In some cultures, breasts play a role in  human sexual activity . Breasts and especially the nipples are among the various human  erogenous zones . They are sensitive to the touch as they have many nerve endings; and it is common to press or  massage  them with hands or  orally  before or during sexual activity. During  sexual arousal , breast size increases,  venous  patterns across the breasts become more visible, and nipples harden. [ citation needed ]  Compared to other primates, human breasts are proportionately large throughout adult females' lives. Some writers have suggested that they may have evolved as a visual signal of sexual maturity and fertility. [ 98 ]  In  Patterns of Sexual Behavior , a 1951 analysis of 191 traditional cultures, the researchers noted that stimulation of the female breast by a male sexual partner "seemed absent in all subhuman forms, although it is common among the members of many different human societies." [ 99 ]


Many people regard bare female breasts to be aesthetically pleasing or  erotic , and they can elicit heightened  sexual desires  in men in many cultures. In the  ancient Indian  work the  Kama Sutra , light scratching of the breasts with nails and biting with teeth are considered erotic. [ 100 ]  Some people show a  sexual interest  in female breasts distinct from that of the person, which may be regarded as a  breast fetish . [ 101 ]  A number of Western fashions include clothing which accentuate the breasts, such as the use of  push-up bras  and  decollete  (plunging neckline) gowns and blouses which show  cleavage . While U.S. culture prefers breasts that are youthful and upright, some cultures venerate women with drooping breasts, indicating mothering and the wisdom of experience. [ 102 ]


Research conducted at the  Victoria University of Wellington  showed that breasts are often the first thing men look at, and for a longer time than other body parts. [ 103 ]  The writers of the study had initially speculated that the reason for this is due to  endocrinology  with larger breasts indicating higher levels of estrogen and a sign of greater fertility, [ 103 ] [ 104 ]  but the researchers said that "Men may be looking more often at the breasts because they are simply aesthetically pleasing, regardless of the size." [ 103 ]


Some women report achieving an  orgasm  from nipple stimulation, but this is rare. [ 105 ] [ 106 ]  Research suggests that the orgasms are genital orgasms, and may also be directly linked to "the genital area of the brain". In these cases, it seems that sensation from the nipples travels to the same part of the brain as sensations from the vagina, clitoris and cervix. Nipple stimulation may trigger uterine contractions, which then produce a sensation in the genital area of the brain. [ 107 ] [ 108 ] [ 109 ]


There are many mountains named after the breast because they resemble it in appearance and so are objects of religious and ancestral veneration as a fertility symbol and of well-being. In Asia, there was "Breast Mountain", which had a cave where the  Buddhist monk   Bodhidharma  (Da Mo) spent much time in  meditation . [ 110 ]  Other such breast mountains are  Mount Elgon  on the  Uganda – Kenya  border;  Beinn Chìochan  and the  Maiden Paps  in Scotland; the  Bundok ng Susong Dalaga  ('Maiden's breast mountains') in  Talim Island , Philippines, the twin hills known as the  Paps of Anu  ( Dá Chích Anann  or 'the breasts of  Anu '), near  Killarney  in Ireland; the 2,086 m high  Tetica de Bacares  or  La Tetica  in the  Sierra de Los Filabres , Spain;  Khao Nom Sao  in Thailand,  Cerro Las Tetas  in  Puerto Rico ; and the Breasts of Aphrodite in  Mykonos , among many others. In the United States, the  Teton Range  is named after the French word for 'nipple'. [ 111 ]


The  maturation  and  size  of the breasts can be measured by a variety of different methods. These include  Tanner staging ,  bra cup size ,  breast volume ,  breast–chest difference , the  breast unit ,  breast hemicircumference , and  breast circumference , among other measures.


The  buttocks  ( sg. :  buttock ) are two rounded portions of the exterior anatomy of most  mammals , located on the posterior of the pelvic region. In humans, the buttocks are located between the lower back and the  perineum . They are composed of a layer of exterior skin and underlying  subcutaneous  fat superimposed on a left and right  gluteus maximus  and  gluteus medius muscles . The two gluteus maximus muscles are the largest muscles in the human body. They are responsible for movements such as straightening the body into the upright (standing) posture when it is bent at the waist; maintaining the body in the upright posture by keeping the hip joints extended; and propelling the body forward via further leg (hip) extension when walking or running. [ 1 ]


In many cultures, the buttocks play a role in  sexual attraction . [ 2 ]  Many cultures have also used the buttocks as a primary target for  corporal punishment , [ 3 ]  as the buttocks' layer of subcutaneous fat offers protection against injury while still allowing for the infliction of pain.


The buttocks are formed by the masses of the gluteal muscles or "glutes" (the  gluteus maximus muscle  and the  gluteus medius muscle ) superimposed by a layer of  fat . The superior aspect of the buttock ends at the  iliac crest , and the lower aspect is outlined by the  horizontal gluteal crease . The gluteus maximus has two insertion points:  1 ⁄ 3  superior portion of the  linea aspera  of the  femur , and the superior portion of the iliotibial tractus. The masses of the gluteus maximus muscle are separated by an intermediate  intergluteal cleft  or "crack" in which the  anus  is situated.


The buttocks allow primates to sit upright without resting their weight on their feet as  four-legged animals  do. Females of certain species of  baboon  have red buttocks that blush to attract males. In the case of humans, females tend to have proportionally wider and thicker buttocks due to higher  subcutaneous fat  and proportionally wider  hips . In humans they also have a role in propelling the body in a forward motion and aiding bowel movement. [ 4 ] [ 5 ]


Some baboons and all  gibbons , though otherwise  fur -covered, have characteristic naked  callosities  on their buttocks. While human children generally have smooth buttocks, mature males and females have varying degrees of hair growth, as on other parts of their body. Females may have hair growth in the gluteal cleft (including around the anus), sometimes extending laterally onto the lower aspect of the cheeks. Males may have hair growth over some or all of the buttocks.


The  Latin  name for the buttocks is  nates  (English pronunciation  / ˈ n eɪ t iː z /   NAY -teez , [ 6 ]  classical pronunciation  nătes   [ˈnateːs] [ 7 ] ) which is plural; the singular,  natis  (buttock), is rarely used. There are many colloquial terms for them.


Human consumption of  cannabis  (which is commonly known as  marijuana ,  pot  or  weed ) is commonly thought to enhance  sexual pleasure [ 1 ] [ 2 ]  but there is limited scientific research on the relationship between cannabis and sex, in part due to U.S. drug policies that focus on prohibition. [ 3 ]  Effects of cannabis are difficult to study because sexual arousal and functioning are extremely complex and differ among individuals. [ 3 ]  Cannabis affects people differently, making it difficult to study. Both men and women report greater sexual pleasure after having consumed cannabis but there is no  scientific evidence  of the effects on the physiological components of the  sexual response cycle  when using the drug. [ 1 ]


As of 2010, research on the effects of cannabis on sex in humans is limited to  self-report studies . [ 4 ]  This type of study has disadvantages because it requires people to accurately remember how much they consumed and its effects, leaving researchers unable to verify responses. [ 3 ]  In these studies, the majority of people who consumed cannabis before sex reported they experienced greater pleasure than those without it. [ 1 ] [ 2 ]  Researchers believe this reported increase in sexual pleasure is likely a result of the drug’s effects on the senses. In particular, it commonly makes users feel more relaxed. [ 1 ]


Some research says the amount of cannabis consumed affects one's sexual experience. In one study, 59% of users thought sexual pleasure was enhanced after smoking one joint, though 39% thought consuming more than one joint provided any further enhancement; [ 1 ]  and large doses of cannabis have been used in India as a sexual  depressant . [ 5 ] [ 2 ]


It is not clear whether cannabis consumption affects the quality of  orgasms ; over half of male consumers, as well as a lower percentage of female consumers, reported it enhances their orgasms. [ 1 ]  In a small study published in 1979, 84 graduate students, the majority of whom were men and identified as "experienced smokers", believed cannabis increased the intensity of orgasms and should be considered an aphrodisiac. [ 6 ]  Some more-recent studies said orgasms are improved with cannabis use. [ 7 ] [ 8 ]


Studies on the effects of cannabis consumption on sex have shown few other significant physical improvements. In 1979,  Masters and Johnson  completed a five-year-long study with a sample size of 800 men and 500 women whose ages ranged between 18 and 30 years old. In this study, men reported no improvements in maintaining  erections  or any increase in penile firmness. Women reported no increase of  vaginal lubrication . [ 1 ] [ 2 ]


A study in 2017 in the Journal of Sexual Medicine looked at data from the large, nationally representative  National Survey of Family Growth  and included more than 28,000 women and nearly 23,000 men. It reviewed survey responses on the frequency of cannabis  consumption and intercourse in the four weeks prior to the survey. It found women who consumed cannabis daily had an average of 7.1 sexual encounters in the previous four weeks compared with 6 for those who never consumed it. Men who consumed cannabis daily reported having 6.9 sexual encounters on average compared with 5.6 in those men who never consumed it. [ 9 ]


There is evidence of the negative effects of cannabis use during sex. Some studies show a correlation between chronic cannabis use and reduced  testosterone  levels in men. [ 4 ]  It has been found heavy use of cannabis decreases the sperm count of healthy men, though this reduction can be reversed. [ 5 ]  Habitual use of cannabis is also linked to decreased sexual performance while increasing sexual arousal. [ 4 ]


The effects of cannabis begin as a chemical process in the brain in which the neural communication network becomes altered.  Tetrahydrocannabinol 's (THC) chemical structure is similar to that of  anandamide , which is responsible for sending chemical messages between neurons throughout the nervous system. [ 10 ]  The brain areas that are affected influence memory, pleasure, thinking, concentration, movement, coordination, and sensory and  time perception . These areas include the  amygdala ,  hippocampus ,  basal ganglia , and  prefrontal cortex . Within those areas are  cannabinoid receptors  that make up a part of the endocannabinoid system. [ 11 ]


Such effects within the nervous system may vary among individuals. Cannabis influences experiences of sexual pleasure and memory in distinctive ways. Studies have observed differences between male and female neuropsychological functioning. While the results have shown little significant differences, limited studies have been undertaken with very small  sample sizes . [ 12 ]


