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Child abuse is a public-health problem of major importance worldwide.[ 1] Child sexual abuse is a particularly severe, unacceptable, and frequent form of maltreatment,[ 2] and is a major social concern in occidental societies. One reason is recent awareness of the devastating consequences of child sexual abuse on the health and wellbeing of victims, including risk-taking behaviours, drug abuse, sexual dysfunctions, developmental problems, anxiety disorders, or suicidal behaviour.
The sexually abused child has become an archetype of the innocent victim, the paedophile one of evil and monstrosity. In this context, the repetition of the abuse by the victim is a shocking, scandalous, and depressing observation. This phenomenon has been confirmed in the case of child physical abuse.[ 3] However, this is a complex field of investigation, and few data are available. Furthermore, sexual offenders are not directly comparable with violent offenders.[ 4]
In this issue of The Lancet, David Skuse and colleagues report a longitudinal study that sheds new light on this topic. These investigators were able to follow up 224 male children, victims of sexual abuse, up to the age of 18-32 years, and to assess whether they were known by the police or by social services, on a national basis, to have themselves committed sexual aggressions. Overall, 11.6% of victims became perpetrators in later life.
This important result confirms that the repetition of sexual abuse by the victim becomes a reality in a significant proportion of cases. This finding brings us back to tragedies of antique times: is human destiny directed by insurmountable forces? This is a perturbing question, even more since in the Skuse study, unlike retrospective studies, victim children had been referred to a specialised clinic. For a significant proportion of victims, the care and therapy they were offered did not succeed in avoiding such a destiny.
Moreover, a strong influence of genetic factors has recently been demonstrated in relation to the repetition of physical abuse, emphasising further the weight of fate.[ 5] However, in the field of human behaviour, biological factors do not generally act alone, but in interaction with environmental factors.[ 6] In the study of Skuse and colleagues, environmental factors such as intrafamilial violence and child neglect are associated with repetition of sexual abuse. These factors should be taken into account in the management of victims[ 7] and, as Skuse and colleagues suggest, might help in the conception of preventive interventions more specifically targeted to victims at higher risk of becoming perpetrators.
What are the prospects for prevention? Preventive efforts directed towards children, as Skuse and colleagues recall, have had limited efficacy in preventing child abuse. Still, developing children's competence remains essential, if not as primary prevention, more realistically with the objective of helping children to recognise abusive situations and disclose victimisation.[ 8] Such preventive programmes should be developed in schools, integrated into sexual education.
The Skuse study focused on one outcome, the repetition of the abuse by the victim, thus leaving aside other unfavourable outcomes such as risk behaviour or suicide. Furthermore, it would be most interesting to study those victims who became resilient. About 20-44% of previous victims of child sexual abuse seem to have no symptoms or mental health problems.[ 9] How did these individuals manage to get out of the circle of repetition of the abuse, to avoid other risks, and to develop a meaningful life in spite of their terrible history? There is much to be learnt from resilient individuals. Resilience, just as vulnerability, is influenced by genetic and environmental factors, which interact,[ 6] most probably with a contribution of the will of the subject.[ 10] A better understanding of the construction of resilience in victims of sexual abuse should give new prospects for prevention, opening paths away from fate towards human freedom and creativity.
Peer-Reviewed Journal Article References: