Child sexual abuse: Raising awareness and empathy is essential to promote new public health responses

Child sexual abuse is a major global public health concern, affecting one in eight children and causing massive costs including depression, unwanted pregnancy, and HIV. The gravity of this global issue is reflected by the United Nations ’ new effort to respond to sexual abuse in the 2015 Sustainable Development Goals . The fundamental policy aims are to improve prevention, identification, and optimal responses to sexual abuse. As shown in our literature review, policymakers face difficult challenges because child sexual abuse is hidden, psychologi-cally complex, and socially sensitive. This article offers new ideas for international progress. Insights about needed strategies are informed by an innovative multidisciplinary analysis of research from public health, medicine, social science, psychology, and neurology. Using an ecological model comprising individual, institutional, and societal dimensions, we propose that two preconditions for progress are the enhancement of awareness of child sexual abuse, and of empathic responses towards its victims.


Introduction
Worldwide, child sexual abuse is a massive challenge for public health, social justice, human rights, gender equality, and science. 1 The socioeconomic costs are profound, with the average cost for each victim conservatively estimated at $US210 000. 2 Health consequences include anxiety, depression, post-traumatic stress disorder, and suicidality. 3 Child sexual abuse is also associated with subsequent sexual victimisation, unwanted pregnancy, and HIV acquisition. 4 Child sexual abuse is endemic worldwide: 12.7 per cent of all children experience sexual abuse (18.0 per cent of girls (16.4-19.7 per cent) and 7.6 per cent of boys (6.6-8.8 per cent)). 5 Girls are two to three times as likely as boys to be victimized in Asia, Australia, Europe, and North America, 5 and higher prevalence for girls was recently found in five African nations. 4 Some nations like China, however, have reported lower prevalence for girls. 6 International and national communities have acknowledged the urgent need for governments and policymakers to do more to prevent, identify, and respond appropriately to child sexual abuse. The United Nations' 2015 Sustainable Development Goals has set an agenda for global human development efforts from 2015-2030. 7 Significantly, these Goals have added two new targets acknowledging child abuse as a fundamental obstacle to health, demanding concerted action. Target 16.2 aims to end abuse and exploitation of children, and Target 5.2 aims to eliminate all forms of violence against women and girls, including sexual exploitation. Governments will be required to report on progress against these targets. Yet, child sexual abuse has been an apparently intractable problem across societies for centuries. What impediments do governments face in their endeavours to meet the United Nations' new child sexual abuse prevention targets, and how might these problems be overcome? Impediments at Individual, Institutional, and Societal Levels that Contribute to Perpetration, Concealment, and Continuance The challenge to respond to child sexual abuse confronts health policymakers in low and middle income countries, and developed nations, due in part to multiple factors at individual, institutional, and societal levels which influence its perpetration, concealment, and continuance.
At the individual level, perpetrators of child sexual abuse have poorly developed socio-emotional skills, attitudinal and cognitive distortions, 8,9 and possess similar attributes to sex offenders against adult women, 8 namely a sense of sexual entitlement, empathy deficits, a construction of masculinity emphasizing sexual performance and dominance, and a history of childhood victimisation. 10,11 At the institutional level, such as in schools and religious institutions, child sexual abuse is more likely to be perpetrated, concealed, and to continue when there is a rigid power hierarchy, a culture of silence protecting the institution's reputation, and an absence of protective regulatory mechanisms including robust organizational policy, employee screening, codes of conduct, incident reporting processes, and staff education. 12,13 At the societal level, child sexual abuse is enabled when children's rights are not recognized, laws and policies do not prohibit and prosecute sexual offending, social norms against sexual violence are weak, gender inequality persists, constructions of masculinity emphasize aggression and sexual dominance, 14 there is ignorance about sex and sexual violence, and opinion leaders in social institutions lack the will to act.
Two other difficult aspects of the problem contribute to these impediments. First, despite the Convention on the Rights of the Child, Article 19 that requires nations to take all appropriate legislative, administrative, social, and educational measures to protect children from sexual abuse, problems of perpetration and concealment persist because institutional and societal protection of children remains weak. Major inquiries into widespread child sexual abuse in England and Wales, 15,16 Ireland, 17 Germany, 18 the USA, 19 and Australia 20 show that even in nations with a well-established rule of law, environments within and beyond children's homes and institutions are frequently unsafe. Even where strong regulatory measures have been taken, this protective fabric can be compromised. Dozens of nations have passed laws requiring doctors, nurses, teachers, and police to report suspected cases. 21 Assessed against the arc of history, this recruitment of professionals as protective sentinels for abused children is a major policy innovation grounded in science, public health, and ethics. These duties have resulted in remarkable gains in identifying cases of sexual abuse. Yet, even with such measures, there remain instances of inappropriate failure by professionals and institutions to report known cases of sexual abuse. 19,20,22 Second, across all societies, most victims do not disclose to health, welfare or legal agencies. Prevalence studies show the true incidence is 30 times that identified in cases officially confirmed by government agencies. 5 Multifaceted barriers to disclosure confront child victims at individual, institutional, and societal levels. 23 Disclosure by children is Child sexual abuse often inhibited by feelings of shame and fear, and the lack of a trusted confidante. Children are frequently ignored, blamed or punished when they do disclose; and cultural norms and gender constructions constitute further powerful deterrents. [23][24][25] Responding to child sexual abuse therefore presents multiple, unique, and cross-disciplinary challenges for health policymakers. Its hidden, private nature is an immediate problem. Its inherent concern with sexual behaviour and human psychology adds layers of complexity for responses to individual victims, perpetrators, and agents of change. The connection with institutional and societal forces, including gender constructions and power relations between adults and children, contribute additional challenges. The ongoing socialised reluctance to discuss sexual matters is a further complicating feature. In this article, we suggest two fundamental challenges must be faced in developing a systematic response to improving policy and healthcare for these children. Our proposals are informed by the aetiology of child sexual abuse and cross-disciplinary analysis. They are based on a three part ecological model animated by a coherent theory of change.