A study published in March 2019 observing women using cannabis prior to sex and their sexual function measured outcomes of satisfaction in drive, orgasm, lubrication, dyspareunia, sexual experience, and the frequency of cannabis use on satisfaction. [ 13 ]  The results of the study show women who used cannabis prior to having sex are more likely to have satisfactory orgasms and an increased sex drive. Women who frequently use cannabis had higher chances of satisfactory orgasms, regardless of whether they used it prior to sex. Such results show cannabis has a positive relationship to increased sexual satisfaction, and such results can be considered in research to develop treatment for  female sexual dysfunction . In another study, a large portion of participants reported having increased desire and sexual satisfaction while using cannabis before sex. In contrast, some reported the experience being worse than usual. [ 14 ]


The orbitofrontal cortex and hippocampus help with the formation of new memories, and cannabinoid receptors are found in these areas. Thus, cannabis will affect abilities regarding memory and learning. While using cannabis to enhance sexual experience and satisfaction, cannabis will also influence perception and sensation. [ 12 ]  Studies conducted observe neurocognitive behaviour of individuals under the influence of cannabis and the relationship between cannabis with risky behaviour. [ citation needed ]


Cannabis can have negative effects on learning and memory. Cannabis users show lower spans of attention, concentration, and abstract reasoning than non-users. [ 12 ]  Cannabis use impairs neurocognitive functioning, and the user may lose the ability to effectively recall or learn while intoxicated. This can hinder responses to the surrounding environment and decision-making, leading to the individual's inability to accurately remember details accurately or their perception of time becomes distorted. While such results are studied, the neurocognitive domains remain inconsistent in results when observing neurocognitive behaviour of users. One study observed the risky behaviour ( [ clarification needed ]  of individuals who use cannabis. [ 15 ]  The findings of the study revealed that adolescents who use cannabis are more likely to voluntarily engage in unprotected sex repeatedly, while the participants who never used cannabis or started to use cannabis after adolescence were less likely to have unprotected sex. [ citation needed ]


There are a variety of cannabis-infused sex products, such as lubricants and massage oils containing  CBD  and THC. [ 16 ]


The  casting couch  is a  euphemism  for the practice of soliciting  sexual favors  from a  job applicant  in exchange for  employment  in the  entertainment industry , primarily  acting  roles. [ 1 ] [ 2 ]  The practice is illegal in the United States. Predominantly male  casting directors  and  film producers  use the casting couch to extract sex from aspiring actors in  Hollywood ,  Bollywood , [ 3 ] [ 4 ]   Broadway , and other segments of the industry. [ 9 ]  The term  casting couch  originally referred to physical  couches  in the  casting  office, but is now a  metonym  for the phenomenon as a whole. Depictions of casting couch sexual encounters have also become a genre of  pornography .


The casting couch is illegal under  United States  and especially  California law . In the United States, the majority of  lawsuits  related to the practice are  settled , resulting in a lack of  case law . [ 10 ]


In  The Atlantic , linguist  Ben Zimmer  described the casting couch as "a  metonym  for the skewed sexual politics of  show business ", which has been  normalized  into a  cliché  due to the prevalence of sexually aggressive men with positions of authority in  Hollywood cinema  and  Broadway theatre . [ 11 ]


According to economists  Thomas Borcherding  and Darren Filson, the high  risk  and  returns  in Hollywood cinema encourage the casting couch phenomenon. The possibility of high returns incentivizes unestablished actors to accept minimal  wages  in exchange for roles. With the exception of a few extremely talented actors, producers are unable to evaluate the  aptitude  of the vast majority of qualified actors due to  uncertainty . As a result, some actors give sexual favors to producers to obtain a perceived advantage in the  casting ; the casting couch functions as a counterpayment that effectively reduces their wages. This creates a  conflict of interest  in which corrupt producers substitute aptitude (an unquantifiable variable) with sexual activity in their decision-making. [ 10 ]


Actors who submit to the casting couch are not guaranteed roles, as there is an abundance of actors who participate in the practice. An actor's decision of whether to provide sex is comparable to the  prisoner's dilemma , and results in a  tragedy of the commons  in which sex is needed to obtain film roles from producers who demand it, but fails to provide an advantage relative to other actors who offer sexual favors. The practice is illegal in the United States and likely involves some degree of  sexual exploitation  or  sexual harassment . Actors who do not participate in the casting couch are subject to  externalities , including reduced  employability . [ 10 ]


Borcherding and Filson argue that the casting couch became less prominent after the  Hollywood studio system , which enforced long-term  employment contracts  for actors, was eliminated on  antitrust  grounds in  United States v. Paramount Pictures, Inc.  (1948). Long-term contracts gave producers stronger  bargaining power , which was used by corrupt producers to extract sex from actors more effectively. [ 10 ]


The Casting Couch  ( c.  1924), a classic title in the  stag film  genre, [ 12 ]  was an early depiction of the casting couch as a  pornographic   trope  that later became mundane as it grew in popularity. [ 13 ]  In the sixteen-minute film, a  casting director  tells a young actress to wear a  swimsuit  during an  audition , spies on her in a  voyeuristic  manner while she undresses in a different room, and enters the room to solicit sex from her. The actress initially rebuffs his advances with disgust, but returns to the director after taking advice from a book titled  How to Become a Movie Star . She performs  fellatio  and  vaginal intercourse  in exchange for a role in his film; the latter takes place on a couch.  The Casting Couch  concludes with an  intertitle  that states, "the only way to become a  star  is to get under a good director and work your way up". [ 12 ]  Zimmer credited the film with popularizing the term  casting couch . [ 11 ]


The trend of casting couch scenarios used on  pornography websites  began with Backroom Casting Couch in 2007. [ 14 ]


The website  GirlsDoPorn , which operated between 2009 and 2020, was described as a casting couch site. [ 15 ] [ 16 ] [ 17 ] [ 18 ]  The depicted women were manipulated, coerced, lied to, given marijuana or other drugs or physically forced to have sex, according to the accounts of victims and material from a lawsuit against the company. [ 19 ] [ 16 ] [ 18 ] [ 20 ]  Six people involved in the website were charged with  sex trafficking  by force, fraud and coercion in November 2019. [ 18 ]


Child sexual abuse  ( CSA ), also called  child molestation , is a form of  child abuse  in which an adult or older adolescent uses a  child  for  sexual stimulation . [ 1 ] [ 2 ]  Forms of child sexual abuse include engaging in  sexual activities  with a child (whether by asking or pressuring, or by other means),  indecent exposure ,  child grooming , and  child sexual exploitation , [ 3 ] [ 4 ] [ 5 ]  such as using a child to produce  child pornography . [ 1 ] [ 6 ]


CSA is not confined to specific settings; it permeates various institutions and communities. CSA affects children in all socioeconomic levels, across all racial, ethnic, and cultural groups, and in both rural and urban areas.  In places where  child labor  is common, CSA is not restricted to one individual setting; it passes through a multitude of institutions and communities. This includes but is not limited to schools, homes, and online spaces where adolescents are exposed to abuse and exploitation.  Child marriage  is one of the main forms of child sexual abuse;  UNICEF  has stated that child marriage "represents perhaps the most prevalent form of sexual abuse and exploitation of girls". [ 7 ]  The effects of child sexual abuse can include  depression , [ 8 ]   post-traumatic stress disorder , [ 9 ]   anxiety , [ 10 ]   complex post-traumatic stress disorder , [ 11 ] [ not verified in body ]  and physical injury to the child, among other problems. [ 12 ]  Sexual abuse by a family member is a form of  incest  and can result in more serious and long-term  psychological trauma , especially in the case of  parental incest . [ 13 ]


Before the age of 18, 1 in 5 children are sexually abused. [ where? ]  This equates to more than 1 million children will be sexually abused this year. [ 14 ] [ 15 ]  Reports by the  Centers for Disease Control and Prevention , reveal that about 1 in 4 girls and 1 in 20 boys in the United States experience child sexual abuse. [ 14 ]  One study found an estimated 19.7% of females and 7.9% of males experienced some form of child sexual abuse prior to the age of 18. [ 16 ]  Most sexual abuse offenders are acquainted with their victims; approximately 30% are relatives of the child, most often brothers, fathers, uncles, or cousins; [ 17 ] [ not verified in body ]  around 60% are other acquaintances, such as "friends" of the family, babysitters, or neighbors; strangers are the offenders in approximately 10% of child sexual abuse cases. [ 18 ]  Most child sexual abuse is committed by men; studies on female child molesters show that women commit 14% to 40% of offenses reported against boys and 6% of offenses reported against girls. [ 18 ] [ 19 ] [ 20 ] [ not verified in body ]


The word  pedophile  is commonly applied indiscriminately to anyone who sexually abuses a child, [ 21 ]  but child sexual offenders are not pedophiles unless they have a strong sexual interest in  prepubescent  children. [ 22 ] [ 23 ] [ not verified in body ]  Under the law,  child sexual abuse  is often used as an  umbrella term  describing criminal and civil offenses in which an adult engages in sexual activity with a  minor  or exploits a minor for the purpose of sexual gratification. [ 6 ] [ 24 ] [ not verified in body ]  The  American Psychological Association  states that "children cannot consent to sexual activity with adults", and condemns any such action by an adult: "An adult who engages in sexual activity with a child is performing a criminal and immoral act which never can be considered normal or socially acceptable behavior." [ 25 ] [ not verified in body ]


Child sexual abuse can result in both short-term and long-term harm, including  psychopathology  in later life. [ 12 ] [ 26 ]  Indicators and effects include  depression , [ 8 ] [ 27 ] [ 28 ]   anxiety , [ 10 ]   eating disorders , [ 29 ]  poor  self-esteem , [ 29 ]   somatization , [ 28 ]   sleep disturbances , [ 30 ] [ 31 ]  and  dissociative  and  anxiety disorders  including  post-traumatic stress disorder . [ 9 ] [ 32 ]  While children may exhibit regressive behaviours such as  thumb sucking  or  bedwetting , the strongest indicator of sexual abuse is sexual  acting out  and inappropriate sexual knowledge and interest. [ 33 ] [ 34 ]   Victims may withdraw from school and social activities [ 33 ]  and exhibit various learning and behavioural problems including  cruelty to animals , [ 35 ] [ 36 ] [ 37 ] [ 38 ]   attention deficit/hyperactivity disorder  (ADHD),  conduct disorder , and  oppositional defiant disorder  (ODD). [ 29 ]   Teenage pregnancy  and risky sexual behaviors may appear in adolescence. [ 39 ]  Child sexual abuse victims report almost four times as many incidences of  self-inflicted harm . [ 40 ]  Sexual assault among teenagers has been shown to lead to an increase in mental health problems,  social exclusion  and worse school performance. [ 41 ] [ 42 ]


