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groups, such as the income distribution of female plumbers. Only censuses provide the large numbers of cases needed for complex multivariate analyses. But censuses are so large and difficult to process that by the time the data are released they are, for some purposes, out of date, and this problem increases throughout the interval, commonly ten years, until the next census.

To address the timeliness problem, most national statistical agencies conduct a series of large sample surveys that provide select information on key topics at timely intervals. In the United States, for example, the latest unemployment rate, released on the first Friday of each month, is headline news. It is based on the Current Population

Survey, a monthly sample survey that provides current information on many social and economic characteristics.

A few countries keep population registers, continuous records of where people live along with some of their characteristics. If reasonably complete and accurate, these may be used to supplement and update some census information.

In many nations, administrative records such as social security, national health, tax, and utility company files, may be adapted to provide periodic estimates of population size and a few characteristics, but difficult questions arise about data quality and comparability with censusand survey-based information. Citizens of many nations are wary about letting the government and corporations compile extensive personal data. Legislative restrictions are increasingly being placed on what information may be gathered and stored and how it may be used.

The questions asked in successive censuses typically change more slowly than the procedures. Keeping the same topics and the same wordings of questions help a government measure change from one census to the next. This appeals to researchers and policy analysts, but policymakers and administrators, whose attention is focused mainly on current programs and next year’s budget, often plead for new wording to better serve current concepts. Another reason tending to stifle innovation is that the census is an expensive and visible tool. A lengthy review process confronts any agency that seeks to add, delete, or alter a question. In the

United States, both the executive branch and the

Congress must approve the final census schedule. A question on pet ownership has been regularly proposed but rejected because there is no compelling governmental interest in such a question and private sample surveys can provide the desired information. A third reason the content of the questionnaire changes little is that proponents of new topics and questions must compete for questionnaire space, while questions previously asked tend to already have a network of users who have a vested interest in retaining the topic. This competition spurs extensive lobbying and mobilization of support from federal agencies, congressional committees, and interest groups.

An innovative approach to providing timely data is ‘‘continuous measurement’’ using a ‘‘roll- ing-sample’’ survey. The American Community Survey has been implemented by the U.S. Census

Bureau (1999), with plans to expand to three million households a year in 2003. Because the survey uses a small, permanent, well-trained and supervised staff (as compared to the large, temporary, briefly trained staff utilized for a census), data quality may be higher than in a census. Another advantage of a monthly survey over a decennial census is the ease of introducing new topics and testing the effects of changes in the wording of questions.

American Community survey results will be cumulated over a year to provide estimates of numbers and characteristics for the nation, states, and places or groups of 65,000 or more people. For smaller places and groups, or for more reliable and detailed data for larger places, data will be cumulated for periods of up to five years. The fiveyear cumulated sample is designed to be approximately equivalent to the census ‘‘long-form’’ sample and may eliminate the need for a ‘‘long form’’ in the 2010 census. Moving averages could provide annual updates and be used for time series. There are many issues to be worked through in developing and evaluating this type of survey and in determining how well information averaged over a long period compares to standard statistical measures based on time-specific censuses and surveys.

In many nations, questions on race and ethnicity are a sensitive and contentious topic. In the

United States, the groups recognized have changed

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from each census to the next. For example, special tallies were made from the 1950 and 1960 censuses of persons with Spanish surnames, but only for five southwestern states. Beginning in 1970, and elaborated in later censuses, persons were asked if they were of Spanish/Hispanic origin. Many responses to this question have seemed to be inconsistent with responses to the separate question on race. The Bureau has conducted sample surveys to test various question wordings, and has sponsored field research and in-depth interviews to provide insights into how people interpret and respond to questions about ethnicity. For the 2000 census the basic concepts were retained, but the wording of each was adjusted, provision was made for individuals to report more than one race, and the question on Hispanic ethnicity was placed before the question on race.

In recent decades, extensive social science research has been conducted in many parts of the world on issues of racial and ethnic identity. These identities are almost always more flexible and more complex than can be captured with simple questions. A further complication is that many persons have ancestral or personal links to two or more racial and ethnic groups; how they respond depends on how they perceive the legitimacy and purposes of the census or survey.

In the 1990s, the U.S. Office of Management and Budget conducted an extensive review of its policy statement that specifies the standard race and ethnic classifications to be used by all government agencies, including the Census Bureau (Edmonston and Schulze 1995). Serious methodological problems have arisen as a result of inconsistencies among classifications of individuals on repeated interviews and in different records. A dramatic example occurs with infant mortality rates for race and ethnic groups, which are based on the ratio of counts based on birth registration to counts based on death registration of infants less than one year old. Comparing birth and death certificates for the same person, recorded less than one year apart, revealed large numbers for whom the race/ethnic classification reported at birth differed from that reported at death. The high-level government review also heard from many interest groups, such as Arab-Americans, multiracial persons, and the indigenous people of Hawaii,

who were anxious for the government to enumerate and classify their group appropriately.

