The future of a pandemic
The term ‘pandemic’ (from the ancient Greek ‘pan’ meaning total, comprehensive, all and ‘demos’ meaning people) is one we have all become intimately acquainted with in the past year due to the spread of COVID-19. The term describes a globally widespread disease and is generally understood to refer to infectious diseases. The public’s familiarity with the term in the wake of the COVID-19 pandemic provides an opportunity to reconceptualise child sexual abuse (CSA) and the use of child sexual abuse material (CSAM) in a similar manner. This too is a health issue so prevalent worldwide that it has, arguably, reached the level of a pandemic.
Is there a CSA pandemic?
According to figures published by the World Health Organization, one in five women and one in thirteen men aged 17 or younger have been sexually abused worldwide (WHO, 2013). The situation is comparable in Australia. A recent study reported that one in six Australian women and one in nine men report having been sexually abused at age 15 or under (Australian Institute of Health & Welfare, 2018). Meanwhile, the use of CSAM is increasing on a global scale. In 2010, the Internet Watch Foundation identified 1351 websites containing what is sometimes described as ‘child pornography’. The number of these identified sites escalated to 13,182 in 2013 and to 132,730 by 2019 (Internet Watch Foundation, 2020), a shocking near one-hundred-fold increase in just nine years. This increase is explained by the growth of the dark web and technical developments that make searching for and locating CSAM easier for users but detection of these users harder for law enforcement.
The use of CSAM is problematic especially because it creates a demand for, and maintains, ‘contact CSA’. As a result, children are sexually abused repeatedly to continually produce content. Based on an enormous number of unreported cases, these statistics represent only the tip of the iceberg, which means the number of victims of sexual trauma is easily in the hundreds of millions – many times higher than the number of people who have been diagnosed with COVID-19.
A pandemic inflicts harm on both the individual and society due to the disease itself and the resulting health implications for those infected. While COVID-19 is highly infectious, it is an illness that leads to death, or severe and lasting illnesses in a just small percentage of cases. The same cannot be assumed for the effects of sexual traumatisation on victims. Rather, research shows that neurobiological changes in the nervous system can result, which are not only associated with increased susceptibility to stress and a greater likelihood of developing mental or psychosomatic illnesses, but also an increase in the risk of cardiovascular and metabolic diseases (Heim et al., 2013).
The sharing of abuse images via the internet has been framed as ‘viral spreading’ and ‘super spreaders’ are also recognisable, which cause an increased number of cases, making image materials available to many others. Victims of the production and dissemination of CSAM are not spared health consequences. An online study on the consequences of this form of victimisation from Gewirtz-Meydan and colleagues (2018) surveyed adults (n = 133) who had been photographed or filmed during abuse acts. Three-quarters of them were under nine years of age when the incident occurred and reported that the incident occurred for more than a year. In almost all cases (93%), the perpetrator was a family member or acquaintance, and many victims (61%) did not disclose the abuse to anyone. About half knew that the pictures had been spread, the other half did not know about it, but they described the fear of being confronted with it as a constant burden, and it was common for victims to feel helpless due to being unable to remove the visual material.
Counting the cost
The tangible economic cost of the COVID-19 pandemic in under two years has been immense. Several local and international studies have found the same of the CSA pandemic, albeit this pandemic has existed for much longer. Deloitte (2018) reported that in Australia, it is estimated that in the 2016/17 financial year, $793.1 million could be attributed to the direct health system costs of responding to child sexual abuse, notwithstanding the additional legal costs, child protection and many other costs.
In the German context, the ‘German Trauma Consequence Study’ determined that the direct and indirect costs of child sexual abuse, depending on the severity of the traumatisation, amount to between €400,000 and €1.2 million per person affected (Habetha et al., 2012). While methodologies of estimating such costs vary from country to country, similarly high costs have been concluded in the US and the UK. Even without factoring in incalculable intangible costs, this economic impact alone should be impetus enough for government and policymakers to seriously consider a comprehensive public health approach to the CSA pandemic.
Mitigating the consequences of sexual trauma
During the COVID-19 pandemic, hospitals worldwide have been overwhelmed with the sheer quantity of patients requiring acute care, despite having the medical expertise to treat many of the symptoms of the disease thanks to data that has been published at an astonishing rate to describe as precisely as possible the phenomenology, symptomatology and treatment options for COVID-19. Notwithstanding impressive levels of information sharing and research, healthcare systems have still found themselves under-resourced and, in many cases, unable to provide the level of care required for severe COVID-19 cases. Therefore, high priority has been placed on the prevention of transmission. Slowing the spread of COVID-19 enables health professionals to have the best chances of mitigating the consequences of being infected by the virus.