CSA is associated with experiencing additional victimization in adolescence and adulthood. [ 44 ] [ 45 ]  Correlations have been found between childhood sexual abuse and various adult psychopathologies, including  crime  and  suicide , [ 18 ] [ 46 ] [ 47 ] [ 48 ] [ 49 ] [ 50 ]  in addition to alcoholism and drug abuse. [ 43 ] [ 45 ] [ 51 ]  Males who were sexually abused as children more frequently appear in the criminal justice system than in a clinical mental health setting. [ 33 ]  A study comparing middle-aged women who were abused as children with non-abused counterparts found significantly higher health care costs for the former. [ 28 ] [ 52 ]  Intergenerational effects have been noted, with the children of victims of child sexual abuse exhibiting more conduct problems, peer problems, and emotional problems than their peers. [ 53 ]


A specific characteristic pattern of symptoms has not been identified, [ 54 ]  and there are several hypotheses about the causality of these associations. [ 8 ] [ 55 ] [ 56 ]


Studies have found that 51% to 79% of sexually abused children exhibit psychological symptoms. [ 48 ] [ 57 ] [ 58 ] [ 59 ] [ 60 ]  The risk of harm is greater if the abuser is a relative, if the abuse involves intercourse or attempted intercourse, or if threats or force are used. [ 61 ]  The level of harm may also be affected by various factors such as penetration, duration and frequency of abuse, and use of force. [ 12 ] [ 26 ] [ 62 ] [ 63 ]  The  social stigma  of child sexual abuse may compound the psychological harm to children, [ 63 ] [ 64 ]  and adverse outcomes are less likely for abused children who have supportive family environments. [ 65 ] [ 66 ]


Child abuse , including sexual abuse, especially chronic abuse starting at early ages, has been found to be related to the development of high levels of dissociative symptoms, which includes amnesia for abuse memories. [ 67 ]   When severe sexual abuse (penetration, several perpetrators, lasting more than one year) had occurred, dissociative symptoms were even more prominent. [ 68 ]  Recent research showed that females with high exposure to child sexual abuse (CSA) develop PTSD symptoms that are associated with poor social functioning, which is also supported by prior research studies. [ 69 ]  The feeling of being "cut-off" from peers and "emotional numbness" are both results of CSA and highly inhibit proper social functioning. Furthermore, PTSD is associated with higher risk of substance abuse as a result of the "self-medication hypothesis" and the "high-risk and susceptibility hypothesis". [ 70 ]


Besides  dissociative identity disorder  (DID),  post-traumatic stress disorder  (PTSD), and  complex post-traumatic stress disorder  (C-PTSD), child sexual abuse survivors may present  borderline personality disorder  (BPD) and eating disorders such as  bulimia nervosa . [ 71 ]


Because child sexual abuse often occurs alongside other possibly confounding variables, such as poor family environment and physical abuse, [ 72 ] [ non-primary source needed ]  some scholars argue it is important to control for those variables in studies which measure the effects of sexual abuse. [ 26 ] [ 55 ] [ 73 ] [ 74 ]  In a 1998 review of related literature, Martin and Fleming state "The hypothesis advanced in this paper is that, in most cases, the fundamental damage inflicted by child sexual abuse is due to the child's developing capacities for trust, intimacy, agency and sexuality, and that many of the mental health problems of adult life associated with histories of child sexual abuse are second-order effects." [ 75 ]  Other studies have found an independent association of child sexual abuse with adverse psychological outcomes. [ 10 ] [ 26 ] [ 55 ]


Kendler et al. (2000) found that most of the relationship between severe forms of child sexual abuse and adult psychopathology in their sample could not be explained by family discord, because the  effect size  of this association decreased only slightly after they controlled for possible confounding variables. Their examination of a small sample of CSA-discordant twins also supported a causal link between child sexual abuse and adult psychopathology; the CSA-exposed subjects had a consistently higher risk for psychopathologic disorders than their CSA non-exposed twins. [ 55 ] [ non-primary source needed ]


A 1998  meta-analysis by Bruce Rind et al.  generated controversy by suggesting that child sexual abuse does not always cause pervasive harm, that girls were more likely to be psychologically harmed than boys, that some college students reported such encounters as positive experiences and that the extent of psychological damage depends on whether or not the child described the encounter as "consensual". [ 76 ]  The study was criticized for flawed methodology and conclusions. [ 77 ] [ 78 ]  The US Congress condemned the study for its conclusions and for providing material used by pedophile organizations to justify their activities. [ 79 ]


Depending on the age and size of the child, and the degree of force used, child sexual abuse may cause internal lacerations and  bleeding . In severe cases, damage to internal organs may occur, which, in some cases, may cause death. [ 80 ]


Child sexual abuse may cause  sexually transmitted infections . [ 81 ]  Due to a lack of sufficient  vaginal fluid , chances of infections can heighten depending on the age and size of the child.  Vaginitis  has also been reported. [ 81 ]


Research has shown that traumatic stress, including stress caused by sexual abuse, may cause notable changes in brain functioning and development. [ 82 ] [ 83 ]  Various studies have suggested that severe child sexual abuse may have a deleterious effect on brain development. Ito et al. (1998) found "reversed hemispheric asymmetry and greater left hemisphere coherence in abused subjects;" [ 84 ]  Teicher et al. (1993) found that an increased likelihood of "ictal temporal lobe epilepsy-like symptoms" in abused subjects; [ 85 ]  Anderson et al. (2002) recorded abnormal  transverse relaxation  time in the cerebellar vermis of adults sexually abused in childhood; [ 86 ]  Teicher et al. (1993) found that child sexual abuse was associated with a reduced  corpus callosum  area; various studies have found an association of reduced volume of the left hippocampus with child sexual abuse; [ 87 ]  and Ito et al. (1993) found increased electrophysiological abnormalities in sexually abused children. [ 88 ]


Some studies indicate that sexual or physical abuse in children can lead to the overexcitation of an undeveloped  limbic system . [ 87 ]  Teicher et al. (1993) [ 85 ]  used the "Limbic System Checklist-33" to measure ictal temporal lobe epilepsy-like symptoms in 253 adults. Reports of child sexual abuse were associated with a 49% increase to LSCL-33 scores, 11% higher than the associated increase of self-reported physical abuse. Reports of both physical and sexual abuse were associated with a 113% increase. Male and female victims were similarly affected. [ 85 ] [ 89 ]


Navalta et al. (2006) found that the self-reported math  Scholastic Aptitude Test  scores of their sample of women with a history of repeated child sexual abuse were significantly lower than the self-reported math SAT scores of their non-abused sample. Because the abused subjects' verbal SAT scores were high, they hypothesized that the low math SAT scores could "stem from a defect in hemispheric integration." They also found a strong association between short-term memory impairments for all categories tested (verbal, visual, and global) and the duration of the abuse. [ 90 ]


Incest between a child or adolescent and a related adult is known as  child incestuous abuse , [ 91 ]  and has been identified as the most widespread form of child sexual abuse with a highly significant capacity to damage the young person. [ 13 ]  One researcher stated that more than 70% of abusers are immediate family members or someone very close to the family. [ 92 ]  Another researcher stated that about 30% of all perpetrators of sexual abuse are related to their victim, 60% of the perpetrators are family acquaintances, like a neighbor, babysitter or friend and 10% of the perpetrators in child sexual abuse cases are strangers. [ 18 ]  A child sexual abuse offense where the perpetrator is related to the child, either by blood or marriage, is a form of  incest  described as  intrafamilial child sexual abuse . [ 93 ]


The most-often reported form of incest is father–daughter and stepfather–stepdaughter incest, with most of the remaining reports consisting of mother/stepmother–daughter/son incest. [ 94 ]  Father–son incest is reported less often; however, it is not known if the actual prevalence is less or it is under-reported by a greater margin. [ 95 ] [ 96 ] [ 97 ] [ 98 ]  Similarly, some argue that sibling incest may be as common, or more common, than other types of incest: Goldman and Goldman [ 99 ]  reported that 57% of incest involved siblings; Finkelhor reported that over 90% of  nuclear family  incest involved siblings; [ 100 ]  while Cawson et al. show that sibling incest was reported twice as often as incest perpetrated by fathers/stepfathers. [ 101 ]


Prevalence of parental child sexual abuse is difficult to assess due to secrecy and privacy; some estimates state that 20 million Americans have been victimized by parental incest as children. [ 94 ]


Child sexual abuse involves a variety of sexual offenses, such as:


Commercial sexual exploitation of children (CSEC) is defined by the Declaration of the First World Congress against Commercial Sexual Exploitation of Children, held in Stockholm in 1996, as "sexual abuse by an adult accompanied by remuneration in cash or in kind to the child or third person(s)." [ 108 ]  CSEC usually takes the form of  child prostitution  or  child pornography , and is often facilitated by  child sex tourism . CSEC is particularly a problem in developing countries of  Asia . [ 109 ] [ 110 ]  In recent years, new innovations in technology have facilitated the trade of Internet child pornography. [ 111 ]


In the United Kingdom, the term  child sexual exploitation  covers any form of sexual abuse which includes an exchange of a resource for sexual activity with a child. [ 3 ] [ 112 ]  Prior to 2009, the term commonly used to describe child sexual exploitation was  child prostitution . [ 113 ] [ 114 ]  The term  child sexual exploitation  first appeared in government guidance in 2009 as part of an attempt to promote an understanding that children involved in exploitation were victims of abuse rather than criminals. [ 115 ] [ 116 ]  Because early definitions of child sexual exploitation were created to foster a move away from use of the term  child prostitution , the concept of exchange, which made child sexual exploitation different from child sexual abuse, referred to financial gain only. However, in the years since the birth of the concept of child sexual exploitation, the notion of exchange has been widened to include other types of gain, including love, acquisition of status and protection from harm. [ 116 ]


Children who received supportive responses following disclosure had less traumatic symptoms and were abused for a shorter period of time than children who did not receive support. [ 117 ] [ 118 ]  In general, studies have found that children need support and stress-reducing resources after disclosure of sexual abuse. [ 119 ] [ 120 ]  Negative social reactions to disclosure have been found to be harmful to the survivor's well-being. [ 121 ]  One study reported that children who received a bad reaction from the first person they told, especially if the person was a close family member, had worse scores as adults on general trauma symptoms, post traumatic stress disorder symptoms, and dissociation. [ 122 ]   Another study found that in most cases when children did disclose abuse, the person they talked to did not respond effectively, blamed or rejected the child, and took little or no action to stop the abuse. [ 120 ]  Non-validating and otherwise non-supportive responses to disclosure by the child's primary attachment figure may indicate a relational disturbance predating the sexual abuse that may have been a risk factor for the abuse, and which can remain a risk factor for its psychological consequences. [ 123 ]


