"Can I tell you something, Dr. Lee?" my adolescent patient asked. I nodded.
She whispered into my ear: "He raped me." Her large eyes pleaded with me to believe her, and she suddenly pushed her baby face into my shoulder and let the tears come.
I don't allow physical contact with patients. But instinctively, I let her stay there. There are no words to describe the bitterness of the moment; it was a pain transcending language. She -- younger-looking than her years, disappearing into an oversized sweatshirt -- clinging to me. I -- a young doctor on call, exhausted -- numb after the revelation.
He was her teacher. As she cried silently, my mind raced with physician responsibilities: psychiatric stabilization, documentation, and notifying Mom, child protective services, my superiors at the hospital. Even after doing all those things, I knew the abuse had irreparably altered her life's trajectory. Healing was possible, as many child sexual abuse (CSA) survivors know. But it could never un-happen to her.
I've treated CSA survivors as young as 6 and as old as 70. The willfully inflicted damage to these patients cannot, and must not, be minimized.
Pedophile Math
In a moment enraging many abuse survivors, podcaster Megyn Kelly appeared to downplay late sex offender (and convicted pedophile
) Jeffrey Epstein's crimes, making space for the perspectivethat Epstein was not, in fact, a pedophile. She paraphrased a source describing Epstein's "type" as the "barely legal" look, and then went on to say:
"We have yet to see anybody come forward and say I was under 10, I was under 14...You can say that's a distinction without a difference. I think there is a difference. There's a difference between a 15-year-old and a 5-year-old, you know?"
Kelly's comments seem profoundly perfidious, especially in the context of #MeToo, her own experience of sexual harassment
, and her carefully curated image of a woman protecting women's interests. She appears to paint abuse as a mere preference, transforming predators into horny men and ostensibly laying the groundwork for their actions to become forgivable. It's a gross disservice to survivors.
If truly a matter of sexual preference, Epstein could have consensually dated young-looking women of legal age. Yet, he sexually abused minors.
Child predators specifically target minors because they're vulnerable. The physical appearance of the child is not a turn-on; the ability to dominate is.
Clinically Assessing Abusers
Abuse is not about sexual preferences, but power dynamics. Perpetrators do not enjoy the mutuality of a healthy sexual relationship, and Epstein's crimes
at the intersection of sex trafficking, soliciting prostitution from a minor, and child sexual abuse highlight this point.
I first started thinking about this after leaving an abusive partner with a penchant for prostitutes -- I couldn't understand why he preferred them sexually to a healthy relationship. But a domestic violence counselor gave me the evidence-based answer to that question: "Abusive men seek transactional sex because they feel they control the scene when they pay for it. They create a scene where they're allowed to overpower a woman."
found that men who go to prostitutes share many characteristics with sexually violent men and generally have less empathy for prostituted women.
"Both groups tend to have a preference for impersonal sex, a fear of rejection by women, a history of having committed sexually aggressive acts, and a hostile masculine
self-identification [meaning dominance, acceptance of violence against women, and hostility towards women]," said study authorNeil Malamuth, PhD.
Malamuth developed the Confluence Model
that can help clinicians understand men at risk of perpetrating sexual violence and identify points of intervention. The model highlights two risk pathways: hostile masculinity and impersonal sex -- like prostitution. At the intersection of these pathways is a high likelihood of sexual violence against women.
Alarmingly, the men in the study were fully cognizant of the harms they inflicted. One told researchers, "[The women] feel degraded. I mean the ones I know have no self-confidence." Another could tell that some of the women dissociated during sex -- a common trauma response. They were additionally aware of the fact that many women who find themselves in prostitution are tricked or trafficked into it.
They bought the women anyway.
Women and girls are disposable to these men. One study participant likened prostitution to purchasing a cup of coffee: "When you're done, you throw it out."
The research shows that these men -- abusive, predatory, seeking transactional sex -- know what they're doing is wrong. Abuse is not a psychiatric disorder, but a choice.
The girls are not a "type." They're objects to be dominated.
What Is a Child?
In its definition of CSA
, the CDC defines "child" as "person less than 18." Developmentally, a child does not understand and cannot consent to sex with an adult.
I do not dispute that there is a difference between a 5-year-old and a 15-year-old. I dispute that the difference matters when it comes to sexual abuse.
The costs of CSA are dire. Survivors are at disproportionate risk of multiple health consequences
: sexually transmitted infections, chronic pain, gastrointestinal and cardiopulmonary disorders, gynecologic disorders, and high utilization of healthcare, among others. The annual economic burdenof CSA in the U.S. exceeds $9 billion.
And the mental health costs are even higher-stakes: post-traumatic stress disorder, mood disorders, and suicidal behavior or completed suicide. From my work with CSA survivors, I'll say this: a child abused at the age of 15 is no less affected than a child abused at the age of 6. The distinction is meaningless.
Even the most fastidious of moral particularists
in clinical bioethics cannot justify child sexual abuse. There are ethical exceptions to many unacceptable things, like killing (self-defense). But no one with a shred of morality can possibly find a context in which the rape of a child is acceptable, and playing semantics over what constitutes a pedophile serves no meaningful purpose but to center the perpetrator, redraw the boundaries of acceptable, and hurt survivors.
The patient I described earlier did poorly, even after disclosing her abuse to me. I wish I could have ended this piece on a hopeful note, but this is the stark reality of sexual abuse.
Now that we know what a child is, what sexual abuse is, and what the risk factors for perpetration of sexual violence are, I leave you with some important questions whose answers will speak volumes: What will we as a country do about it? Will something change? Will we hold perpetrators truly accountable?
is a resident physician in the Department of Psychiatry at the University of Rochester Medical Center in New York. The views expressed above reflect only those of the author and are not necessarily shared by any institution with which she is affiliated.
If you or someone you know has been trafficked or abused, call 1-888-373-7888 for the National Human Trafficking Hotline or 1-800-799-7233 (SAFE) for the
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