In the United Kingdom, controversy about a proposed question on ethnic identity led to the question’s omission from the 1981 census schedule, thus hindering analyses of an increasingly diverse population.

The most politically intense and litigious controversy about recent U.S. censuses is not that of content but of accuracy. States, localities, and many interest groups have a stake in the many billions of dollars of government funds that are distributed annually based in part on census numbers.

President George Washington commented about the first census that ‘‘our real numbers will exceed, greatly, the official returns of them; because the religious scruples of some would not allow them to give in their lists; the fears of others that it was intended as the foundation of a tax induced them to conceal or diminish theirs; and through the indolence of the people and the negligence of many of the Officers, numbers are omitted’’ (quoted in Scott 1968, p. 20).

A perfect census of a school, church, or other local organization is sometimes possible, if membership is clearly defined and the organization has up-to-date and accurate records, or if a quick and easily monitored enumeration is feasible. A national census, however, is a large-scale social process that utilizes many organizations and depends on cooperation from masses of individuals. Planning, execution, and tabulation of the 2000 U.S.

Census of Population extended over more than ten years. Hundreds of thousands of people were employed at a cost of several billion dollars. A discrepancy between the results of a national census and ‘‘our real numbers’’ is inevitable.

Statisticians, recognizing that error is ubiquitous, have developed many models for identifying, measuring, and adjusting or compensating for error. Census statisticians and demographers around the world have participated in these developments and in trying to put professional insights to practical use.

Following the 1940 U.S. census, studies comparing birth certificates and selective service records to census results documented a sizable net

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undercount. To provide more information on census coverage and accuracy, a post-enumeration survey was conducted following the 1950 census using specially selected and closely supervised enumerators. One finding from the survey was that the undercount of infants in the census did not arise, as first thought, from a tendency for new parents to forget to mention a new baby to the census enumerator. The problem, rather, was that many young couples and single parents had irregular and difficult-to-find living arrangements, and entire households were missed by census enumerators. Based on this and related findings, much effort was given in subsequent censuses to precensus and postcensus review of lists of dwelling units.

Special surveys preceding, accompanying, and following censuses are increasingly used to provide evidence on magnitude of error, location of error in specific groups or places, and procedural means for reducing error. Techniques of ‘‘demographic analysis’’ have also been developed and continually refined to provide evidence of census error. The basic technique is to analyze the numbers of persons of each age, sex, and race in successive censuses. For example, the number of twenty-eight year-old white women in the 1990 census should be consistent with the number of eighteen-year-olds in 1980 and eight-year-olds in

1970. Information on births, deaths, immigration, and emigration is taken into account. Based on demographic analysis, the estimated net undercount for the total U.S. population was about 5.6 percent in 1940, 1.4 percent in 1980 (Fay, Passel, and

Robinson 1988, Table 3.2) and 1.8 percent in 1990. Estimates of net undercount have also been made for specific age, sex, and race groupings.

If the net undercount were uniform for all population groups and geographic regions, it would not affect equity in the distribution of seats in Congress or public funds. But census errors are not uniform. The estimates for 1990 show net undercounts exceeding 10 percent of adult black males and small net overcounts for some age and race groups.

In 1980, the mayor of Detroit, the City of Detroit, New York City, and others sued the federal government, alleging violation of their constitutional rights to equal representation and fair distribution of federal funds (Mitroff, Mason, and

Barabba 1983). More litigation occurred with respect to the 1990 census. In neither case were the initially reported census counts adjusted to reflect estimated errors in enumeration, although in the case of the 1990 census the Census Bureau technical staff and director thought their methodology would improve the accuracy of the counts.

The Census Bureau developed innovative plans for the 2000 census to integrate an evaluation survey with the census, to use sampling to increase quality and reduce costs of enumerating nonresponsive households, and to produce official counts that already incorporate the best available procedures for minimizing error.

These Census Bureau plans engendered major political and budgetary battles between the Republican-controlled Congress and the Democratic administration. Many of the persons hardest to reach using traditional census methods are poor, often minorities. Many members of Congress assumed that a census with near-zero undercount would increase the population reported for states and localities that tend to vote more for Democrats, and hence reduce, relatively, the representation for states and localities that tend to vote more for Republicans. At the national level, this could alter the reapportionment among states of seats in the House of Representatives. Legislatures in states, counties, and cities are also subject to decennial redistricting according to the ‘‘oneperson, one-vote’’ rule, and similar shifts in relative political power could occur.