The  American Academy of Child and Adolescent Psychiatry  provides guidelines for what to say to the victim and what to do following the disclosure. [ 124 ]  As Don Brown has indicated: "A minimization of the trauma and its effects is commonly injected into the picture by parental caregivers to shelter and calm the child. It has been commonly assumed that focusing on children's issues too long will negatively impact their recovery. Therefore, the parental caregiver teaches the child to mask his or her issues." [ 125 ]


In many jurisdictions, abuse that is suspected, not necessarily proven, requires reporting to  child protection  agencies, such as the  Child Protection Services  in the United States. Recommendations for healthcare workers, such as  primary care providers  and  nurses , who are often suited to encounter suspected abuse are advised to firstly determine the child's immediate need for safety. A private environment away from suspected abusers is desired for interviewing and examining. Leading statements that can distort the story are avoided. As disclosing abuse can be distressing and sometimes even shameful, reassuring the child that he or she has done the right thing by telling and that they are not bad and that the abuse was not their fault helps in disclosing more information. Anatomically correct dolls are sometimes used to help explain what happened. However, some researchers have found that the use of these dolls may be too graphic and overstimulating, which may lead children that were not abused to behave as though they were sexually abused. [ 126 ]   For the suspected abusers, it is also recommended to use a nonjudgmental, nonthreatening attitude towards them and to withhold expressing shock, in order to help disclose information. [ 127 ]


The initial approach to treating a person who has been a victim of sexual abuse is dependent upon several important factors:


The goal of treatment is not only to treat current mental health issues, and  trauma  related symptoms, but also to prevent future ones.


Children often present for treatment in one of several circumstances, including criminal investigations, custody battles, problematic behaviors, and referrals from child welfare agencies. [ 128 ]


The three major modalities for therapy with children and adolescents are  family therapy ,  group therapy , and  individual therapy . Which course is used depends on a variety of factors that must be assessed on a case-by-case basis. For instance, treatment of young children generally requires strong parental involvement and can benefit from family therapy. Adolescents tend to be more independent; they can benefit from individual or group therapy. The modality also shifts during the course of treatment; for example, group therapy is rarely used in the initial stages, as the subject matter is very personal and/or embarrassing. [ 128 ]  In a 2012 systematic review,  cognitive behavior therapy  showed potential in treating the adverse consequences of child sexual abuse. [ 129 ]


Major factors that affect both the pathology and response to treatment include the type and severity of the sexual act, its frequency, the age at which it occurred, and the child's family of origin.  Roland C. Summit, a medical doctor, defined the different stages the victims of child sexual abuse go through, called  child sexual abuse accommodation syndrome . He suggested that children who are victims of sexual abuse display a range of symptoms that include secrecy, helplessness, entrapment, accommodation, delayed and conflicted disclosure and recantation. [ 130 ]


Adults who have been sexually abused as children often present for treatment with a secondary mental health issue, which can include  substance abuse ,  eating disorders ,  personality disorders ,  depression , and conflict in romantic or interpersonal relationships. [ 131 ]


Generally, the approach is to focus on the present problem, rather than the abuse itself. Treatment is highly varied and depends on the person's specific issues. For instance, a person with a history of sexual abuse and severe depression would be treated for  depression . However, there is often an emphasis on  cognitive restructuring  due to the deep-seated nature of the trauma. Some newer techniques such as  eye movement desensitization and reprocessing  (EMDR) have been shown to be effective. [ 132 ]


Although there is no known cure for pedophilia, [ 133 ]  there are  a number of treatments for pedophiles and child sexual abusers . Some of the treatments focus on attempting to change the sexual preference of pedophiles, while others focus on keeping pedophiles from committing child sexual abuse, or on keeping child sexual abusers from committing child sexual abuse again.  Cognitive behavioral therapy  (CBT), for example, aims to reduce attitudes, beliefs, and behaviors that may increase the likelihood of sexual offenses against children. Its content varies widely between therapists, but a typical program might involve training in self-control, social competence and empathy, and use  cognitive restructuring  to change views on sex with children. The most common form of this therapy is  relapse prevention , where the patient is taught to identify and respond to potentially risky situations based on principles used for treating addictions. [ 134 ]


The evidence for cognitive behavioral therapy is mixed. [ 134 ]  A 2012  Cochrane Review  of randomized trials found that CBT had no effect on risk of reoffending for contact sex offenders. [ 135 ]  Meta-analyses in 2002 and 2005, which included both randomized and non-randomized studies, concluded that CBT reduced recidivism. [ 136 ] [ 137 ]  There is debate over whether non-randomized studies should be considered informative. [ 133 ] [ 138 ]  More research is needed. [ 135 ]


Child sexual abuse prevention programmes were developed in the United States of America during the 1970s. Some programme are delivered to children and can include one-to-one work [ 4 ]  and group work. [ 5 ]  Programmes delivered to parents were developed in the 1980s and took the form of one-off meetings, two to three hours long. [ 139 ] [ 140 ] [ 141 ] [ 142 ] [ 143 ] [ 144 ]  In the last 15 years, web-based programmes have been developed. School-based education programs were evaluated in 2015 by Cochrane that demonstrated improvements in protective behaviors and knowledge among children. [ 145 ]  The American CDC lists that improving surveillance systems can help monitor and prevent child abuse. [ 146 ] [ 147 ]  While progress has been made in raising awareness and implementing preventive measures, challenges persist in identifying and prosecuting perpetrators, supporting victims, and addressing systemic factors contributing to abuse. Cultural and societal stigmas, coupled with underreporting and insufficient resources, further complicate the landscape. Additionally, the rapid evolution of technology introduces new challenges, such as online exploitation and grooming. The National Center for Missing and Exploited Children (NCMEC) combats child sexual abuse and exploitation through a range of initiatives including providing assistance to law enforcement, offering resources and support to families of missing and exploited children, raising public awareness, facilitating prevention programs, and operating a hotline for reporting and responding to incidents of child sexual exploitation. [ 148 ]  Despite advancements in understanding and addressing CSA, a more comprehensive and coordinated approach is needed to effectively combat this deeply concerning issue and ensure the safety and well-being of all children. Legislative efforts like the Child Abuse Prevention and Treatment Act (CAPTA), originally enacted in 1974 and subsequently amended, provide federal funding and guidance to states for prevention, investigation, and treatment activities. [ 149 ]  Erin’s Law, enacted in 38 states, mandates prevention-oriented CSA programs in public schools, illustrating ongoing efforts to address this critical issue at both federal and state levels. [ 150 ]


Offenders are more likely to be relatives or acquaintances of their victim than strangers. [ 151 ]  A 2006–07 Idaho study of 430 cases found that 82% of juvenile sex offenders were known to the victims (acquaintances 46% or relatives 36%). [ 152 ] [ 153 ]


More offenders are male than female, though the percentage varies between studies. The percentage of incidents of sexual abuse by female perpetrators that come to the attention of the legal system is usually reported to be between 1% and 4%. [ 154 ]  Studies of sexual misconduct in US schools with female offenders have shown mixed results with rates between 4% and 43% of female offenders. [ 155 ]  Maletzky (1993) found that, of his sample of 4,402 convicted child sex offenders, 0.4% were female. [ 156 ]


According to research conducted in Australia by Kelly Richards on child sexual abuse, 35.1% of female victims were abused by another male relative and 16.4% of male victims were abused by another male relative. Male relatives were found to be the most relevant predators in the case of both gender. [ 157 ]


In U.S. schools, educators who offend range in age from "21 to 75 years old, with an average age of 28". [ 158 ]


According to C.E. Dettmeijer-Vermeulen, Dutch national spokeswoman on human traffic and sexual violence against children, in the Netherlands, 3% of the convicted perpetrators are women, [ 159 ]  14.58% of the victims are boys [ 159 ]  and "most victims were abused by a family member, friend or acquaintance." [ 159 ]  One in six perpetrators is underage. [ 160 ]


Early research in the 1970s and 1980s began to classify offenders based on their motivations and traits. Groth and Birnbaum (1978) categorized child sexual offenders into two groups, "fixated" and "regressed". [ 161 ]  Fixated were described as having a primary attraction to children, whereas regressed had largely maintained relationships with other adults, and were even married. This study also showed that adult  sexual orientation  was not related to the sex of the victim targeted, e.g. men who molested boys often had adult relationships with women. [ 161 ]


Later work (Holmes and Holmes, 2002) expanded on the types of offenders and their psychological profiles.  They are divided as follows: [ 162 ]


Causal factors of child sex offenders are not known conclusively. [ 163 ]  The experience of sexual abuse as a child was previously thought to be a strong risk factor, but research does not show a causal relationship, as the vast majority of sexually abused children do not grow up to be adult offenders, nor do the majority of adult offenders report childhood sexual abuse. The US  Government Accountability Office  concluded, "the existence of a cycle of sexual abuse was not established." Before 1996, there was greater belief in the theory of a "cycle of violence", because most of the research done was retrospective—abusers were asked if they had experienced past abuse. Even the majority of studies found that most adult sex offenders said they had  not  been sexually abused during childhood, but studies varied in terms of their estimates of the percentage of such offenders who had been abused, from 0 to 79 percent. More recent prospective  longitudinal  research—studying children with documented cases of sexual abuse over time to determine what percentage become adult offenders—has demonstrated that the cycle of violence theory is not an adequate explanation for why people molest children. [ 164 ]


Offenders may use  cognitive distortions  to facilitate their offenses, such as  minimization  of the abuse,  victim blaming , and  excuses . [ 165 ]


Cognitive behavioral therapy  (CBT) aims to reduce attitudes, beliefs, and behaviors that may increase the likelihood of sexual offenses against children. Its content varies widely between therapists, but a typical program might involve training in self-control, social competence and empathy, and use  cognitive restructuring  to change views on sex with children. The most common form of this therapy is  relapse prevention , where the patient is taught to identify and respond to potentially risky situations based on principles used for treating addictions. [ 166 ] : 171


The evidence for cognitive behavioral therapy is mixed. [ 166 ] : 171   A 2012  Cochrane Review  of randomized trials found that CBT had no effect on risk of reoffending for contact sex offenders. [ 167 ]  Meta-analyses in 2002 and 2005, which included both randomized and non-randomized studies, concluded that CBT reduced recidivism. [ 168 ] [ 169 ]  There is debate over whether non-randomized studies should be considered informative. [ 170 ] [ 171 ]  More research is needed. [ 167 ]


