Chapter 5 Domestic and sexual violence occur in all settings in which children find themselves: home, school, neighbourhood, prisons, police stations and other forms of custody and detention, residential institutions and other forms of childcare outside the home. Child sexual abuse and the sexual exploitation of children are forms of sexual violence. Both can take many different forms. Definitions vary by country and jurisdiction but there is always a power imbalance in the relationship between the abuser and the victim. Victims of sexual violence in childhood have an increased risk of adverse outcomes for health and well being in the short, medium and long term. Domestic violence affects children and young people in a number of different ways. Children can be witnesses to violence between parents/carers in their family or perpetrators of violence in their own intimate relationships. Growing up in a household where there is domestic violence has well-recognised adverse effects on a child. Intimate partner (or teen dating) violence is increasingly recognised as a common problem in partnerships between young people. It is important to note that the different forms of violence against children, including domestic and sexual violence, are not mutually exclusive but can overlap. Children frequently experience multiple forms of violence in multiple settings. Some children who experience violence in the family go on to become perpetrators of violence. Others become resilient and may even go on to be champions of campaigns against child abuse (see Box 5.1). NAPAC (www.napac.org.uk) is a British nationwide organisation focused on supporting adults who have been abused in any way as children and who may never have discussed or received support for their experiences. The chief executive, who set up the organisation, was born and brought up in London. Painful memories of his childhood abuse kept coming to the front of his mind until, at the age of 38, he decided to set up a charity to help people like himself. NAPAC provides a helpline and a wide range of useful booklets, survivor stories and links to other Web sites and organisations. Only a small proportion of acts of violence against children is reported and investigated, and few perpetrators are held to account. In many parts of the world there are no systems responsible for recording or thoroughly investigating reports of violence against children. Where official statistics based on reports of violence in the home and other settings exist, they dramatically underestimate the true magnitude of the problem. Obtaining accurate data concerning sexual violence is often difficult, due to different definitions of what constitutes sexual abuse, underreporting, a focus on sexual abuse in specific settings and a paucity of any data in many countries. Most frequently-cited estimates of child sexual abuse have come from retrospective surveys of adults. Accurate information on sexual exploitation, female genital mutilation, forced marriage and honour-based violence is even harder to obtain. The definition of child sexual abuse currently used in England is given in Box 5.2. It is similar to that used in other jurisdictions and by the World Health Organization. ‘Sexual abuse involves forcing or enticing a child or young person to take part in sexual activities, not necessarily involving a high level of violence, whether or not the child is aware of what is happening. The activities may involve physical contact, include assault by penetration (for example rape or oral sex) or non-penetrative acts such as masturbation, kissing, rubbing and touching outside of clothing. They may also include noncontact activities, such as involving children in looking at, or in the production of, sexual images, watching sexual activities, encouraging children to behave in sexually inappropriate ways, or grooming a child in preparation for abuse (including via the Internet). Sexual abuse is not solely perpetrated by adult males. Women can also commit acts of sexual abuse, as can other children.’ From: HM Government (2013). From population-based studies in developed countries (Australia, New Zealand, Canada and the USA), it is estimated that the cumulative prevalence of any childhood sexual abuse is 15–30% for girls and 5–15% for boys (‘any sexual abuse’ includes noncontact, contact and penetrative abuse). For penetrative sexual abuse, estimates are 5–10% for girls and 1–5% for boys. Most sexual crimes against children are not witnessed, and cases are unlikely to get to court (even in countries with adequate legal frameworks) unless the circumstances and physical evidence are overwhelming (see Box 5.3). Within 3 months of the sexual abuse scandal involving TV presenter Jimmy Savile, some 589 people came forward with information, with a total of 450 complaints against Savile himself, mainly alleging sexual abuse. Early analysis showed that 82% of those coming forward reporting abuse were female, and 80% of the total victims were children or young people. Police said the number of sexual abuse allegations reported against a single person was ‘unprecedented’ in the UK, and 12 other inquiries or related reviews were launched. There has been a significant increase in the reporting of both ‘nonrecent’ child abuse unrelated to Savile and previously undisclosed adult serious sexual offences. In London there was a fourfold increase in reports to the police’s child abuse investigation teams. The sexual exploitation of children and young people under 18 involves exploitative situations, contexts and relationships where young people (or a third person or persons) receive ‘something’ (e.g. food, accommodation, drugs, alcohol, cigarettes, affection, gifts, money) as a result of performing, and/or others performing on them, sexual activities (HM Government, 2009). Child sexual exploitation can occur through the use of technology without a child’s immediate recognition, via the Internet or mobile phones. In all cases, those exploiting the child or young person have power over them by virtue of their age, gender, intellect, physical strength and/or economic or other advantages. Violence, coercion and intimidation are common, as the child or young person’s limited availability of choice results from their social, economic and/or emotional vulnerability. In many societies, a marriage or permanent union is arranged by parents and family elders, usually at or soon after puberty for girls. This occurs in some cultural groups and immigrant populations in mixed societies. Young people may be married in the country of residence or taken