In Australia, the reverse could be said for the CSA pandemic. Resources have been invested into mitigating the consequences of sexual trauma. Interventions such as crisis lines, helplines and dedicated treatment centres for victim-survivors of CSA exist throughout the country (McKibbin & Humphreys, 2020) and funding for tertiary interventions is a critical element of a comprehensive approach. However, it is well known that CSA is chronically underreported. In the case of significantly more victims disclosing CSA and seeking support, most countries currently have a healthcare system that would be under-resourced or unable to provide sufficiently skilled and reliable care.
Therefore, in dealing with the consequences, there is a need to expand therapeutic measures for victims of sexual traumatisation. To increase access, resources should be made available with as few barriers to access as possible. The national health system should cover the cost of treatment, and remote treatment concepts like telehealth (i.e., via the internet or telephone) should be made available. This is particularly so, given that the healthcare environment has been identified as one of several reasons why men might refrain from disclosing abuse (Gruenfeld, 2017) and given that access to therapeutic care in Australia can be hampered by geographical location.
Replicating a prevention-centred approach
The costs of the uninhibited spread of COVID-19 can be observed at a fast pace, and the cost is individuals’ lives. A clear relationship between cause and effect provides intense motivation to act. In a very short time, we have seen comprehensive and expedited legal and political steps that have been taken worldwide to promote the containment of COVID-19 to avoid overwhelmed healthcare systems. Prevention strategies observed globally have differed in form. Many nations have successfully implemented a whole tapestry of policies to reduce transmission from all angles, including institutional and individual level regulations. The CSA pandemic can learn from two key areas of the COVID-19 response: intercepting institutional transmission pathways and implementing individual level causation-related intervention.
Intercepting transmission pathways
As with COVID-19, human contact is the decisive factor that turns an endemic disease into a pandemic. In modern times, this spread is made much easier because transport is available to many people on an almost global scale, and many people live in crowded and busy cities where contact with others is inevitable. The institutional and community setting has quickly adapted the physical space to reduce exposure to the virus. For example, restaurants have erected physical barriers between tables, workplaces have reimagined the office space and institutions in which high-risk individuals reside have been prioritised in terms of protection.
In the case of the CSA pandemic, institutions and digital settings act as transmission pathways. The speed at which technology has developed, the borderless nature of the spread of CSA and the inability for law enforcement to keep up are also contributing factors. Concerning the digital setting, regulatory intervention targeted at the multinational tech giants is necessary. After all, they provide the breeding ground for the ‘viral’ spread of CSAM. The internet has also become a platform whereby grooming can occur, both by strangers unknown to victims and by potential offenders wanting to build trust with a potential victim (Finkelhor et al., 2020). At the very least, effective and verifiable containment measures for the spread of sexual traumatisation on the internet (e.g., regarding grooming, livestreaming and the use of abuse images) should be demanded. This is necessary, just as facilities and environments with an increased risk of spreading COVID-19 would be closed or regulated immediately.
Physical settings must also be considered. The Royal Commission into Institutional Responses to Child Sexual Abuse identified several institutional settings whereby a pattern of CSA was evident. These institutions included religious organisations, out-of-home care settings, childcare and school environments. The Royal Commission submitted 24 recommendations aimed at making institutions safer for children. This is an important step towards intercepting transmission pathways at an institutional level.
Addressing causes – A German case study
As the saying goes, prevention is better than a cure. Significant resources have been invested into preventing the transmission of COVID-19 between humans, and significant requests and demands have been placed on individuals to prevent transmission, including, but not limited to, mask-wearing, curfews, lockdowns and quarantine obligations. In the case of the CSA pandemic, causation-related intervention includes all measures that contribute to the ultimate goal. In an ideal world, sexual traumatisation does not occur in the first place. Specifically, a potential perpetrator does not commit an assault and does not access or view abuse images. In contrast to political support and the great competition for the first effective vaccination against COVID-19, no real political commitment is apparent in this area to date, even though potential offenders have demonstrated demand and willingness to receive treatment.
It has long been accepted that we will have to learn to ‘live with the virus’. This also applies to paedophilia as sexual responsiveness to the child’s body pattern, which is classified as a disorder in the World Health Organization’s diagnostic manual (ICD-11: ‘paedophilic disorder’) and to which not only a significant proportion of sexual abuse acts can be attributed, but also a substantial proportion of the use of abuse images on the internet. Admittedly, there are no exact figures on the proportion of paedophilic preference disorders as a background for sexual abuse acts but only estimates, according to which about 40 to 50% of perpetrators show a paedophilic sexual preference. It is also common for such offenders to have sexually abused not only one child but several children (Beier, 1995; Seto, 2008). Prevention is a foreseeable solution, for example, by providing easily accessible, affordable and high-quality therapy in conjunction with research and provision of appropriate medication to increase behavioural control.