The controversy between legislative and administrative branches over methods for the 2000 census was taken to the Supreme Court, with plaintiffs seeking a ruling that the Bureau’s plans to use sample-based estimates would be unconstitutional. The Supreme Court avoided the constitutional argument, but ruled that current law did not permit such use of sampling. The Democrats lacked the power to rewrite that part of the basic census law. The two parties compromised by appropriating additional dollars to cover the extra costs of complete enumeration while retaining funds for many of the methodological innovations that permit preparation of improved estimates. Reapportionment among states of seats in Congress could therefore use the results of traditional complete enumeration. Most scholars, analysts, and other

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users of census data are likely to consider the	(SEE ALSO: Demography; Population)
adjusted estimates more accurate and hence
more useful.	REFERENCES

The percentage net undercount understates the total coverage error in the census. If one person is omitted and another person counted twice, the total count is correct but there are two ‘‘gross’’ errors that may affect the counts for specific places and characteristics. Identification of gross errors is receiving increased attention, to improve information on the nature of census error and potential error-reducing methods, and to facilitate development of techniques of data analysis that compensate for known and unknown errors.

One of the difficulties in debates about undercount and other census error arises from confusion between the idea of a knowable true count and the reality that there is no feasible method for determining with perfect accuracy the size and characteristics of any large population. A national census is a set of procedures adopted in a political, economic, and social context to produce population estimates. It is politically convenient if all parties accept these results as the common basis for further action, much as sports contests use decisions by umpires or referees. The more that policy and budgets depend on census results and the more aware that politicians and citizens become of the importance of the census, the more contentious census taking will be.

Every nation confronts political and social problems with its censuses. Regularly scheduled censuses are often postponed or abandoned because of international conflict. The United States and the United Kingdom canceled plans for middecade censuses because of national budget constraints. West Germany was unable to take a census for several years because of citizen fears about invasions of privacy. Ethnic conflict has interfered with census taking in India, Lebanon, and other nations.

The processes by which census procedures are determined, the ways in which census figures are used, and the conflicts that occur about these procedures and numbers are not merely ‘‘technical’’ but are embedded in a broader social process. The character of a nation’s census and the con-

flicts that surround it are core topics for the ‘‘sociology of official statistics’’ (Starr 1987).

Anderson, Margo J. 1988 The American Census: A Social History. New Haven: Yale University Press.

——— and Stephen E. Fienberg 1999 Who Counts? The Politics of Census-Taking in Contemporary America. New York: Russell Sage Foundation.

Edmonston, Barry, and Charles Schultze 1995 Modernizing the U.S. Census. Washington, D.C.: National Academy Press.

Mitroff, Ian I., Richard O. Mason, and Vincent P. Barabba 1983 The 1980 Census: Policymaking and Turbulence. Lexington, Mass.: Lexington Books.

Scott, Ann H. 1968 Census, USA: Fact Finding for the American People, 1790–1970. New York: Seabury Press.

Starr, Paul 1987 ‘‘The Sociology of Official Statistics.’’ In W. Alonso and P. Starr, eds., The Politics of Numbers. New York: Russell Sage Foundation.

Steffey, Duane, and Norman Bradburn (eds.) 1994 Counting People in the Information Age. Washington, D.C.: National Academy Press.

United Nations 1998 Principles and Recommendations for Population and Housing Censuses. ST/ESA/STAT/ SER.M/67/Rev.1. New York: United Nations.

United States Census Bureau. Census Bureau Home Page. On the Internet at http.//www.census.gov. See links to Census 2000 and American Community Survey.

KARL TAEUBER

CHANGE MEASUREMENT

See Experiments; Longitudinal Research; Quasi-

Experimental Research Design; Measurement.

CHILD ABUSE

See Childhood Sexual Abuse; Family Violence;

Incest; Sexual Violence.

CHILDBEARING

See Family Planning; Family Size; Fertility

Determinants; Pregnancy and Pregnancy

Termination.

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CHILDHOOD SEXUAL ABUSE

Although child abuse is probably as old as childhood itself, serious research into child abuse arguably began in 1962 with the publication of Kempe and colleagues’ seminal paper, ‘‘The Battered Child Syndrome’’ (Kempe, Silverman, Steele, Droegemuller, and Silver 1962). Not long afterwards, health care professionals began to direct their attention to the specific problem of childhood sexual abuse (Cosentino and Collins 1996).

