providing care to victims of sexual abuse. Equipped with a more comprehensive understanding of who is sexually abusing children, forensic nurses can best identify victims of sexual abuse and intervene appropriately. Obtaining a thorough familial psychosocial history (see Table 3), including a familial history of sexual abuse, can be crucial to the protection of children. Understanding a child's lived experience at home provides the forensic nurse with vital information to develop interventions to ensure their safety. Educating families about sexual abuse perpetrators can help families better protect their children from sexual abuse (see Table 4). The forensic nurse can assist parents in understanding that they are truly their child's best protection against sexual abuse. Emphasis should be placed on the importance of consistent supervision of their child, both physically and electronically, and that parents need to be concerned if an adult consistently wants to spend alone time with their child. Parents the need to teach their children the correct anatomical name for all body parts, including genitalia, and the importance of children understanding the concept of private parts and also the need to tell if those parts have been violated. Frank discussions should be conducted regarding the potential chronicity of sexual abuse perpetration and that an individual who sexually abuses a child once is at a high risk to offend again despite treatment, prison, and a desire to change their behavior (Kim et al., 2016).

TABLE 3 Familial Psychosocial Assessment

TABLE 4 Child Sexual Abuse Parent Education

Forensic nurses are also leaders in the community regarding child sexual abuse. Sharing knowledge regarding sexual abuse perpetration assists other healthcare professionals, school personnel, and community members to fully understand the complexity of child sexual abuse. Forensic nurses are also uniquely positioned to advocate at the community, state, and national levels for political and legislative changes to better protect children from sexual abuse, including advocacy for sex offender treatment to reduce recidivism.

References