VICTIMIZATION PROCESS AND DISCLOSURE INHIBITORS
I believe child sexual abuse should be viewed as a sequence of events, rather than an isolated event. While most children who are abused recognize that something is wrong, they lack the maturity to identify what that is specifically or don’t know how to respond to it or end it. In general, I have found sexual victimization involves three overlapping stages: 1) sexualization of the relationship, 2) justification of the sexual contact, and 3) maintenance of the child's cooperation/silence.

After engaging the child in some form of sexual behavior, the activity then enters a secrecy phase (Burgess and Holmstrom, 1975). The primary task for the perpetrator after the sexual behavior has taken place is to impose secrecy. Why? Secrecy eliminates accountability. Secrecy also enables repetition of the behavior. The perpetrator, in all likelihood, is sexually abusing the child in order to meet non-sexual needs (Groth and Burgess, 1977). The child usually does keep the secret. Some children never tell anyone. Others keep the secret throughout their childhood and only disclose the sexual behavior many years later. Why? Rewards have probably been offered and given. More importantly, the child may keep the secret because he or she enjoyed the physical/emotional pleasurable aspects of the activity. This premature introduction to sexuality by a known and valued perpetrator, a person who is a significant other for the child, may feel good on several levels—pleasurable sexual stimulation, enhancement of self-esteem, feeling important to another person, and so forth. Although not especially pleasing to contemplate, to deny the physically pleasurable aspects of the sexual behavior and interpersonal attention is to ignore the obvious and to neglect consideration of one of the more important dynamics in continued silence.

On the other hand, threats may have been used to reinforce secrecy. In general, the less socially/interpersonally adept the perpetrator, the more likely he or she is to threaten the child. Of course, many compelling threats made to a child do not include physical violence to the recipient of abuse. For example, the threat may be directed towards a third party (e.g., "If you tell, I will hurt your mother (or father!")). Separation is a potent threat, too, especially for a younger child. Likewise, a threat of personal separation, for the child may be particularly anxiety provoking: for example, "If you tell anyone, they'll send you away." A variation might involve threat of harm to someone else ("If you tell anybody, I'll hurt your brother."). Finally, the threat may entail violence against the child, ("If you I tell anybody, I'll hurt you or kill you.").

In sum, many wonder why sexually abused children do not tell. One of the most common and compelling reasons that children do not tell is fear. The offender is usually older than the child and wields overt or covert authority and power over the child. Commonly, vague threats of violence are sufficient to make the child victim feel powerless, afraid, and fearful of physical repercussions from the abuser because the offender is usually physically larger and stronger than the child. In addition, victims of sexual abuse often feel ashamed or guilty and find few safe opportunities to disclose their victimization because of the power differential in the relationship. While fear and shame are powerful factors in maintaining a child's silence, ignorance of personal boundaries, especially in pre-pubescent children, also contribute to a child's silence or delayed disclosure. Often by the time a child recognizes the unacceptable nature of abusive behavior, the child is likely experiencing feelings of responsibility, shame, and/or isolation—feelings that further inhibit disclosure of victimization experiences. Lastly, I should note that some offenders, rather than using threats, secure a child's compliance and silence through bribes and/or special privileges—such as continued personal acceptance and friendship-like behavior. Over many years of clinical work, I have found that virtually all children who disclose a history of sexual abuse say they wish they would have told someone earlier, but don’t because of fear of retribution from the abuser. Overall, I believe that it is impossible to overemphasize the significance of the exploitation and misuse of accepted power relationships when assessing the impact of sexual abuse on the child.

ABUSED-TO-ABUSER CYCLE
The scientific literature suggests a cycle of violence for victims of sexual abuse. Although limited in scope and predictive power, this cycle indicates that sexual abuse in childhood appears to increase the risk for later sexual acting-out (Longo, 1988; Gaffney et al., 1984; Becker, 1988). Specifically, children who have a history of child sexual victimization often act out sexually and/or engage in sexual activity with others—oftentimes siblings. Behaviors may include fondling, oral copulation, anal and/or vaginal penetration. In one study, greater than 50% of the boys who abused a sibling were victims of prior sexual abuse. Although research cannot reliably predict who will become abusive to others, there is ample evidence of the damaging influence of initial abuse. While little direct evidence exists for an intergenerational transmission of sexual abuse, the complex traumatic components of child sexual abuse are clearly associated with the behavioral symptoms—especially sexual assertiveness by child victims towards others (Finkelhor & Browne, 1985; Dodge, 1990).