In the past few decades, numerous instances have been documented in detailed case histories, and important research into the causes and consequences of childhood sexual abuse has been initiated.

Numerous extensive reviews have been published that summarize what is presently known about childhood sexual abuse, focusing on the following domains.

•Short-term effects (Beitchman et al. 1991;

Beitchman et al. 1992; Briere and Elliott 1994; Browne and Finkelhor 1986;

Finkelhor 1990; Gomes-Schwartz et al. 1990; Green 1993; Kelley 1995; Kendall-

Tackett et al. 1993; Trickett and McBrideChang, 1995).

•Long-term consequences (Beitchman et al. 1991; Briere 1988; Briere and Elliott 1994;

Briere and Runtz 1991; Cahill et al.1991a; Collings 1995; Ferguson 1997; Finkelhor

1987; Gibbons 1996; Glod 1993; Green 1993; Murray 1993; Polusny and Follette

1995; Trickett and McBride-Chang 1995; Wolfe and Birt, 1995).

•Prevention of abuse (Adler and McCain 1994; Berrick and Barth 1992; MacMillan et al. 1994; Olsen and Widom 1993; Wolfe et al. 1995).

•Treatment of both survivors and abusers (Cahill et al. 1991b; Cosentino and Collins 1996; Faller 1993; Finkelhor and Berliner 1995; O’Donohue and Elliot 1993).

Consequently, this chapter is not intended to provide a detailed analysis and review of the literature on childhood sexual abuse. Rather, it is meant to serve as a brief overview of, and introduction to, this area of inquiry.

DEFINITION OF THE PROBLEM

Before delving into the field of childhood sexual abuse, one must first understand what is meant by the term. Indeed, the lack of a standard definition has been a major criticism of the field and controversies abound (Finkelhor 1994a; Gibbons 1996; Gough 1996a; Green 1993). In general, the legal and practical research definitions of child sexual abuse require the following two elements: (1) sexual activities involving a child (sometimes construed as including adolescence), and (2) the existence of an ‘‘abuse condition’’ indicating lack of consensuality (Faller 1993; Finkelhor 1994a). ‘‘Sexual activities’’ refer to behaviors intended for sexual stimulation; such activities need not involve physical contact, however, leading to separate definitions for ‘‘contact sexual abuse’’ and ‘‘noncontact sexual abuse.’’

Contact sexual abuse includes both penetrative

(e.g., insertion of penis or other object into the vagina or anus) and nonpenetrative (e.g., unwanted touching of genitals) acts. Noncontact sexual abuse refers to activities such as exhibitionism, voyeurism, and child pornography (see Faller 1993 and Finkelhor 1994a for reviews on definitions of childhood sexual abuse).

An abuse condition is said to exist when there is reason to believe that the child either did not, or was incapable of, consenting to sexual activity. Three main conditions can be distinguished: (1) the perpetrator has a large age or maturational advantage over the child; or (2) the perpetrator is in a position of authority or in a caretaking relationship with the child; or (3) activities are carried out against the child’s will using force or trickery.

As evident from this brief summary, ‘‘Childhood Sexual Abuse’’ covers a wide range of acts and situations, and therefore is open to considerable subjective interpretation.

INCIDENCE AND PREVALENCE OF CHILDHOOD SEXUAL ABUSE

Increasing attention has been directed toward childhood sexual abuse not only because of the psychosocial sequelae associated with its occurrence, but also because it now appears to be more widespread than previously thought (Adler and

McCain 1994). However, accurate estimates of the occurrence of childhood sexual abuse are difficult

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to obtain because many cases are never reported.

Thus, available statistics represent only those cases reported to child protection agencies or to law enforcement, and therefore underestimate the true magnitude of the problem.

There are two official sources of incidence data for cases in the United States: The National Incidence Study of Child Abuse and Neglect (NIS), a federally funded research project; and statistics from state child protection agencies (Finkelhor

1994a). The NIS conducted in 1993 documented over 300,000 cases of sexual abuse among children known to professionals in the course of a year, or a rate of approximately forty-five cases per 10,000 children (Sedlak and Broadhurst 1996). Child protective services data suggest that approximately

140,000 cases of childhood sexual abuse occur annually, or twenty-one cases per 10,000 children (Leventhal 1998). An editorial by Finkelhor (1998) suggested that the incidence may be declining.

However, this remains to be substantiated. In general, reports suggest that the rate of childhood sexual abuse has increased substantially over the past decades (Sedlak and Broadhurst 1996).