Behavioral treatments target sexual arousal to children, using satiation and aversion techniques to suppress sexual arousal to children and  covert sensitization  (or  masturbatory  reconditioning) to increase sexual arousal to adults. [ 166 ] : 175   Behavioral treatments appear to have an effect on sexual arousal patterns during phallometric testing, but it is not known whether the effect represents changes in sexual interests or changes in the ability to control genital arousal during testing, nor whether the effect persists in the long term. [ 172 ] [ 173 ]  For sex offenders with mental disabilities,  applied behavior analysis  has been used. [ 174 ]


Pharmacological interventions are used to lower the sex drive in general, which can ease the management of pedophilic feelings, but does not change sexual preference. [ 175 ]   Antiandrogens  work by interfering with the activity of testosterone.  Cyproterone acetate  (Androcur) and  medroxyprogesterone acetate  (Depo-Provera) are the most commonly used. The efficacy of antiandrogens has some support, but few high-quality studies exist. Cyproterone acetate has the strongest evidence for reducing sexual arousal, while findings on medroxyprogesterone acetate have been mixed. [ 166 ] : 177–181


Gonadotropin-releasing hormone analogs  such as  leuprorelin  (Lupron), which last longer and have fewer side-effects, are also used to reduce  libido , [ 176 ]  as are  selective serotonin reuptake inhibitors . [ 166 ] : 177–181   The evidence for these alternatives is more limited and mostly based on open trials and case studies. [ 170 ]  All of these treatments, commonly referred to as " chemical castration ", are often used in conjunction with cognitive behavioral therapy. [ 177 ]  According to the  Association for the Treatment of Sexual Abusers , when treating child molesters, "anti-androgen treatment should be coupled with appropriate monitoring and counseling within a comprehensive treatment plan." [ 178 ]  These drugs may have side-effects, such as weight gain, breast development, liver damage and osteoporosis. [ 170 ]


Historically, surgical  castration  was used to lower sex drive by reducing testosterone. The emergence of pharmacological methods of adjusting testosterone has made it largely obsolete, because they are similarly effective and less invasive. [ 175 ]  It is still occasionally performed in Germany, the Czech Republic, Switzerland, and a few U.S. states. Non-randomized studies have reported that surgical castration reduces recidivism in contact sex offenders. [ 166 ] : 181–182, 192   The Association for the Treatment of Sexual Abusers opposes surgical castration [ 178 ]  and the  Council of Europe  works to bring the practice to an end in Eastern European countries where it is still applied through the courts. [ 179 ]


Pedophilia is a condition in which an adult or older adolescent is primarily or exclusively attracted to prepubescent children, whether the attraction is acted upon or not. [ 180 ] [ 181 ]  A person with this  paraphilia  is called a  pedophile .


In  law enforcement , the term  pedophile  is sometimes used to describe those accused or convicted of child sexual abuse under  sociolegal definitions of  child  (including both prepubescent children and adolescents younger than the local  age of consent ); [ 21 ]  however, not all child sexual offenders are pedophiles and not all pedophiles engage in sexual abuse of children. [ 22 ] [ 182 ] [ 183 ]  For these reasons, researchers recommend against imprecisely describing all child molesters as  pedophiles . [ 184 ] [ 185 ]


The term  pedocriminality  ( De :  Pädokriminalität ;  Fr :  pédocriminalité ) is a controversial term which originated in the 1980s and has been used by organisations such as  UNICEF ,  UNHRC , the  World Health Organization [ 186 ]  and the  Council of Europe [ 187 ]  to refer to child sexual abuse and sexual violence used against children, [ 188 ] [ 189 ]   child prostitution ,  child trafficking  and the use of  child pornography . [ 190 ]  The term "cyber-pedocriminality" has been used to refer to the activities of viewers of child pornography online. [ 191 ]


Although reconviction data suggest that not many sex offenders reoffend, [ 192 ]   OJP  reported that observed recidivism rates of sex offenders are underestimated of actual reoffending. [ 193 ]  Estimated rates among child sex offenders vary by surveys and it is difficult to estimate accurately. One study found that 42% of offenders re-offended (either a sex crime, violent crime, or both) after they were released. Risk for re-offense was highest in the first 6 years after release, but continued to be significant even 10–31 years later, with 23% offending during this time. [ 194 ]  A study done in California in 1965 found an 18.2% recidivism rate for offenders targeting the opposite sex and a 34.5% recidivism rate for same-sex offenders after 5 years. [ 195 ]


Because recidivism is defined and measured differently from study to study, one can arrive at inaccurate conclusions being made based on comparison of two or more studies that are not conducted with similar methodology. [ 196 ]


When a prepubescent child is sexually abused by one or more other children or adolescent youths, and no adult is directly involved, it is defined as  child-on-child sexual abuse . The definition includes any sexual activity between children that occurs without  consent , without equality, or due to  coercion , [ 197 ]  whether the offender uses physical force, threats, trickery or  emotional manipulation  to compel cooperation. When sexual abuse is perpetrated by one sibling upon another, it is known as " intersibling abuse ", a form of  incest . [ 198 ]


Unlike research on adult offenders, a strong causal relationship has been established between child and adolescent offenders and these offenders' own prior victimization, by either adults or other children. [ 199 ] [ 200 ] [ 201 ] [ 202 ]


According to a 2010  UNICEF  report, 46% of Congolese schoolgirls confirmed that they had been victims of sexual harassment, abuse, and violence committed by their teachers or other school personnel. [ 203 ]  In  Mozambique , a study by the Ministry of Education found that 70 percent of female respondents reported knowing teachers who use sexual intercourse as a necessary condition to advance students to the next grade. [ 203 ]  A survey by Promundo found that 16% of girls in  North Kivu  said they had been forced to have sex with their teachers. [ 203 ]  According to UNICEF, teachers in  Mali  are known to use "La menace du bic rouge" ("the threat of the red pen"), using the threat of bad grades to coerce girls into acquiescing to sexual advances. [ 203 ]  According to Plan International, 16% of children in  Togo , for instance, named a teacher as responsible for the pregnancy of a classmate. [ 203 ]


Based on  self-disclosure data , a 2011  meta-analysis  of 217 studies estimated a global prevalence of 12.7%–18% for girls and 7.6% for boys. The rates of self-disclosed abuse for specific continents were as follows: [ 204 ]


A 2009 meta-analysis of 65 studies from 22 countries found a global prevalence of 19.7% for females and 7.9% for males. In that analysis, Africa had the highest prevalence rate of child sexual abuse (34.4%), primarily because of high rates in South Africa; Europe showed the lowest prevalence rate (9.2%); and America and Asia had prevalence rates between 10.1% and 23.9%. [ 16 ]


A ten-country school-based study in southern Africa in 2007 found 19.6% of female students and 21.1% of male students aged 11–16 years reported they had experienced forced or coerced sex. Rates among 16-year-olds were
28.8% in females and 25.4% in males. Comparing the same schools in eight countries between 2003 and 2007, age-standardised on the 2007 Botswana male sample, there was no significant decrease between 2003 and 2007 among females in any country and inconsistent changes among males. [ 205 ]


The prevalence of child sexual abuse in Africa is compounded by the  virgin cleansing myth  that sexual intercourse with a virgin will cure a man of  HIV  or  AIDS . The myth is prevalent in  South Africa ,  Zimbabwe , [ 206 ]   Zambia  and  Nigeria  and is being blamed for the high rate of sexual abuse against young children. [ 207 ]


In November 2007,  Thomson Reuters Foundation  reported that  child rape is on the rise  in the war-ravaged eastern  Democratic Republic of the Congo . [ 208 ]   Aid workers  blame combatants on all sides, who operate with much impunity, for a culture of  sexual violence . [ 209 ]   South Africa  has some of the highest incidences of child rape (including the rape of babies) in the world (also see  sexual violence in South Africa ). [ 210 ]  A survey by CIET found around 11% of boys and 4% of girls admitted to forcing someone else to have sex with them. [ 210 ]  In a related  survey  conducted among 1,500 schoolchildren, a quarter of all the boys interviewed said that "jackrolling", a term for  gang rape , was fun. [ 211 ]  More than 67,000 cases of rape and sexual assaults against children were reported in 2000 in South Africa, compared to 37,500 in 1998. Child welfare groups believe that the number of unreported incidents could be up to 10 times that number. The largest increase in attacks was against children under seven. The  virgin cleansing myth  is especially common in  South Africa , which has the highest number of HIV-positive citizens in the world.  Eastern Cape  social worker Edith Kriel notes that "child abusers are often relatives of their victims – even their fathers and providers." [ 212 ]


A number of high-profile baby rapes appeared since 2001 (including the fact that they required extensive reconstructive surgery to rebuild urinary, genital, abdominal, or tracheal systems). In 2001, a 9-month-old was raped and likely lost consciousness as the pain was too much to bear. [ 213 ]  In February 2002, an 8-month-old infant was reportedly gang-raped by four men. One has been charged. The  infant  has required extensive reconstructive surgery. The 8-month-old infant's injuries were so extensive, increased attention on prosecution has occurred. [ 214 ]


In  Afghanistan , some boys are forced to participate in  sexual activities with men .  They are also termed 'dancing boys'. The custom is connected to sexual slavery and child prostitution. [ 215 ] [ 216 ]


In  Bangladesh , child prostitutes are known to take the drug  Oradexon , an over-the-counter  steroid , usually used by farmers to fatten cattle, to  make child prostitutes look larger and older . Charities say that 90% of prostitutes in the country's legalized brothels use the drug. According to social activists, the steroid can cause  diabetes  and  high blood pressure  and is highly addictive. [ 217 ] [ 218 ] [ 219 ]


In 2007, the  Indian   Ministry of Women and Child Development  published the "Study on Child Abuse: India 2007". [ 220 ]  It sampled 12447 children, 2324 young adults and 2449 stakeholders across 13 states. It looked at different forms of child abuse:  physical abuse ,  sexual abuse  and  emotional abuse  and girl  child neglect  in five evidence groups, namely, children in a family environment, children in school, children at work, children on the street and children in institutions. The study's [ 220 ]  main findings included: 53.22% of children reported having faced sexual abuse. Among them, 52.94% were boys and 47.06% girls.  Andhra Pradesh ,  Assam ,  Bihar  and  Delhi  reported the highest percentage of sexual abuse among both boys and girls, as well as the highest incidence of sexual assaults. 21.90% of child respondents faced severe forms of sexual abuse, 5.69% had been sexually assaulted and 50.76% reported other forms of sexual abuse. Children on the street, at work and in institutional care reported the highest incidence of sexual assault. The study also reported that 50% of abusers are known to the child or are in a position of trust and responsibility and most children had not reported the matter to anyone. Despite years of lack of any specific  child sexual abuse laws in India , which treated them separately from adults in case of sexual offense, the  Protection of Children Against Sexual Offences Bill, 2011  was passed the  Indian parliament  on May 22, 2012, which came into force from 14 November 2012. [ 221 ]


