Svedin, Carl Göran, M.D., Associate professor BUP-Elefanten,University Hospital, Linköping, Sweden

There are four levels based on ours and others experiences throughout the world when it comes to thinking and organising the efforts and services that a society have to provide for exploited children. These four levels are awareness and recognition, plan of action, education and co-operation. It is in my view of thinking our task, that independently of wherever we work or to what profession we belong, it is our duty to make the uttermost to prevent that children are exposed to sexual abuse. When an abuse already have taken place it is our duty to try to perform investigations and offer help in a way that children and families can benefit without getting into more distress than before. AWARENESS AND RECOGNITION It is well known that when people don t know what to do, they don t react on the signs of abuse or stories of abuse even if they are more or less overtly presents to them. On the other hand if you think that sex with children is not a crime or a bad thing, you won t take action even if you are aware of the problem. Information, policymaking and change of attitude are therefore crucial and primary steps in this community process. The definition made by Roberge and Schecter is today internationally well accepted and to that defenition could nowadays orginised sexual abuse be added. With organised sexual abuse we include sex-rings, child prostitution, child pornography, and child sex tourism. All these include planned action of adults in using children for sexual purposes with or without making money in the same time. The offender uses the child for his own sexual needs and/or offer or sells sexual service to others in different forms including child pornography. The scope of the problem The problem with estimating the prevalence and incidence of sexual abuse constitutes a major problem. The first and overshadowing difficulty is all the unknown and unreported cases. Other problems emanate from the difficulties with definition and sample techniques. By prevalence studies we know that approximately 10-20 % of all women and 3-10 % of all men in Europe have experienced sexual abuse before the age of 18. Even if we looks at the lower figures as in Sweden these constitutes a great proportion of the population and if it is associated with mental illness and difficulties in the social adaptation it also constitutes a major health problem in the society. Throughout the western societies with some kind of incidence registers a three to fourfold increase in the numbers of reports can be noticed. If this is a true increase is difficult if not impossible to say. When it comes to organised sexual abuse we have even more difficult to produce reliable data. From research we know that sex-ring are more prevalent than we earlier expected, and in one study from Great Britain 5% of all sex-crimes during a two year period constituted children in sex-rings. In the same study 13% of the children were documented in pornography. Several studies of prostitutes show that they were used in pornography in their childhood, varying up to almost 40%. We don t have accurate or reliable figures how many children that are exploited in child-sex tourism, but there is today a common feature that almost every day some newspaper is reporting of sex-tourism in different parts of Europe and/or south-east Asia. Consequences Today s knowledge is that there is no single symptom or syndrome that is synonymous or ''proof'' of sexual abuse. In a review paper, Kendall-Tacket et al, studied the impact of child sexual abuse and noticed that almost two thirds of every abused child showed psychological disturbances or behavioural disturbances in the aftermath of sexual abuse. The interesting findings of the study was also that no single symptom or behaviour was characteristic for the majority of the children. Fears, posttraumatic stress disorder, behaviour problem, sexualised behaviour, and poor self-esteem were the most prevalent symptoms. When comparing sexually abused children with other children with mental problems two areas was stood out, namely posttraumatic stress disorder and sexualised behaviour. This pointing to the sometimes forgotten matter of course, namely that sexual abuse is not a disease but a traumatic event that like other traumatic event causes stress and in this case also interferes with the normal development of sexuality. When it comes to lasting effects of sexual abuse we can se a clear overrepresentation of mental illness among the adult psychiatric population in diagnoses such as depression and self-destructive behaviour including suicide attempts, eating disorders, substance abuse, psychoses, promiscuity, and posttraumatic stress disorder. We know that factors that influence the seriousness of sexual abuse trauma is complex and is dependent of both non-specific factors and abuse related factors. Among the first are of course socio-economical and family related factors such as poverty, family violence and substance abuse among parents. In a broader context we can see that in every society in turmoil or wherever poverty is prevalent there is an increased number of run-away children, street-children, child criminality, and child prostitution. On the other hand, only a minority of the population are what we call paedophiles but when a country strengthen their legislation or the police force work more effectively there is a tendency that paedophiles are more cautious, go underground or go abroad. In a way we can see that the problem gets exported and therefore it is an international and a global problem. Among abuse related factors are the nature of the abuse, which means that the more forceful the abuse is or whether and if penetration has occurred is connected to a worsened prognosis. The intensity, frequency, duration and if the abuse has taken place over a longer period of time are also factors related to an increased trauma. If there is a close and dependent