Retrospective surveys provide a second source of information on the occurrence of childhood sexual abuse. Reported rates depend upon how it is defined and operationalized in any given survey. When childhood sexual abuse has been assessed with a single item that narrowly defines it as rape or sexual intercourse, reported prevalence rates tend to be low (e.g., less than 12 percent). Conversely, when it is defined more broadly (e.g., touching genitalia) and assessed using multiple items, prevalence rates tend to be much higher, but with a wide range. The discrepancies observed in the estimated prevalence of childhood sexual abuse points to the need for increased standardization and the use of better assessment instruments in this research.

Because rates of childhood sexual abuse are substantially greater among females than males (e.g., Cosentino and Collins 1996; Finkelhor et al.

1990; Sedlak and Broadhurst 1996), the majority of this research has focused on women. Surveys suggest that anywhere from 18 percent to 30 percent of college women and 8 percent to 33 percent of male and female high school students report having experienced this abuse at some point in

their lives (Ferguson 1997; Finkelhor 1994a; Gibbons 1996; Green 1993; Gorey and Leslie 1997). Among the general adult female population, prevalence rates range from 2 percent to 62 percent (Finkelhor 1987; Finkelhor et al. 1990; Saunders et al. 1992). Rates are even higher within various clinical populations, with 35 percent to 75 percent of female clients reporting a history of some form of sexual abuse during childhood (Gibbons 1996;

Wurr and Partridge 1996).

The number of males who have been sexually abused is difficult to estimate because it has been the subject of fewer high-quality studies (Holmes and Slap 1998; Watkins and Bentovim 1992). Nonetheless, a few studies have examined this issue among men and estimate that approximately 3 percent to 16 percent of all men in the United States were sexually abused during childhood

(Finkelhor et al. 1990; Gibbons 1996; Holmes and

Slap 1998). As is the case for women, rates are higher when studying clinical populations, with estimates ranging from 13 percent to 23 percent

(Holmes and Slap 1998; Metcalfe et al. 1990).

In sum, based on the evidence available in the literature, Finkelhor (1994a) estimates that 20 percent of adult women and 5 percent to 10 percent of adult men are survivors of childhood sexual abuse. Similarly, a synthesis of sixteen cross-sec- tional surveys on the prevalence of it among nonclinical populations reported unadjusted estimates of 22.3 percent for women and 8.5 percent for men (Gorey and Leslie 1997).

SEQUELAE

Research conducted over the past decade indicates that a wide range of psychological and interpersonal problems are more prevalent among those people who have been sexually abused than among those who have not been sexually abused. Although a definitive casual relationship between such problems and sexual abuse cannot be established using retrospective or cross-sectional research methodologies (Briere 1992a; Plunkett and

Oates 1990), the aggregate of consistent findings in this literature has led many investigators and health care providers to conclude that childhood sexual abuse is a major risk factor for a variety of problems, both in the short-term and in later

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adulthood (Briere and Elliott 1994; Faller 1993).

The various problems and symptoms described in the literature can be categorized as follows: (1) posttraumatic stress; (2) cognitive distortions; (3) emotional distress; (4) impaired sense of self; (5) avoidance phenomena; (6) personality disorders; and (7) interpersonal difficulties. In the remainder of this section, each of these categories is defined and illustrated using examples from the research literature.

Posttraumatic stress refers to certain enduring psychological symptoms that occur in reaction to a highly distressing, psychiatric disruptive event. To be diagnosed with posttraumatic stress disorder (PTSD) an individual must experience not only a traumatic event, but also the following problems: (1) frequent re-experiencing of the event through nightmares or intrusive thoughts; (2) a numbing of general responsiveness to, or avoidance of, current events; and (3) persistent symptoms of increased arousal, such as jumpiness, sleep disturbances, or poor concentration (American Psychiatric Association (APA) 1994). In general, researchers have found that children and adults who have been sexually abused are significantly more likely to receive a PTSD diagnosis than their nonabused peers (McLeer et al. 1992; Murray 1993; Rowan and Foy 1993; Saunders et al. 1992; Wolfe and Birt 1995).

Cognitive distortions are negative perceptions and beliefs held with respect to oneself, others, the environment, and the future. In the abused individual, this type of thought process is reflected in his or her tendency to overestimate the amount of danger or adversity in the world and to underestimate his or her worth (Briere and Elliott 1994; Dutton et al. 1994; Janoff-Bulman 1992). Numerous studies document such feelings and perceptions such as helplessness and hopelessness, impaired trust, self-blame, and low self-esteem among children who have been sexually abused (Oates et al. 1985). Moreover, these cognitive distortions often continue on into adolescence and adulthood (Gold 1986; Shapiro and Dominiak 1990).