According to research published in 2019 India had the largest number of child sexual abuse imagery searches along with being responsible for producing a third of the worlds child sexual abuse content online. [ 222 ] [ 223 ] [ 224 ]


In  Pakistan , sexual abuse of children is a problem in some  madrassas . [ 225 ] [ 226 ]  Child sexual abuse has also been reported in Madrassas across Bangladesh and India. [ 227 ] [ 228 ] [ 229 ] [ 230 ]


The  Kasur child sexual abuse scandal , which involved  forced sex acts  and an estimated 280 to 300 children, was termed the largest child abuse scandal in Pakistan's history. [ 231 ]


In 2019, Pakistan's Human Rights Minister, Shirin Mazari has said that Pakistan was ranked as the country with the largest numbers of  child pornography  viewers. [ 232 ]   Geo Pakistan, the  Federal Investigation Agency , cyber-crime chief has said, "Child pornography is a business  . . with those involved in the crime linked to international child pornography rings." [ 233 ]


In  Taiwan , a survey of adolescents reported 2.5% as having experienced childhood sexual abuse. [ 234 ]


In  Uzbekistan , the UK Ambassador  Craig Murray  wrote that the government, under president  Islam Karimov , used child rape to force false confessions from prisoners. [ 235 ]


According to UNICEF, nearly half of  reported rape victims  in  Papua New Guinea  are under 15 years of age and 13% are under 7 years of age [ 236 ]  while a report by  ChildFund  Australia citing former Parliamentarian Dame  Carol Kidu  stated 50% of those seeking medical help after rape are under 16, 25% are under 10 and 10% are under 8. [ 237 ]


Additionally, a study found that men with a history of victimization, especially having been raped or otherwise sexually coerced themselves, were more likely than otherwise to have participated in both single-perpetrator and  multiple-perpetrator  non-partner rape. [ 238 ]  57·5% (587/1022) of men who raped a non-partner committed their first rape as teenagers. [ 238 ]


Child sexual abuse occurs frequently in Western society, [ 239 ]  although the rate of prevalence can be difficult to determine. [ 240 ] [ 241 ] [ 242 ]  Research in  North America  has concluded that approximately 15% to 25% of women and 5% to 15% of men were sexually abused when they were children. [ 18 ] [ 19 ] [ 242 ]  In the UK, a 2010 study estimated prevalence at about 5% for boys and 18% for girls [ 243 ]  (not dissimilar to a 1985 study that estimated about 8% for boys and 12% for girls [ 244 ] ). More than 23,000 incidents were recorded by the UK police between 2009 and 2010. Girls were six times more likely to be assaulted than boys with 86% of attacks taking place against them. [ 245 ] [ 246 ]   Barnardo's   charity  estimates that two thirds of victims in the  United Kingdom  are girls and one third are boys. Barnardo's is concerned that boy victims may be overlooked. [ 247 ]


The estimates for the United States vary widely. A literature review of 23 studies found rates of 3% to 37% for males and 8% to 71% for females, which produced an average of 17% for boys and 28% for girls, [ 248 ]  while a statistical analysis based on 16 cross-sectional studies estimated the rate to be 7.2% for males and 14.5% for females. [ 242 ]  The  US Department of Health and Human Services  reported 83,600 substantiated reports of sexually abused children in 2005, [ 249 ] [ 250 ]  while state-level child protective services reported 63,527 sexual abuse incidents in 2010. [ 251 ]  Including incidents which were not reported would make the total number even larger. [ 252 ]  According to Emily M. Douglas and  David Finkelhor , "Several national studies have found that  black  and  white  children experienced near-equal levels of sexual abuse. Other studies, however, have found that both blacks and  Latinos  have an increased risk for sexual victimization". [ 253 ] [ 254 ]


Surveys have shown that one fifth to one third of all women reported some sort of childhood sexual experience with a male adult. [ 255 ]
A 1992 survey studying father-daughter incest in Finland reported that of the 9,000 15-year-old high school girls who filled out the questionnaires, of the girls living with their biological fathers, 0.2% reported father-daughter incest experiences; of the girls living with a stepfather, 3.7% reported sexual experiences with him. The reported counts included only father-daughter incest and did not include prevalence of other forms of child sexual abuse.  The survey summary stated, "the feelings of the girls about their incestual experiences are overwhelmingly negative." [ 256 ]  Others argue that prevalence rates are much higher, and that many cases of child abuse are never reported. One study found that professionals failed to report approximately 40% of the child sexual abuse cases they encountered. [ 257 ]  A study by Lawson & Chaffin indicated that many children who were sexually abused were "identified solely by a physical complaint that was later diagnosed as a venereal disease ... Only 43% of the children who were diagnosed with venereal disease made a verbal disclosure of sexual abuse during the initial interview." [ 258 ]   It has been found in the epidemiological literature on CSA that there is no identifiable demographic or family characteristic of a child that can be used to bar the prospect that a child has been sexually abused. [ 240 ]


Child marriage  is often considered to be another form of child sexual abuse. [ 7 ]  Over 200,000 marriages involving minors were allowed between 2000 and 2015 in the US. These marriages were most often between an adult male and female minor. [ 259 ]   Child marriage in the United States  is allowed in the majority of states as long as parental consent or judicial approval (typically for pregnancy) is given. [ 259 ]


In US schools, according to the  United States Department of Education , [ 260 ]  "nearly 9.6% of students are targets of educator sexual misconduct sometime during their school career." In studies of student sex abuse by male and female educators, male students were reported as targets in ranges from 23% to 44%. [ 260 ]  In U.S. school settings same-sex (female and male) sexual misconduct against students by educators "ranges from 18 to 28% of reported cases, depending on the study" [ 261 ]  An American survey found that children sexually abused by relatives were much more likely to be affiliated with Protestantism, while persons sexually abused by nonrelatives were affiliated with liberal denominations or irreligious. [ 262 ]


Significant underreporting of sexual abuse of boys by both women and men is believed to occur due to sex stereotyping, social denial, the minimization of male victimization, and the relative lack of research on sexual abuse of boys. [ 263 ]  Sexual victimization of boys by their mothers or other female relatives is particularly rarely researched or reported. Sexual abuse of girls by their mothers, and other related and/or unrelated adult females is beginning to be researched and reported despite the highly taboo nature of female–female child sex abuse. In studies where students are asked about sex offenses, they report higher levels of female sex offenders than found in adult reports. [ 264 ]  This underreporting has been attributed to cultural denial of female-perpetrated child sex abuse, [ 265 ]  because "males have been socialized to believe they should be flattered or appreciative of sexual interest from a female." [ 155 ]  Journalist Cathy Young writes that under-reporting is contributed to by the difficulty of people, including jurors, in seeing a male as a "true victim". [ 266 ]


In the United Kingdom, reported child sex abuse has increased, but this may be due to greater willingness to report.  Police need more resources to deal with it.  Also parents and schools need to give children and adolescents regular advice about how to spot abuse and about the need to report abuse.  Software providers are urged to do more to police their environment and make it safe for children. [ 267 ]


Cross-cultural studies  have reported that sexual relations between men and pubescent girls were sometimes performed for functional reasons in  pre-industrial societies . [ 268 ]  Other accounts of sexual relations between adults and minors have also been registered. A 1951 research document reports  Siwan  men engaging with anal intercourse with boys. The report also stated that, among  Aranda aborigines , "pederasty [between a man and a boy between the ages of ten and twelve] is a recognized custom". An 18th century report by  James Cook  reported an act of copulation between a man and a female estimated to be 11 or 12 in a public street "without the least sense of it being indecent or improper". In some Oceanic societies, adult men have been reported to have sexual contact with prepubertal females. A 19th century document by missionary John Muggeridge Orsmond reads that "in all  Tahitians  as well as officers who come in ships there is a cry for little girls". Other instances of adult-child sexual behaviors have been reported in the  Marquesas Islands ,  Polynesia ,  New Guinea  and in  Kaluli  societies. [ 269 ]


Accounts of sexual intercourse between children and adults have also been reported in  Ancient Greece  and Rome. [ 270 ] [ 271 ]


Child sexual abuse is outlawed nearly everywhere in the world, generally with severe criminal penalties, including in some jurisdictions,  life imprisonment  or  capital punishment . [ 272 ] [ 273 ]   An adult's sexual intercourse with someone below the legal  age of consent  is defined as  statutory rape , [ 274 ]  based on the principle that a child is not capable of consent and that any apparent consent by a child is not considered to be  legal consent .


The United Nations  Convention on the Rights of the Child  (CRC) is an international  treaty  that legally obliges states to protect children's rights.  Articles 34 and 35 of the CRC require states to protect children from all forms of sexual exploitation and sexual abuse. This includes outlawing the coercion of a child to perform sexual activity, the  prostitution of children , and the  exploitation of children in creating pornography . States are also required to prevent the abduction, sale, or trafficking of children. [ 275 ]   As of November 2008, 193 countries are bound by the CRC, [ 276 ]  including every member of the  United Nations  except the  United States  and  South Sudan . [ 277 ] [ 278 ]


The Council of Europe has adopted the  Council of Europe Convention on the Protection of Children against Sexual Exploitation and Sexual Abuse  in order to prohibit child sexual abuse that occurs within home or family.


In the  European Union , child sexual abuse is subject to a  directive . [ 279 ]  This directive deals with several forms of sexual abuse of children, especially  commercial sexual exploitation of children .