The Institute of Sexology & Sexual Medicine at the Charité – Universitätsmedizin Berlin has significant experience in this field and Germany is the only country that has integrated prevention measures into the healthcare system. The intervention, which enables people with paedophilic sexual preferences to receive skilled preventive therapy anonymously and free of charge, was established in 2005 and currently offers in-person treatment at 11 regional treatment sites. This is achieved with a budget of €5 million per year and the program is currently undergoing external evaluation. From the start of the project until the end of 2019, more than 11,374 contacts were registered, of which 3613 were fully diagnosed and a therapy offer was made to 2007 individuals altogether (www.kein-taeter-werden.de).
The establishment of this kind of program is not at all straightforward. It requires political support to ensure sustainability, but early financing is also possible through alternative concepts. In Germany, the program was initially funded through the Volkswagen Foundation and received support from child protection NGOs and media agencies, who took on the important role of public relations. Political support followed (through the Federal Ministry of Justice and Consumer Protection) and, finally, the integration into the healthcare system.
The program is based on the prevalence of paedophilic tendencies in the general male population estimated at approximately 1% (Ahlers et al., 2011; Beier et al., 2005; Dombert et al., 2015). Relevant issues from a clinical point of view are the onset of corresponding sexual interests at the fantasy level in adolescence, the associated impairment in the ability to form relationships with partners with a high risk of social stigmatisation when sexual responsiveness to children becomes known to others and the associated increased risks for mental health (increased rate of depression, anxiety disorders, etc.), as well as the risk of using abuse images or directly sexually abusing children (Beier, 2021).
Over 15 years of prevention work, it became apparent that most adults with paedophilia stated that they had already known about their sexual preference in adolescence and that they had frequently sexually abused children. This corresponds with the results of the study by Elliott and colleagues (1995). According to the 2016 police statistics in Germany, approximately 25% of suspects concerning child sexual abuse and approximately 12% concerning possession, acquisition and distribution of child abuse images were individuals under 18 (Bundeskriminalamt, 2017). The Australian context is similar, with various police statistics collected between 1995 and 2005 attributing up to 16% of sexual abuse offences to adolescents between the ages of 13 and 17 (Boyd & Bromfield, 2006).
This reality was the background for the establishment of an additional prevention service designed for adolescents, which has been available at the Institute of Sexology and Sexual Medicine of the Charité since April 2014 and was financed by the Federal Ministry for Family Affairs, Senior Citizens, Women and Youth until the end of 2017. It is now also financed by the health insurance funds within the framework of the model project. The Prevention Project for Adolescents (PPJ) offers free counselling, diagnostics and therapy for adolescents between the ages of 12 and 18 who voluntarily seek help and who, due to sexually conspicuous behaviour and/or fantasies, can be assumed to have a sexual preference for the child’s body schema.
Fundamentally, the therapy program (known as the Berlin Dissexuality Therapy [BEDIT]) aims to strengthen the motivation for abstaining from dissexual behaviours, as well as increasing the experience of self-efficacy and behaviour control (including sexual fantasies and interests). The goal is to replace emotion-oriented, avoidance-oriented and sexualised coping strategies by building up adequate management strategies, strengthening social functionality (with a focus on the attachment dimension of sexuality), reducing abuse-supporting attitudes and behaviours, fostering empathy regarding the victims of child sexual abuse, and finally developing appropriate measures and goals for relapse prevention.
The German case study describes one possible offering for a specific target group. Additional interventions, such as helplines and dedicated programs designed for other target groups are complementary to this approach. Some possibilities are already being scoped and/or piloted in the Australian context, such as the ‘StopItNow!’ helpline model and programs like Bravehearts’ ‘Turning Corners’, which responds to adolescents who have engaged in harmful sexual behaviour.
These types of interventions correspond to the approach taken during COVID-19 in that there are efforts made to ‘defuse’ the transmission of the virus, however, similarly, no one assumes that the problem can be entirely and permanently eliminated. Therefore, a comprehensive approach is necessary and, as mentioned, transmission pathways should be intercepted, and consequences should be mitigated in cases where offending cannot be prevented.
Future of the CSA pandemic
The future of a pandemic depends on whether it is recognised as such, including the associated consequences, and whether efforts are made to contain it by society as well as through international cooperation.
It is a fact that the CSA pandemic is progressing and, from a preventive and therapeutic point of view, is only receiving a fraction of the resources required for dealing with and overcoming it.
The steps to be taken would be relatively straightforward, but they could only be implemented through (legal-political) action. In terms of content, they would have to concentrate on the causative agents, the transmission paths and the consequences, in each case embedded in accompanying research for the continuous optimisation of the processes.
Without these measures, the future of the CSA pandemic is likely to be such that it will continue to unfold unchecked, because it is not recognised as such. Therefore, no comparable efforts are being made by society and internationally to contain it, as is the case with other pandemics, taking the COVID-19 pandemic as a prevailing example.
Contact the authors: sexualmedizin.charite.de; [email protected]
The content of this publication is for informational purposes only and is not intended to be a substitute for professional psychological, psychiatric or medical advice. Support services in your state or territory can be found here. The APS Position Statement on Child Sexual Abuse and Psychology can be found here.