Emotional distress or pain, which typically manifests itself as depression, anxiety, anger, or all of these, is reported by many survivors of childhood sexual abuse. Depression is the most commonly reported symptom among adults with a

history of childhood sexual abuse (Beitchman et al. 1992; Browne and Finkelhor 1986; Cahill et al. 1991a; Polusny and Follette 1995). Greater depressive symptomatology is also found among children who have been abused (Lipovsky et al.1989; Yama et al.1993).

Similarly, elevated anxiety levels have been documented in child victims of sexual abuse and adults who have a history of it (Gomes-Schwartz et al. 1990; Mancini et al. 1995; Yama et al. 1993).

Adults with a history of childhood sexual abuse are more likely than their nonabused counterparts to meet the criteria for generalized anxiety disorder, phobias, panic disorder, obsessive compulsive disorder, or all of these (Mancini et al. 1995; Mulder et al. 1998; Saunders et al. 1992).

Another common emotional sequel of childhood sexual abuse is anger; specifically, chronic irritability, unexpected or uncontrollable feelings of anger, difficulties associated with expressing anger, or all of these (Briere and Elliott 1994; Van der Kolk et al. 1994). During childhood and adolescence, anger is most likely to be reflected in behavioral problems such as fighting, bullying, or attacking other children (Chaffin et al. 1997; Garnefski and Diekstra 1997).

Sexual abuse also can damage a child’s developing sense of self, with adverse long-term consequences. The development of a sense of self is thought to be one of the earliest developmental tasks of the infant and young child, typically unfolding in the context of early relationships (Alexander 1992). Thus, how a child is treated early in life critically influences his or her growing selfawareness. Childhood sexual abuse can interfere with this process, preventing the child from establishing a strong self image (Cole and Putnam

1992). Without a healthy sense of self, the person is unable to soothe or comfort himself or herself adequately, which may lead to overreactions to stressful or painful situations, and to an increased likelihood of re-victimization (Messman and Long 1996). Indeed, numerous studies have found high rates of sexual re-victimization (e.g., rape, coercive sexual experience) among individuals reporting a history of childhood sexual abuse (Fergusson et al.

1997; Urquiza and Goodlin-Jones 1994; Wyatt et al. 1992)

Avoidance is another major response to having been sexually abused. Avoiding activities among

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victims may be viewed as attempts to cope with the chronic trauma and dysphoria induced by the abuse. Among the dysfunctional activities associated with efforts to avoid recalling or reliving specific memories are: dissociative phenomena, such as losing time, repression of unpleasant memories, detachment, or body numbing (APA 1994; Cloitre et al. 1997; Mulder et al. 1998; Nash et al. 1993); substance abuse and addiction (Arellano 1996; Briere 1988; Wilsnack et al. 1997); suicide or suicidal ideation (Briere and Runtz 1991; Saunders et al. 1992; Van der Kolk et al. 1991); inappropriate, indiscriminate, and/or compulsive sexual behavior (McClellan et al. 1996; Widom and Kuhns, 1996), (for reviews see Friedrich 1993; KendallTackett et al. 1993; Tharinger 1990); eating disorders (Conners and Morse 1993; Douzinas et al. 1994; Schwartz and Cohn 1996; Wonderlich et al. 1997); and self-mutilation (Briere 1988; Briere and Elliott 1994). Each of these behaviors serve to prevent the individual from experiencing the considerable pain of abuse-specific awareness and thus reduces the distress associated with remembrance. However, avoidance and self-destructive methods of coping with the abuse may ultimately lead to higher levels of symptomatology, lower self-esteem, and greater feelings of guilt and anger (Leitenberg et al. 1992).

Numerous investigations have found a greater rate of borderline personality and dissociative identity (formerly multiple personality disorder) disorders among adult female survivors of chilhood sexual abuse (Green 1993; Polusny and Follette 1995; Silk et al. 1997). Borderline personality disorder includes symptoms of impulsiveness associated with intense anger or suicidal, self-mutilating behavior, and affective instability with depression which are typical sequelae in sexually abused children and in adult survivors of sexual abuse (APA 1994). Childhood trauma, especially continued sexual abuse, is an important etiological factor in many cases of dissociative identity disorder, the most extreme type of dissociative reaction (APA 1994).

