LAUSR

Child sexual abuse is a concern not just in Philadelphia, but across the globe. Resources are limited, but we need to take action to address this reality. We need to connect the dots between academia, practitioners, local and national government agencies, nongovernmental organizations, and civil society. This sad reality was recently documented in a report prepared by the Intelligence Unit of The Economist. This benchmarking index examined the response of 40 countries representing 70% of all world's children and concludes that child sexual abuse is ubiquitous in both wealthy and poor countries (Kloppen, Haugland, Svedin, Mæhle, & Breivik, 2016). Other key findings are, that although girls are the primary victims, boys are also at high risk. This indexing report – Out of the Shadows: Shining Light on the Response to Child Sexual Abuse and Exploitation refers to the most recent UNICEF data that as many as 120 million girls have been subjected to some form of sexual abuse, but fewer than 1 or 2% have sought professional help (see: https://outoftheshadows.eiu.com/). As clinicians, we know that many victims blame themselves especially when the perpetrator is a family member or a respected member of their community. Sadly, current estimates indicate that in some 90% of cases the perpetrator is known to the child (Finkelhor & Shattucket, 2012). We live in a world in which people choose to remain silent about this reality. Often decades will pass before victims are willing to acknowledge their trauma. Indeed, victims are often blamed and stereotyped by society and the media. As practitioners, we know that the effects of sexual violence in childhood can have detrimental effects on the child's health and wellbeing for the remainder of their lives. Yet, too often we do not focus enough on detecting and addressing child sexual abuse and exploitation. Unfortunately, there have been very few studies that have closely examined the impact of sexual abuse from a symptomatic and neuropsychological perspective (Hagan, Gentry, Ippen, & Lieberman, 2018). In Philadelphia, this shortcoming is addressed by an article in this issue of Depression and Anxiety authored by Barzilay, Patrick, Calkins, Moore, & Gur et al. (2019) at the Lifespan Brain Institute at the University of Pennsylvania. They take a detailed look at the impact of abuse, including sexual abuse, in a cross‐sectional study of >7,000 community youth, aged 11 to 21 years, which are being followed in the Philadelphia Neurodevelopmental Cohort (Barzilay, Patrick, Calkins, Moore, & Gur et al., 2019; Barzilay, Patrick, Calkins, Moore, & Wolf et al., 2019). While they focus across a number of psychiatric symptoms and disorders, they have examined the presence and correlates of obsessive‐compulsive symptoms (OCS) in great detail. Indeed, to the best of our knowledge, this is the first large‐scale study to examine the relationship between abuse and OCS. The authors found that early‐life trauma is associated with OCS in a dose‐response manner, particularly among prepubertal girls. The trauma‐ OCS association was also found to vary by the type of trauma and by OCS subtypes. Perhaps not surprisingly, sexual assault, showed stronger associations with OCS compared with other forms of early life stress that were “nonassaultive” in nature. Slightly less than 4% of the youth (n=269) in the cohort had a history of sexual assault. A large majority of these cases were postpubertal females. The youth with a history of sexual assault were 6.13 to 10.84 times (p<0.001) more likely to report that they are bothered by “bad intrusive thoughts,” that is thoughts about harming others or one's self, or fears of doing/saying something bad without intending to, and having forbidden, bad, religious, or violent thoughts “that do not make sense,” and “that come to mind over and over again and would not go away”. These youth also had significantly (p<0.001) more OCS with regard to each of the other OC symptom dimensions, that is contamination/cleaning, a need for symmetry, and a need to repeatedly check to make sure things were “just right.” Remarkably, they were also 4.1 to 8.65 times more likely to endorse hoarding behaviors (P<0.001). The authors also found that OCS and early‐life trauma were each independently associated with an increased risk of depression, suicide ideation, and psychosis. Early‐life stress and OCS also showed a significant interaction with increased rates of psychosis. Physical and sexual abuse against children and youth is a major humanitarian and public health crisis in Philadelphia and across the globe (Hillis, Mercy, Amobi, & Kress, 2016; UNICEF, 2012). Boys as well as girls are at risk. Sexual abuse and exploitation can reach epidemic proportions in vulnerable populations including migrants and refugees (Digidiki & Bhabha, 2017). This brings to mind families fleeing from Central America who are seeking asylum at our southern border with Mexico as well as families from Syria and Sub‐Saharan Africa seeking safety in Europe and North Africa (De Schrijver, Vander Beken, Krahé, & Keygnaert, 2018; Keygnaert & Guieu, 2015; Ouyang, 2013; Soylu et al., 2016). Prevention through the creation of safe settings and access to quality services for victims and their families as well as the perpetrators are high priorities that have yet to be adequately addressed (Hegarty & Tarzia, 2019; Murray, Nguyen, & Cohen, 2014; Wild, Fromberger, Jordan, Müller, & Müller, 2019). This is essential if we are to meet the 2030 United Nations Sustainable Development Goals, especially Goal 16.2 to end abuse, exploitation, trafficking, and all forms of violence against and torture of children (United Nations, 2018). This will surely have a positive impact on the mental and physical wellbeing of millions of children, and they will be less likely to be plagued by bad intrusive obsessive‐ compulsive thoughts.