overseas. Globally, the majority of countries have legislation which prohibits marriage of girls under the age of 16, and some forbid marriage under the age of 18. However, such laws are frequently ignored: marriages are not registered, customary or religious rules are accepted and few cases result in court proceedings even where clear legislation and statutory procedural guidance exist. Voluntary-sector organisations have been set up to help women and girls with this and other gender-based issues. Early and forced marriage also directly impacts boys, on a smaller scale. It can have profound psychological consequences and is no less a violation of their rights. This is covered more fully in Chapter 17. Female genital mutilation or ‘cutting’ is seen by parents as beneficial – as a protection of virginity, a beautification process and a precondition for marriage – but it has no medical benefit and entails an unacceptably high likelihood of pain and of immediate and long-term medical complications. It breaches international human rights laws, in particular the United Nations Convention on the Rights of the Child, and has been criminalised in much of the world. The UK is one of several countries that have enacted specific legislation in response to international migration of children for the purpose of procuring the procedure. There is controversy about infant male circumcision: views range from considering it a form of sexual violence and an abuse of the rights of the child to considering that the potential harm is slight and falls within the scope of parental freedom to determine religious and cultural rites for children. Circumcision is one of the commonest surgical procedures performed on males, despite there being few absolute medical indications. Worldwide, about 30% of men are circumcised, mostly in infancy; in most English-speaking and Muslim countries circumcised men form the majority. Opponents argue that infant circumcision can cause both physical and psychological harm. There is some contested evidence that circumcision is medically beneficial. Even if competently performed, it carries a small amount of risk, and most paediatricians will have seen cases with poor outcomes during their career. The rights and wrongs of this ancient practice are currently being vigorously debated both in medical journals and in some courts. ‘Domestic’ or ‘family’ violence refers to physical, sexual, psychological or financial violence that takes place within an intimate or family-type relationship and that forms a pattern of coercive and controlling behaviour (see also Chapters 3, 7, 8 and 9). This can include forced marriage and so-called ‘honour crimes’. Domestic violence may include a range of abusive behaviours, not all of which are inherently ‘violent’ in themselves or individually. There is mounting evidence that where there is violence between adults in the home there is also abuse of children. They may suffer and be harmed merely by witnessing the violence. A recent survey in the UK (Barter et al., 2009) explored with young people their experiences of physical, emotional and sexual forms of violence in their partner relationships, with the following results: Sexual behaviour as displayed by children and young people exists on a continuum from mutually agreed experimentation through to harmful, abusive exploitation. Retrospective research studies show that between 25 and 40% of all alleged sexual abuse involves young perpetrators. The majority of those are adolescent males, but young children and females also commit sexually harmful acts. Children and young people with learning disabilities are over-represented within this group but the reason for this is not fully understood. The majority of these children and young people have been or are being sexually, physically and/or emotionally abused themselves. It is helpful to consider the harm that all forms of violence can have on children (see Table 5.1), as sexual violence usually overlaps with other forms of child maltreatment and is often associated with domestic or other forms of violence in the child’s environment. Table 5.1 Acute and long-term consequences of violence against children. Source: UNICEF (2006). Legislation on sexual violence against children, when it exists, varies widely. In the UK, a child under 13 years of age is deemed to be unable to consent to sexual acts, so both police and social services always need to be involved. Consent and confidentiality often present challenges in children aged over 13. Many do not want their parents informed and will refuse to involve the police or social services. Even when a young person is old enough to consent and has the capacity to do so, there remains a tension between their confidentiality and their welfare or that of other children. Always seek advice from senior local clinicians and child protection staff. Legal advice may also be required. Medical management consists of psychological support and management of the risk of pregnancy and/or sexually transmitted infections. Ideally, management will be coordinated and undertaken by experienced sexual health, paediatric and child and adolescent mental health professionals. Acute assault is defined by the likelihood of collecting forensic evidence – e.g. the sperm of the alleged perpetrator – and varies according to the gender and pubertal status of the victim: Acute assault is best dealt with by a sexual assault referral centre (see Chapters 18 and 19), if available, as these are set up to deal with all aspects of acute assault and can maximise the collection of forensic evidence according to best practice (see Box 5.4).
Children
OVERVIEW
Scope of the problem
Box 5.1 A child abuse survivor set up the National Association for People Abused as Children
Forms of sexual violence affecting children and young people
Child sexual abuse
Box 5.2 Definition of child sexual abuse
Box 5.3 Sexual predators may commit crimes against children with impunity
Sexual exploitation
Forced marriage
Female genital mutilation
Infant male circumcision
Forms of domestic violence affecting children and young people
Domestic violence from family members
Intimate partner violence in adolescent relationships
Child perpetrators of sexual violence
Adverse effects of sexual and domestic violence on children and young people
Physical health
Sexual and reproductive
Psychological
Other longer-term health
Financial (direct, indirect and costs borne by criminal justice and other institutions)
Management of sexual and domestic violence against children
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