Although efforts for the enforcement of child protection laws have increased internationally, in countries with inadequate legal systems or where corruption runs rampant, the implementation of these laws has been difficult. [ 280 ]  There are several cases where law enforcement agencies lack the manpower and resources to efficiently resolve CSA crimes, which leads to reduced rates of prosecution and  conviction . [ 281 ]  Furthermore, with the addition of ever-changing technology and new information, the tension placed on law enforcement agencies to effectively pursue, and arrest offenders has increased. To effectively address these challenges, cooperation among government agencies,  international organizations , and  law enforcement  must increase, along with the development of a new legal agenda to improve the training of law enforcement on how to properly handle CSA. [ 282 ] [ 283 ]


Child sexual abuse has gained public attention since the 1970s and has become one of the most high-profile crimes. While sexual use of children by adults has been present throughout history, public interest in prevention has tended to fluctuate. [ 284 ]  Initially, concern centered around children under the age of ten, but over time, advocates have attracted attention toward the sexual abuse of children between the ages of 11 and 17. [ 284 ]  Up until the 1930s, the psychological impact of sexual abuse was not emphasized, instead emphasis was placed on the physical harm or the child's reputation. [ 284 ]  Widespread public awareness of children's sexual abuse did not occur until the 1970s in the West. [ 285 ]


The first published work dedicated specifically to child sexual abuse appeared in France in 1857:  Medical-Legal Studies of Sexual Assault   (Etude Médico-Légale sur les Attentats aux Mœurs) , by  Auguste Ambroise Tardieu , the noted French pathologist and pioneer of  forensic medicine . [ 286 ]


Child sexual abuse became a public issue in the 1970s and 1980s. Prior to this point in time, sexual abuse remained rather secretive and socially unspeakable. [ citation needed ]  Studies on child molestation were nonexistent until the 1920s and the first national estimate of the number of child sexual abuse cases was published in 1948. By 1968 44 out of 50 U.S. states had enacted mandatory laws that required physicians to report cases of suspicious child abuse. Legal action began to become more prevalent in the 1970s with the enactment of the  Child Abuse Prevention and Treatment Act  in 1974 in conjunction with the creation of the National Center for Child Abuse and Neglect. Since the creation of the Child Abuse and Treatment Act, reported child abuse cases have increased dramatically.  Finally, the  National Abuse Coalition  was created in 1979 to create pressure in congress to create more sexual abuse laws. [ citation needed ]


Second wave feminism  brought greater awareness of child sexual abuse and  violence against women , and made them public, political issues. [ 287 ] [ 288 ]   Judith Lewis Herman , Harvard professor of psychiatry, wrote the first book ever on father-daughter incest when she discovered during her medical residency that a large number of the women she was seeing had been victims of father-daughter incest. Herman notes that her approach to her clinical experience grew out of her involvement in the civil rights movement. [ 289 ]   Her second book  Trauma and Recovery  coined the term  complex post-traumatic stress disorder  and included child sexual abuse as a cause. [ 290 ]


In 1986, Congress passed the  Child Abuse Victims' Rights Act , giving children a civil claim in sexual abuse cases. The number of laws created in the 1980s and 1990s began to create greater prosecution and detection of child sexual abusers. During the 1970s a large transition began in the legislature related to child sexual abuse.  Megan's Law  which was enacted in 1996 gives the public access to knowledge of sex offenders nationwide. [ 291 ]


Anne Hastings described these changes in attitudes towards child sexual abuse as "the beginning of one of history's largest social revolutions." [ 292 ]


According to John Jay College of Criminal Justice professor B.J. Cling:


By the early 21st century, the issue of child sexual abuse has become a legitimate focus of professional attention, while increasingly separated from second wave feminism ... As child sexual abuse becomes absorbed into the larger field of interpersonal trauma studies, child sexual abuse studies and intervention strategies have become degendered and largely unaware of their political origins in modern feminism and other vibrant political movements of the 1970s. One may hope that unlike in the past, this rediscovery of child sexual abuse that began in the 70s will not again be followed by collective amnesia. The institutionalization of child maltreatment interventions in federally funded centers, national and international societies, and a host of research studies (in which the United States continues to lead the world) offers grounds for cautious optimism. Nevertheless, as Judith Herman argues cogently, 'The systematic study of psychological trauma ... depends on the support of a political movement.' [ 293 ]


Media reporting plays a crucial role in tackling the world-wide problem of child sexual abuse because it puts the issue on the public and political agenda. [ 294 ]  Media reporting can even contribute to the exposure and criminal investigation of sexual abuse cases in institutions. One notorious example is the  Boston Globe  coverage of the  sex abuse scandal in the Catholic Archdiocese of Boston  for which the newspaper received a  Pulitzer Prize for Public Service  in 2003. Another award-winning example is the  Indianapolis Star  coverage of the  USA Gymnastics sex abuse scandal  in 2016. Media reporting can be very beneficial by giving survivors a voice and informing the public. [ citation needed ]


Media reporting can also violate the rights of abuse survivors and disseminate misleading and harmful messages. Content analyses of news reporting have revealed several quality issues such as a focus on sensationalized individual cases (so-called episodic framing) and neglect of thematic framing in the sense of contextualizing individual cases and pointing to the systematic problems that enable child sexual abuse. [ 295 ] [ 296 ]  When media reporting on child sexual abuse is investigated, usual methodological approaches are the media  content analysis  and the media quality analysis. [ 297 ]  Here it is important to not only analyze text but also documentary and stock photos commonly used in media that report about child sexual abuse. Research shows that myths and stereotypes about child sexual abuse are disseminated through text and images alike. [ 298 ]  Several checklists and guidelines for journalist have been published by violence prevention and journalism organizations to help improve the quality of news reporting on child sexual abuse. [ 299 ] [ 300 ]


In the United States, growing awareness of child sexual abuse has sparked an increasing number of civil  lawsuits  for  monetary damages  stemming from such incidents. Increased awareness of child sexual abuse has encouraged more victims to come forward, whereas in the past victims often kept their abuse secret. Some states have enacted specific  laws  lengthening the applicable  statutes of limitations  so as to allow victims of child sexual abuse to file suit sometimes years after they have reached the age of majority. [ 301 ]   Such lawsuits can be brought where a person or entity, such as a school, church or youth organization, or daycare was charged with supervising the child but failed to do so with child sexual abuse resulting, making the individual or institution liable.  In the  Catholic sex abuse cases , the various  Roman Catholic  Diocese in the  United States  have paid out approximately $1 billion settling hundreds of such lawsuits since the early 1990s. There have also been lawsuits involving the  American religious right .  Crimes have allegedly gone unreported and victims were pressured into silence. [ 302 ]
As lawsuits can involve demanding procedures, there is a concern that  children  or adults who file suit will be re-victimized by defendants through the  legal process , much as  rape  victims can be re-victimized by the accused in  criminal  rape trials.  The child sexual abuse plaintiff's attorney  Thomas A. Cifarelli  has written that children involved in the legal system, particularly victims of sexual abuse and molestation, should be afforded certain procedural safeguards to protect them from harassment during the legal process. [ 303 ]


In June 2008 in  Zambia , the issue of teacher-student sexual abuse and sexual assault was brought to the attention of the High Court of Zambia where a landmark case decision, with presiding Judge Philip Musonda, awarded $45 million Zambian kwacha (US$13,000) to the plaintiff, a 13-year-old girl for sexual abuse and rape by her school teacher. This claim was brought against her teacher as a "person of authority" who, as Judge Musonda stated, "had a moral superiority (responsibility) over his students" at the time. [ 304 ]


A 2000 World Health Organization – Geneva report, "World Report on Violence and Health (Chap 6 – Sexual Violence)" states, "Action in schools is vital for reducing sexual and other forms of violence. In many countries a sexual relation between a teacher and a pupil is not a serious disciplinary offence and policies on sexual harassment in schools either do not exist or are not implemented. In recent years, though, some countries have introduced laws prohibiting sexual relations between teachers and pupils. Such measures are important in helping eradicate sexual harassment in schools. At the same time, a wider range of actions is also needed, including changes to teacher training and recruitment and reforms of curricula, so as to transform gender relations in schools." [ 305 ]


Coalition for Positive Sexuality  is an internet-based comprehensive  sexuality  education website, for youth and young adults.


The most commonly used feature of the CPS website is the "Let's Talk" feature, which allows youth members to post anonymously and receive answers to sexual health-related questions from moderators.


CPS staff and moderators are graduate and doctoral-level health educators, researchers, legal professionals, counselors and advocates with years of professional experience addressing myriad adolescent health issues, including teen pregnancy prevention, sexual orientation, reproductive health laws, and  sexually transmitted infections  (STI) and  HIV/AIDS  prevention.


Health education


Comprehensive sex education  ( CSE ) is an instructional approach aimed at providing individuals, particularly young people, with accurate, holistic information about sexuality, relationships, and reproductive health. Unlike  abstinence-only education , CSE includes a broad curriculum that covers topics such as  safe sex  practices, contraception,  sexually transmitted infections  (STIs),  sexual orientation ,  gender identity , and relationship skills. This approach seeks to empower individuals to make informed, responsible decisions regarding their  sexual health  and to promote respect and equality in sexual relationships. [ 1 ] [ 2 ] [ 3 ]


CSE is widely supported by health organizations for its effectiveness in improving public health outcomes. Research shows that comprehensive sex education contributes to reduced rates of  unintended pregnancies  and STIs, delayed initiation of sexual activity, and increased use of contraceptives among sexually active youth. Furthermore, CSE addresses the diverse needs of young people, including  LGBTQ+ youth  and individuals from various cultural backgrounds, fostering inclusivity and helping reduce health disparities across communities. [ 4 ]


In the United States, the implementation of CSE varies significantly across states due to decentralized education policies. Some states mandate CSE or HIV education, while others continue to prioritize abstinence-based programs. The debate around CSE often involves ideological and political conflicts, with advocates emphasizing its health benefits and critics raising concerns about  age-appropriateness  and  cultural values . Internationally, CSE is recognized by agencies like  UNESCO  and the  World Health Organization  as a critical component of  human rights  and  adolescent development , with recommended integration into school curricula for its role in enhancing both individual well-being and public health.


As of 2019,  sex education in the United States  is mandated at the state level, with individual states, districts, and school boards responsible for determining the implementation of federal policy and funds for  sex education . Currently, 24 out of the 50 U.S. states and the  District of Columbia  mandate general sex education, while 34 states mandate  HIV  education. Notably, in states where sex education is mandated, there is no federal policy requiring the instruction of comprehensive sex education.


During the  George W. Bush administration , conservative Republicans in Congress strongly supported abstinence-only-until-marriage sex education. Conversely, under the  Barack Obama administration , there was opposition to abstinence-only education, with suggestions to eliminate it. With advent of President  Trump's administration , the federal agenda reverted back to supporting an abstinence-based approach.