THE EFFECTS OF SEXUAL ABUSE
Empirical studies find sexual abuse associated with a wide range of psychological and behavioral effects. Some abused children are described as "wild' and "out of control," with their distress channeled outward into aggressiveness and inappropriate sexual activity towards others. As with physical abuse, child sexual abuse victims are at risk for compulsive repetition of the abuse and loss of conscious memory of the trauma (Sgorio, 1988). In other words, some sexually victimized children may actually become sexually aggressive and victimize others who are younger and smaller than themselves. My professional experience has been that the child who is a sexual offender should always be regarded as a likely victim of sexual abuse.

Many male victims tend to have confusion about sexual identity, sexual norms and suffer from guilt, betrayal, shame, anger, hostility, lowered self-esteem, grief, depression, extreme dependency, nightmares, phobias, somatic complaints, depression, dissociation, running away, school problems, vulnerability to subsequent abuse (have an impaired ability to judge the trustworthiness of others), and have a sense of “different-ness” from other males. The behavioral impact of childhood sexual abuse can be isolation, drug/alcohol abuse, criminal involvement, self-mutilation, and suicide. Additionally, we are now finding that children who have a history of sexual victimization may develop symptoms consistent with a diagnosis of Posttraumatic Stress Disorder (PTSD). Child sexual abuse victims may also suffer from poor academic achievement, behavioral problems, and social isolation. The victim’s symptoms may also be directed inward and include sleep problems, substance abuse, self-hatred, disturbed relationships with others, and inability to trust others and to protect oneself (Wyatt & Powell, 1988). In sum, identification with the aggressor and resolving conflict about one's own powerlessness, by acting out against others, are well-recognized responses to victimization.

Another often over-looked symptom of sexual abuse is guilt. Specifically, children who have been sexually victimized usually experience guilt on three levels:
1) Responsibility for the sexual behavior. Many child victims feel as if they are responsible for the sexual activity that took place—children are never to blame and I cannot emphasize this enough! By definition, the sexual abuse was initiated by someone who occupied a power position over the child. Nevertheless, the children tend to feel guilty about their participation as soon as they perceive the societal response to their sexual activity. Unfortunately, as Burgess and Holmstrom (1974) have described, so¬ciety tends to blame sexual abuse victims of any age and children are no exceptions to this response. This attitude is conveyed to the child in multiple verbal and nonverbal ways and reinforces the youngster's tendency to assume guilty responsibility for the inappropriate sexual behavior;

2. Responsibility for disclosure. Almost invariably, as described by Burgess and Holmstrom (1975), child sexual abuse is treated as a secret by both the perpetrator and the victim. When the secret is disclosed by the child victim, he or she is obviously responsible for the disclosure. However, children may assume responsibility for disclosure under other circumstances, for example, purposeful disclosure by someone else or accidental disclosure. In all of these instances, the child may feel that he or she has betrayed the perpetrator or has somehow violated a trusted, valued relationship (a sentiment that many can relate to is that negative attention is better than no attention at all). This response is inten¬sified when and if the perpetrator ascribes responsibility for disclosure to the child and conveys hostility or reproach at the same time; and

3. Responsibility for disruption. Disclosure of child sexual abuse can be expected to cause profound disruption for the victim, the victim's family, and the perpetrator. In intrafamily child sexual abuse, the disruption is even greater. If the child was directly responsible for the disclosure, he or she can be expected to feel guilty about the disruption that follows which (in all likelihood) will be greater than anticipated by the youngster. However, as children accept guilt and responsibility for accidental disclosure or for disclosure by others, so also, do they accept blame for the disruption that ensues in the latter circumstances. Since the disruption is likely to be painful, the victim is the family and significant others are likely to perceive him or her as responsible for any discomfort that they must suffer. Again, this type of feedback intensifies the victim's feeling that he or she is guilty for the disruption experienced by everyone else.

TREATMENT PERSPECTIVES
The reported incidence of sexual abuse for male children is about 1 in 7 to 1 in 10 by the time they reach age 18. About 4 of 5 victims experienced sexual abuse from non-family members. However, the family's response to the sexually abused child is critical for the success of treatment. Treatment concerns with male sexual abuse victims usually focus on: breaking the silence, accepting the experience(s), dealing with feelings associated with the abuse (particularly difficult for feelings not consistent with the “male role”, mourning one's "lost childhood, dealing with the negative self-image of not being “strong enough” to end the abuse, learning appropriate social/sexual boundaries/skills, dealing with confusion about sexuality (if abused by a same gender person), dealing with possibility/fear that one could become a victimizer.