Finally, interpersonal difficulties and deficient social functioning often are observed among individuals who have been sexually abused (Briere 1992b; Cloitre et al. 1997). Such difficulties stem from the immediate cognitive and conditioned responses to victimization that extend into the longer term (e.g., distrust of others), as well as the

accommodation responses to ongoing abuse (e.g., passivity). Often, victims of childhood sexual abuse know the perpetrator, who might be a family member, clergy, or friend of the family. The abuse is thus a violation and betrayal of both personal and interpersonal (relationship) boundaries. Hence, it is not surprising that many children and adults with a history of childhood sexual abuse are found to be less socially competent, more aggressive, and more socially withdrawn than their nonabused peers (Cloitre et al. 1997; Mannarino et al. 1991; Mullen et al. 1994).

Among adults, interpersonal difficulties are manifested in difficulties in establishing and maintaining relationships (Finkelhor et al. 1989; Liem et al. 1996) and in achieving sexual intimacy

(Browne and Finkelhor 1986; Mullen et al. 1994).

Children who have been sexually abused are more likely to exhibit increased or precocious sexual behavior, such as kissing and inappropriate genital touching (Cosentino et al. 1995).

The consequences of childhood sexual abuse can be quite severe and harmful. However, it is important to note that an estimated 10 to 28 percent of persons with a history of it report no psychological distress (Briere and Elliott 1994; Kendall-Tackett et al. 1993). This raises the question of why some persons exhibit difficulties while others do not. Research addressing this question has found the following to be important mediators of individual reactions to childhood sexual abuse:

•Age at onset of abuse. Although further elucidation is needed, the available evidence suggests that postpubertal abuse is associated with greater trauma and more severe adverse sequelae than is

prepubertal abuse (Beitchman et al. 1992; Browne and Finkelhor 1986; McClellan et al. 1996; Nash et al. 1993);

•Gender of the victim. One of the main findings in this area is that male victims appear to show greater disturbances of adult sexual functioning (Beitchman et al.

1992; Dube and Herbert 1988; Garnefski and Diekstra 1997);

•Relationship to perpetrator. Abuse involving a father or father figure (e.g., stepfather), which accounts for an estimated 25 percent of all cases (Sedlak and Broadhurst

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1996), is associated with greater longterm harm (Browne and Finkelhor 1986;

Gold 1986);

•Duration and frequency of abuse. In general, the greater the frequency and duration of abuse, the greater the impact on later psychological and social functioning (Nash et al. 1993);

•Use of force. The use of force or threat of force is associated with more negative outcomes (Kendall-Tackett et al. 1993);

•Penetration or invasiveness. Penetrative abuse is generally associated with greater long-term harm than are most other forms of abuse (Kendall-Tackett et al. 1993); and

•Family characteristics and response to abuse disclosure. Individuals who have been abused are more likely to originate from single-parent families, families with a high level of marital conflict, and families with pathology (e.g., parent is an alcoholic, violence between parents, maternal disbelief, and lack of support); all of which are associated with a poorer outcome and greater levels of distress (Beitchman et al. 1992; Draucker 1996; Green 1996; Romans et al. 1995).

CROSS-CULTURAL ISSUES

This review has focused exclusively on studies done in the United States. This is important to keep in mind because the nature of abuse varies according to one’s cultural belief system (Gough 1996). As a result, attempts to compare societies on the basis of their care of children or the extent of violence in family relations are fraught with problems (Gough 1996b; Levinson 1989). In addition, methodological factors, such as the questions asked and how childhood sexual abuse is defined and measured, hamper the ability to make direct comparisons among the rates across different countries. All that can be surmised, to date, is that it is not a phenomena just of the United States, but is an international problem (Finkelhor 1994b).

Finkelhor’s synthesis indicates that most countries have rates similar to those found in the United

States and that females are abused at a greater rater than males.

Nonetheless, cross-cultural studies can shed new light on the origins and impact of sexual abuse (Leventhal 1998; Runyan 1998). Such investigations may enable us to understand better the relative importance of different factors that influence the occurrence of abuse and teach us about societies that have been successful at protecting children. Intercultural comparative investigations can also help us appreciate the range of sexual behaviors that are, or can be considered ‘‘normal,’’ and thereby contribute to a better understanding of abnormality in childhood sexual behavior and adult behaviors toward children.