The Need to Develop Awareness, and Indications for Progress
The first challenge is the awareness problem. Even in Western nations, individual and societal sensitization to child sexual abuse is still only several decades old, 26 and remains incomplete. Knowledge gaps and misperceptions about child sexual abuse are widespread amongst the general public, 24,25 professionals, and societal opinion leaders. 27 Yet, awareness of the nature of child sexual abuse and its multiple dimensions is an essential condition for prevention, recognition, and action, and is required at individual, institutional, and societal levels. At the individual level, awareness must be developed in: children themselves, who may be victims, perpetrators, and confidantes; 23 parents and caregivers, whose supportive reaction is a cornerstone to the child victim's adjustment; 28 and professionals in education, childcare, health, law enforcement, social welfare, and other youth-serving organizations, as they are often the trusting adults to whom children turn. 23 At the institutional level, it is important for managers and leaders of youth-serving organizations to possess this awareness, if they are to train their staff and establish clear policies regarding abuse prevention and response. 12 At the societal level, leaders in community, religious, media, government, and judicial organizations are essential bearers of this knowledge, and awareness is necessary in the general public.
A clear opportunity exists to make substantial progress in developing awareness. Because of the complexity of child sexual abuse, specialist interdisciplinary knowledge must underpin efforts to inculcate awareness in individuals, institutional actors and leaders, 12 and broader society, using optimal pedagogical methods adapted to the audience.
The key components of awareness-building efforts should include: what child sexual abuse is; its prevalence; who experiences it, and at what ages; who inflicts it; its criminality and other legal consequences; how a child feels when and after being victimized; the serious harms and consequences caused to the child; the tendency towards non-disclosure; children's truthfulness in disclosure (even if they recant); children's typical emotional, social and behavioural responses after victimization, including ways in which they may indicate their experience without frank disclosure; and principles of consent, children's rights, and gender equality. Professionals and institutional leaders must also be aware of their legal and ethical duties to report known and suspected cases, and their legal liability for breaching their duty. Enhanced public awareness, including through media campaigns, should also be a priority.
Improved awareness of these factors would greatly assist the response to child sexual abuse. However, awareness alone may not reduce child sexual abuse. It may not by itself produce appropriate responses by adults to disclosures and suspected cases, which is doubly important since survivors are often deeply traumatized through the indifference of bystanders. 29 It may not catalyze institutional reforms, or influence broader societal change to undesirable social norms, legal frameworks, gender inequalities, and constructions of masculinity which facilitate child sexual abuse. Greater gains require enhanced awareness allied with a second attribute.