Although the most frequently reported type of incest is parental, usually in¬volving father and daughter, the most common form of incest may be sexual activity among siblings—typically between brother and sister— even though the incest may take the form of brother-sister, brother-brother, or sister-sister interactions.

Some may wonder why sibling incest occurs. There are no good answers for this. However, one partial answer is that may be a result of sexual curiosity and experimentation among siblings and may evolve out of sex play that has "gone too far." Similarly, sibling incest may occur as a result of situational pres¬sures, personality disorders, and dysfunctions within a family system. As mentioned throughout this letter, sometimes the sexual activity may be encouraged or forced by a third party, which, while not uncommon, is certainly not unknown or unheard of.

FACTORS IN ALTERING THE CYCLE OF ABUSE
Maltreated or neglected children are not predestined to develop into sexually offending adolescents or adults. Existing literature estimates that the actual transmission rate of future abuse to be about 30% to 40%. Variables that have been found to shield children from future offenses are a supportive family environment, good cognitive abilities, absence of major psychopathology, and the availability of non-abusing adults and peers to model appropriate behavior/relationship. Children who are given a chance to make sense of their abuse with a non-abusing adult are less likely to repeat the patterns of victimization in their later lives. Therefore, the availability of alternate relationships is important in interrupting the cycle of sexual abuse.

Having said all of that, what does the research say about recidivism? Unfortunately, the very limited (and controversial) research that has been done is related to adult sex offenders (not children). The bottom line is that there are no reliable predictive profiles or tests that can determine who will become a sexual abuser later in life. There is no doubt that not all sexually abused children will develop problem behaviors. However, it should be assumed that the abusive experience is so potentially toxic to developing sexuality that therapeutic measures should taken accordingly.

Over the course of many years, I have come to find that all child victims of sexual abuse need some level of therapeutic intervention, regardless of the identity of the perpetrator. I further believe that with respect to the child victim and the family's response to disclo¬sure and intervention is paramount to the future functioning of the child. In addition, I believe that there are more similarities and parallels between intra¬family and extrafamily child sexual abuse cases than have previously been recognized. Most statutory child-protection agencies focus almost exclusively on cases of intrafamily child sexual abuse while extrafamily child sexual abuse cases tend to occupy a low priority level if it appears that the perpetrator is "out of the picture" and no longer has access to the child. I have found a similar level of resistance to acknowledging the trauma to the child and permitting significant therapeutic intervention in both intrafamily and extrafamily child sexual abuse cases. Recovery seems to require nearly as much energy and effort to engage the family of a child who has been sexually abused by an outsider as is demanded for the intrafamily child sexual abuse case.

My professional experience has taught me that it is first necessary to address the needs and emotional trauma of the parents and siblings of the child who has been sexually abused by an outsider in order to be able to implement a treatment plan that addresses the therapeutic needs of the victim. Accordingly, I recommend that the intervention and treatment plan for all child sexual abuse victims includes a treatment approach for the family, as well as the individual. While it is true that some cases of the intrafamily and extrafamily abuse appear to be amenable to short-term interven¬tion, those cases are the exception rather than the rule. Generally, cases of both types will require a long-term treatment plan, which will optimally include more than one treatment modality and will be characterized by a focus on the entire family. Of course, each case presents a unique set of circumstances. Therefore, intervention and treatment plans should reflect this fact.

Monitoring the status of any case should, of course, address the issue of victim/family recovery and focus on breaking the cycle of sexual abuse. Likewise, the case should be reassessed at regular intervals by therapists and other involved agencies so that the child does not become abuse again or does not initiate “copy-cat” behavior towards others. So, in sum, there should also be a commitment to reassess for therapeutic progress in the case, evaluating such issues as whether the victim's self-image is improving, are any depressive symptoms persistent, does the family members have clearer role boundaries (setting appropriate role modeling), is the victim completing age-appropriate developmental tasks, does the victim have better improving social skills (compared to when the abuse came to light), is the child less isolated, and is the child using his or her social skills to appropriate use?