It is not surprising that definitions of abuse not only vary within a culture, but also between cultures. The meaning of ‘‘abuse,’’ especially, depends upon ideas of individual rights and roles and responsibilities between people and groups within society (Gough 1996a). How a child is viewed will influence what is evaluated as abuse. Definitions of child abuse would be quite different, for example, in a feudal state in which children are considered to be their parents’ possessions. Cultural expectations about sexual interactions among adolescents and between different age groups will also affect whether particular practices are defined as abuse (Abramson and Pinkerton 1995). Among the Sambia people of the highlands of Papua, New Guinea, for example, all young boys are expected to participate in ritualized fellatio with older boys as part of their initiation into manhood (Abramson and Pinkerton 1995). In essence, the younger boys are forced to submit; thus, this practice fulfills the two main criteria for childhood sexual abuse as defined above (coercive sex with a child or adolescent). Nevertheless, the Sambia consider ritualized fellatio to be critical for survival (they believe that semen is the source of manly strength and that it must be obtained through ingestion).

Definitions of abuse can also be expected to change over time to reflect societal changes. For instance, anecdotal evidence suggests that in Victorian England it was considered acceptable for a nurse or nanny to quiet a male infant by putting his penis in her mouth (Abramson and Pinkerton 1995). Today, this practice would clearly be considered childhood sexual abuse. The recent broadening of definitions of abuse has been accompanied by a greater sensitivity to signs of abuse that fit these changing definitions, and a greater willingness for professionals and others to intervene

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into the private family lives of others, or beyond the walls of institutional life, and so to offer greater visibility of children’s experiences (Gough 1996a).

DIRECTIONS FOR FUTURE RESEARCH

Perusal of the literature in this domain suggests several avenues for future studies. First and foremost, large-scale, longitudinal investigations of child victims are needed that examine global functioning, abuse-specific functioning, and attributional and coping strategies along with abuse, child, family, and community factors. Such studies could provide information about both the initial effects of sexual abuse and the factors that influence adjustment at later developmental stages and into adulthood. Because not all victims of childhood sexual abuse develop adjustment problems, a better understanding of who is likely to experience such problems is needed.

Second, further research is needed regarding the efficacy of various approaches for the treatment of related problems (see Cosentino and Collins 1996; O’Donohue and Elliot 1993 for reviews). The utility or effectiveness of any particular treatment modality has yet to be demonstrated using a large-scale, randomized study in which treatment outcomes are measured using standardized instruments and untreated control groups. Consequently, treatment decisions often are made by clinicians without empirically tested guidelines.

Third, greater attention needs to be paid to methodological rigor in the conduct of childhood sexual abuse studies (Green 1993; Plunkett and Oates 1990; Trickett and McBride-Change 1995). In particular, investigators need to: (1) define it clearly and consistently; (2) use instruments with documented psychometric properties; (3) use control or comparison groups, when appropriate; and

(4) employ large sample sizes whenever this is feasible. Studies of treatment modalities should also conduct multiple follow-up assessments to determine whether intervention effects are sustained over time. Finally, studies are needed that clearly disentangle the effects of sexual abuse from other forms of abuse or maltreatment.

SUMMARY

Childhood sexual abuse is a significant and widespread problem in our society, no matter how it is

defined. Since it was first brought to the public’s attention in the 1960s, a vast amount of research has been conducted in an effort to understand its impact on victims. From the various reviews on the topic, several conclusions can be drawn. First, despite the considerable heterogeneity among sexual abuse victims, as a group, sexually abused children and adolescents tend to display significantly higher levels of symptomatology than their nonabused, nonclinic-referred peers. Second, compared to other clinic-referred children, two problem areas appear to differentiate sexually abused children and adolescents: post-traumatic stress disorder symptomatology and sexuality problems. Third, the type and severity of sequelae experienced by victims depends on the specific characteristics of the abuse situation and the perpetrator. Fourth, research on adult survivors suggest that abuse-related problems tend to persist into adulthood. Indeed, childhood sexual abuse histories are common among several clinical populations, including patients initially diagnosed as depressed or as having a borderline personality disorder.

Taken together, these findings suggest that clinicians and health care providers should screen for sexual abuse among children, adolescents, and adults. For instance, questions about childhood sexual abuse could become part of routine intake procedures. Moreover, it is important that a wide range of service providers are sensitive to, and have staff trained to deal with, issues of childhood sexual abuse when it emerges. Service providers’ policy and practice guidelines should explicitly acknowledge the prevalence and impact of it on women, men, and children.

Schools also need to have greater involvement in the prevention and diagnosis of childhood sexual abuse, especially since it generally occurs between the ages of six and twelve (Finkelhor 1994a; Sedlak and Broadhurst 1996). School-based education programs may be a useful vehicle for intervention and prevention. Teachers need to be educated and trained about their role in recognizing and reporting suspected cases.

Finally, further community awareness is needed to help prevent it from occurring. Greater community efforts toward providing treatment services for persons with a history of childhood sexual abuse are needed as are programs targeting

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