The Need to Develop Empathy, and Indications for Progress
The second challenge is the empathy problem. Empathy is a contested concept that has been given different meanings within philosophy, psychology, and neuroscience. [30][31][32] For our purposes, we accept the interpretation of multiple theorists over several decades that empathy is a two-limbed attribute, which requires both an accurate cognitive understanding of another person's situation, feelings and needs, and an affectively motivated action that is appropriate to that person's situation. 30,[33][34][35] Empathy is a skill which enables understanding of another person's experience, and appropriate responses and behaviours. The key point is that either as a general mechanism, 33 or if specifically contextualized, 36 empathic concern towards another person encourages prosocial altruistic behaviour. 30,31,[33][34][35] In this context, empathy requires a capacity and willingness to imagine the abused child's perceptions, needs, and trauma, and right to bodily inviolability, while avoiding the profound distress some have claimed decreases helping behaviour and produces self-preservation. 37 Empathy is known to be necessary to reduce sexual violence generally, 10,11 and against children in particular. 14,36,38 As a mechanism, empathy catalyzes behaviour appropriate to the needs of the person, and acts as a circuit-breaker on inappropriate impulses and harmful behaviour. 10,34 Empathic responses are influenced by learned preferences and can be developed through education, 31,34,37,39 even in apparently challenging clinical circumstances such as autism. 34,40 While sexual abuse of children is a complex product of contextual, dispositional, and clinical factors, 8,9 empathy development for offenders is a focus of therapy 41 that we contend is also central for health policy and prevention efforts. Empathy is also known to enable clinical professionals to make prosocial responses. 42 We posit that efforts to develop empathy in this context offer multiple opportunities for health policy and for practical gains. At the individual level, heightened empathy may contribute to a potential offender resisting the impulse to abuse a child; to a parent sensitively dealing with a child's disclosure instead of dismissing it; to a professional who does not suppress his or her knowledge or suspicion of a child's experience and instead reports it. At the institutional level, heightened empathy may contribute to a willingness to improve policies that minimize the likelihood of perpetration of child sexual abuse, and to appropriate responses instead of institutional cover-ups and protection of perpetrators. At the societal level, heightened empathy may contribute to governments designing better laws and policy interventions, community leaders advocating for children's safety, and to the development of social norms which protect children's rights, promote gender equality, reframe constructions of masculinity and femininity, and neutralize harmful attitudes such as a sense of entitlement to indulge sexual impulses against children.

Action Steps
Models for responses to violence against children recognize that systematic efforts are required using an ecological approach. 4,14,38,43 Such models, including the THRIVES programme, include components in individual, community, and societal domains to enhance parenting, improve laws and policies, change harmful attitudes, promote education and skill development, and provide therapeutic services. 43 This ecological approach is also required for a health policy response to child sexual abuse. Awareness-building and empathy-building are master keys that unlock the potential to realize programmatic goals.
Steps to promote appropriate responses after infliction of sexual abuse are essential. Parents and caregivers, and professionals in health, education, law enforcement, and other youth-serving institutions, should be prime targets for awareness-building and empathy-building so they can respond appropriately to disclosures, and can even identify cases at an early stage. Educational and religious institutions must develop the necessary culture and regulatory approach to minimize perpetration and prevent a culture of concealment. 12,13,21 Increased efforts to prevent sexual violence are paramount, especially through childhood interventions. 10 While synchronised efforts with both genders are needed, 14,38 dedicated and specialised interventions with men and boys are required and may need focused attention, as in-built biological tendencies may compromise empathic capacity. 33,34 Evidence of successful interventions with boys and men to prevent violence against women and girls is scarce. While some efforts have shown progress in improving attitudes, there is little evidence of reduced perpetration or changes to social norms. 14 This supports our contention that at the level of individual prevention, greater emphasis is required on development in children, particularly in boys, of empathy and related skills of emotional self-regulation, such as impulse control and delay of gratification, together with better education about sexual behaviour towards self and others, sexual relationships, and gender roles.
Such an enhanced individualized emphasis on awareness and empathy building would itself contribute to changing social norms, including norms of sexual behaviour, constructions of masculinity and femininity, and gender inequality. Reframing masculinity as requiring respectful sexual behaviour to achieve an honourable personal identity may help to replace conceptions of masculinity as requiring sexual aggression and dominance. 44 Child sexual abuse In addition, awareness and empathy development at institutional and societal levels would help recalibrate institutional practices and social norms to reduce child sexual abuse and strengthen the protective social fabric. Policymakers and community leaders are essential in instigating and embedding new social norms, and necessary broader structural responses to gender inequality and constructions of masculinity. 14 Indeed, reform of some social norms through legal frameworks and justice responses depends on these leaders' commitment to change, which can crystallize through awareness and empathy.

Conclusion
Worldwide, there is a need for new advances to better prevent and respond to child sexual abuse. At individual, institutional, and societal levels, developing awareness about child sexual abuse and empathy towards victims is necessary to enhance healthy behaviour, responses, and societal change. Levels of cognitive capacity and intrinsic motivation to respond prosocially can be increased through multidisciplinary education and innovative methods of building empathy. Awareness gains may be more readily achievable than empathy gains. However, both are required to promote a stronger social fabric to protect children. Enhanced awareness and empathy are key attributes to facilitate a cascade of beneficial outcomes in violence prevention, humane responses, policy reform, and development of healthy social norms and communities.