relation between the child victim and the perpetrator it is also associated to a more negative prognosis. When it comes to organised abuse several perpetrators and documentation of the abuse in forms of photos and videos add a considerable burden to the child s possibility to adapt to a normal life after abuse. PLAN OF ACTION When the problems are recognised we need to have tools in order to effectively but carefully deal with the problem. On a comprehensive level authorities as the legislative assembly have to make clear laws that forbid sexual abuse of children according to the United Nations declaration of children s rights. The National Boards of Health and Welfare or other governmental bodies have to write guidelines serving as state of the art documents in helping the local professionals from different authorities to perform their difficult task. The role of the social welfare represented by a social worker is to take care of the protection of the child, the role for the police and the prosecutor is law enforcement, while the role of the health system is both to provide medical forensic evidence and evaluate the child and the child s need for treatment. The evaluation process is often very difficult and could be characterised like putting a puzzle together where for example the disclosure and statement from the child often is the only information to act from. The knowledge and the way the police do their interview of the child will then be essential for the whole process. In the plan of action we owe the traumatised child to offer a professional treatment. The child treatment has both short term and long term issues to deal with. To short term issues is treatment of medical injuries or taking specimens due to the risk of sexually transmitted diseases, the question of protection for the child and crisis intervention. Long term issues are dealt with in the so called trauma-oriented or abuse focused psychotherapy and general psychotherapy. In the trauma oriented psychotherapy the child is promoted to tell repeatedly and in detail about his sexual abuse experiences. The child also has the need to express feelings of anger, guilt, shame, disgust, powerlessness and sorrow. This instead of an unconscious pattern of symptom repetition that otherwise is the sequel of the abuse. In later stages of the therapy the child needs to learn and acquire the skills of how to protect oneself including how to say no and avoid risk behaviours. To strengthen the child s self-esteem, learn about normal sexuality and promote peer relations and group oriented leisure activities are goals in the closing stages of the therapy. An issue of importance is also for the child as well as for the parents to accept what has happened as a part of the individual or family past. In parallel parents need their treatment as non-abusing parent or in conjoint sessions together with the child. EDUCATION To perform the above outlined different and often very delicate tasks each profession needs sound knowledge of different kind and training in co-operation skills. First the police need basic knowledge about paedophiles way of thinking and acting. The police needs to know how paedophiles court the child victim and how the child is seduced over time to be engaged in sexual activities. Techniques of surveillance, taking specimens correctly and performing a correct house search are also basic knowledge for the policemen. The most important skill for the policeman to acquire is how to perform a professional interview with the child victim. A god interviewing techniques with non-leading questioning take a long time to learn. Knowledge about child development, communication handicapped children are also necessary to have. Other topics are how to use dolls and other devices such as drawings, toys to assist the child in the interview. The social workers also need knowledge about sexual abuse characteristics, child development, behaviour disturbances, psychological defence mechanisms and pattern of family dysfunction. The most important knowledge for the social worker is how to perform a detailed risk assessment of the child. This comprises both the seriousness of the abuse and the capacity of the non-abusing parents to protect and care for the child. The psychotherapists needs knowledge in crisis intervention, trauma oriented psychotherapy, often also knowledge in family therapy and complementary knowledge in non-verbal techniques such as play therapy and art-therapy. To achieve this knowledge we have to provide the different professionals with both basic and further education and training. CO-OPERATION Co-operation between authorities or their representatives is from experience very difficult. This has to do with many factor where each separately could be a formidable obstacle. A genuine and trustful co-operation is characterised by a genuine wish for co-operation, an interest and knowledge about the other part and mutual confidence. Respect in eachothers role and competence as well as respect and awareness of the own professional role, knowledge and limitations are important ingredients. To acquire and maintain a genuine co-operation is time consuming but often very rewarding in the end and in the process of achieving the aims to prevent children from being abused, helping abused children and taking measures against child sexual offenders. Obstacles for a genuine co-operation are stress, personal dislike, organisational differences, hierarchical problems, the used language etc. In cases of sexual abuse investigations it is obvious that the subject as such produce stress for all parts and that role expectations can upset a fragile co-operation very easily. Adding an international perspective to this matter gives raise to even more difficulties. Differences in culture, values and attitudes towards the phenomena of child sexual abuse, different laws, differences in law enforcement, difference in resources and differences in language are of course difficulties but also a challenge to be met.