According to the 2014 School Health Places and Practices Study conducted by he  Centers for Disease Control and Prevention , high school courses, on average, dedicate 6.2 hours of class time to  human sexuality , with a notable emphasis on abstinence. However, the same study found that 4 hours or less are typically allocated to topics such as HIV, other  sexually transmitted infections  and  pregnancy prevention .


Studies have found that comprehensive sexuality education is more effective than receiving no instruction and/or those who receive abstinence-only instruction. [ 5 ]  Acknowledging that people may engage in  premarital sex  rather than ignoring it (which abstinence-only is often criticized for) allows educators to give the students the necessary information to safely navigate their future sexual lives. [ 6 ]  Additionally, young people that do not identify as heterosexual or their gender identity assigned at birth, have increased sexual risk behaviors and adverse health outcomes compared to their heterosexual and cisgender peers. [ 7 ] [ 8 ] [ 9 ]  Sex educators argue comprehensive sex education, which includes specific attention to minority groups, is essential for improving this health disparity and ensuring the livelihoods of all people, including LGBTQ+ youth, racial minorities, or students with disabilities.


CSE advocates argue that promoting abstinence without accompanying information regarding safe sex practices disregards reality, and is ultimately putting the student at risk. [ 10 ]  For example, programs funded under AEGP are reviewed for compliance with the 8 standards (listed below in "Abstinence Education Grant Program (AEGP) Requirements), but are not screened for medical accuracy. Therefore, critics believe that students under these educational programs are put at a disadvantage because it prevents them from making informed choices about their sexual health. Additionally, under these AEGP programs, health educators have referred to those that engage in sex, especially females, as "dirty" and "used". They have also used phrases such as "stay like a new toothbrush, wrapped up and unused" and "chewed-up gum" to teach abstinence. Under a CSE model, language would be more sensitive.


There is clear evidence that CSE has a positive impact on  sexual and reproductive health  (SRH), notably in contributing to reducing  STIs , HIV and  unintended pregnancy . [ 11 ]  Sexuality education does not hasten sexual activity but has a positive impact on safer sexual behaviours and can delay sexual debut. [ 12 ]  A 2014 review of school-based sexuality education programmes has demonstrated increased HIV knowledge, increased  self-efficacy  related to condom use and refusing sex, increased contraception and condom use, a reduced number of sexual partners and later initiation of first sexual intercourse. [ 13 ]  A Cochrane review of 41 randomized controlled trials in Europe, the United States, Nigeria and Mexico also confirmed that CSE prevents unintended adolescent pregnancies. [ 14 ]  CSE is very beneficial in regards to  teen pregnancy  because studies show that, teen pregnancy and childbearing have a significant negative impact on high school success and completion, as well as future job prospects. [ 5 ]  A study in Kenya, involving more than 6,000 students who had received sexuality education led to delayed sexual initiation, and increased condom use among those who were sexually active once these students reached secondary school compared to more than 6,000 students who did not receive sexuality education. [ 15 ] [ 16 ]  CSE also reduces the frequency of sex and the number of partners which in turn also reduces the rates of sexually transmitted infections. [ 5 ]


UNAIDS  and the  African Union  have recognized CSE's impact on increasing condom use, voluntary HIV testing and reducing pregnancy among adolescent girls and have included comprehensive, age-appropriate sexuality education as one of the key recommendations to fast track the HIV response and end the AIDS epidemic among young women and girls in Africa. [ 17 ] [ 16 ]


As the field of sexuality education develops, there is increasing focus on addressing gender, power relations and human rights in order to improve the impact on SRH outcomes. Integrating content on gender and rights makes sexuality education even more effective. [ 18 ]  A review of 22 curriculum-based sexuality education programmes found that 80 per cent of programmes that addressed gender or power relations were associated with a significant decrease in pregnancy, childbearing or STIs. These programmes were five times as effective as those programmes that did not address gender or power. [ 19 ]  CSE empowers young people to reflect critically on their environment and behaviours, and promotes gender equality and equitable social norms, which are important contributing factors for improving health outcomes, including HIV infection rates. The impact of CSE also increases when delivered together with efforts to expand access to a full range of high- quality, youth-friendly services and commodities, particularly in relation to contraceptive choice. [ 20 ] [ 16 ]


A global review of evidence in the education sector also found that teaching sexuality education builds confidence, [ 21 ]  a necessary skill for delaying the age that young people first engage in sexual intercourse, and for using contraception, including condoms. CSE has a demonstrated impact on improving knowledge, self-esteem, changing attitudes, gender and social norms, and building  self-efficacy . [ 16 ]


Though a focus on behavior change (i.e., increased condom use and delayed onset of sexual debut) is an important benefit and measure of outcomes associated with sex education, a pivot to exploring the mental health and well-being implications associated with shifting the narrative from a purely biological and procreative approach to a pleasure-inclusive and sex positive approach showcases a host of beneficial outcomes. [ 22 ]  Two avenues hold particular interest when implementing a pleasure-based curricula: Benefits of CSE [ 23 ]  and Benefits of Sexual Expression. [ 24 ]


Such avenues have been recognised by official organising bodies such as the  World Association of Sexual Health  (WAS). Indeed, their  Sexual Pleasure Declaration  outlines that the pursuit of pleasurable and safe sexual experiences, free from discrimination and coercion, is integral to sexual health and overall well-being. Recognising sexual pleasure as a fundamental aspect of human rights - which also holds its own  declaration on Sexual Rights  -  its diverse expressions should be incorporated into global education, health promotion, research, and advocacy efforts, fostering comprehensive, immediate, and sustainable actions for individual well-being and contributing to global health and sustainable development.


Another notable organisation paving the way of pleasure-inclusive sex education curricula is  The Pleasure Project . Which recently published a systematic review uncovering the distinct value added by embedding a pleasure-based lens within sexual health interventions. [ 22 ]  The Pleasure Project also underscores seven guiding principles: Be Positive, Rights First, Think Universal, Be Flexible, Talk Sexy, Embrace Learning, and Love Yourself.


While CSE implementation is on the rise in the United States, it remains difficult for state officials to regulate what is and is not taught in the classroom. This is due in large part to the undefinability of CSE; CSE has the potential to comprise such a wide range of sexual information, and over-all focus varies widely between curricula. [ 25 ]  Educators have also accused CSE of fundamentally operating as a form of "abstinence-plus", due to the reality that CSE often involves minimal body-related information and excessive promotions of abstinence. [ 26 ]  "So-called Comprehensive Sex Ed" says Sharon Lamb, a professor at the University of Massachusetts Boston, "has been made less comprehensive as curricula are revised to meet current federal, state, and local requirements." [ 26 ]


The  LGBT  population experiences multiple health disparities which may be impacted by stigma, discrimination, and lack of provider cultural sensitivity. [ 27 ]  This population is subject to systemic barriers to adequate healthcare services ultimately impacting their wellbeing and welfare negatively. [ 27 ]  They often receive care from clinicians without specialty training in addressing the concerns of this population; which may hinder communication and trust, and ultimately influence the quality and adequate delivery of healthcare. [ 28 ]  Discrimination and lack of cultural sensitivity may also contribute to the limited health-seeking behaviors experienced by this population. [ 27 ]  This lack of health-seeking behavior both limits preventative services, and increases and prolongs illness and ailments. Research shows a higher risk of contracting HIV and other STDs; particularly in gay men of color. [ 27 ]  Lesbian and bisexual females are less likely to obtain routine care like breast and cervical cancer screenings. [ 27 ]  Gay men are at an increased risk of prostate, testicular, anal, and colon cancers, while lesbian and bisexual women have an increased risk of ovarian, breast, and endometrial cancers. [ 28 ]  As a result of stigma, discrimination, victimization, and sexual abuse, LGBT youth are more likely to be involved in high-risk sexual behaviors at an earlier age. [ 28 ]


While comprehensive sex education exists in schooling, many programs do not address the needs of the LGBT community. This population faces different health disparities ultimately driven by discrimination, shortfalls of peers, the lack of parental support, community services, and school-based sex education. [ 29 ]  The implementation of LGBT comprehensive sex education utilized as an intervention seeks to combat these health disparities, by informing the population of the importance of developing sexual health. [ 29 ]  Sexual health involves not only preventing disease, but also a respectful approach to sexual relationships, sexuality, and accepting an individual's gender identity and sexual orientation. [ 29 ]


The term "comprehensive" is also often misleading because some comprehensive programs do not show the holistic picture of human sexuality. [ 30 ]  LGBT advocates have long been critical of the ways in which comprehensive sex education generally promotes marriage as the end goal for students.  LGBT advocates want to express other forms of relationships other than marriage. They advocate that students should have sex education that encompasses the different forms and should be allowed to exercise those forms in which they are most comfortable with. Even when curriculums claim to be inclusive of LGBT experiences, they often promote  heteronormative  lifestyles as "normal." [ 31 ]  Inclusion of LGBT identities and health topics is necessary for LGBT students to feel safe and seen in their sex ed classrooms. [ 32 ]  When sex education fails to include LGBT identities and experiences, LGBT youth can be vulnerable to risky sexual behaviors and experience negative sexual health outcomes. Due to the lack of  LGBT sex education  provided in schools, LGBT youth will look to peers and the internet, which can lead to misinformation. [ 33 ]  When these students do not have access to or an interest in marriage they are practically erased from the CSE narrative.


In Canada, a federal report showed that the LGBT community has less access to health services and faces more comprehensive health challenges compared to the general population. As a result of the lack of support for the LGBT population, the Comprehensive Health Education Workers (CHEW) Project emerged in October 2014. Their goal is to educate the LGBT community about topics such as sexual and gender identity, sexually transmitted infections (STIs), healthy social relationships, and depression. They do this through workshops, arts‐based projects, and one‐on‐one meetings. The CHEW project is set exclusively for the LGBT community in order to establish a safe environment in which LGBT youth can gain resources for sex education. [ 34 ]


A cross-sectional study done in New York City analyzed the sexual behaviors of high school girls. Studies found that, "high school girls who identified as LGBT were more likely to report substance use such as: alcohol, marijuana, cocaine, heroin, meth, ecstasy and prescription drugs. They also had higher rates of contemplating and/or attempting suicide." [ 35 ]  Another study found that "the LGBT youth accesses health information online five times more than the  heterosexual  population, and these rates are even higher for LGBT youth that identify as a person of color which stems from the fact that they lack health resources". [ 36 ]   Rights, Respect, Responsibility includes an inclusive LGBT curriculum for grades K-12. By having a curriculum, such as the Right, Respect, Responsibility suggests, students will have accurate information about all identities as well as establishing a safe classroom for LGBT students. [ 37 ]