<s> [INST] <<SYS>> You are a responsible assistant committed to providing accurate and helpful responses. Avoid sharing harmful or biased content. Clarify any unclear or incorrect questions rather than providing false or misleading information. <</SYS>> What is Child sexual abuse and can you explain it in depth? [/INST] 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. Forms of child sexual abuse include engaging in sexual activities with a child (whether by asking or pressuring, or by other means), indecent exposure (of the genitals, female nipples, etc.), child grooming, and child sexual exploitation, such as using a child to produce child pornography.Child sexual abuse can occur in a variety of settings, including home, school, or work (in places where child labor is common). 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". The effects of child sexual abuse can include depression, post-traumatic stress disorder, anxiety, complex post-traumatic stress disorder, propensity to further victimization in adulthood, and physical injury to the child, among other problems. 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.The global prevalence of child sexual abuse has been estimated at 19.7% for females and 7.9% for males. Most sexual abuse offenders are acquainted with their victims; approximately 30% are relatives of the child, most often brothers, fathers, uncles, or cousins; 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. 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.The word pedophile is commonly applied indiscriminately to anyone who sexually abuses a child, but child sexual offenders are not pedophiles unless they have a strong sexual interest in prepubescent children. 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. 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."

Effects
Psychological
Child sexual abuse can result in both short-term and long-term harm, including psychopathology in later life. Indicators and effects include depression, anxiety, eating disorders, poor self-esteem, somatization, sleep disturbances, and dissociative and anxiety disorders including post-traumatic stress disorder. 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.  Victims may withdraw from school and social activities and exhibit various learning and behavioural problems including cruelty to animals, attention deficit/hyperactivity disorder (ADHD), conduct disorder, and oppositional defiant disorder (ODD). Teenage pregnancy and risky sexual behaviors may appear in adolescence. Child sexual abuse victims report almost four times as many incidences of self-inflicted harm. Sexual assault among teenagers has been shown to lead to an increase in mental health problems, social exclusion and worse school performance.

A well-documented, long-term negative effect is repeated or additional victimization in adolescence and adulthood. A causal relationship has been found between childhood sexual abuse and various adult psychopathologies, including crime and suicide, in addition to alcoholism and drug abuse.  Males who were sexually abused as children more frequently appear in the criminal justice system than in a clinical mental health setting.  A study comparing middle-aged women who were abused as children with non-abused counterparts found significantly higher health care costs for the former.  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.A specific characteristic pattern of symptoms has not been identified, and there are several hypotheses about the causality of these associations.Studies have found that 51% to 79% of sexually abused children exhibit psychological symptoms. 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. The level of harm may also be affected by various factors such as penetration, duration and frequency of abuse, and use of force. The social stigma of child sexual abuse may compound the psychological harm to children, and adverse outcomes are less likely for abused children who have supportive family environments.

Posttraumatic stress disorder
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.  When severe sexual abuse (penetration, several perpetrators, lasting more than one year) had occurred, dissociative symptoms were even more prominent. 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. 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." Prolonged exposure therapy (PE) was found to decrease PTSD and depressive symptoms in female methadone using CSA survivors.Besides dissociative identity disorder (DID), posttraumatic 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.

Research factors
Because child sexual abuse often occurs alongside other possibly confounding variables, such as poor family environment and physical abuse, some scholars argue it is important to control for those variables in studies which measure the effects of sexual abuse. 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 childs 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." Other studies have found an independent association of child sexual abuse with adverse psychological outcomes.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.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." The study was criticized for flawed methodology and conclusions. The US Congress condemned the study for its conclusions and for providing material used by pedophile organizations to justify their activities.

Physical
Injury
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.

Infections
Child sexual abuse may cause infections and sexually transmitted diseases. 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.

Neurological damage
Research has shown that traumatic stress, including stress caused by sexual abuse, causes notable changes in brain functioning and development. 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;" Teicher et al. (1993) found that an increased likelihood of "ictal temporal lobe epilepsy-like symptoms" in abused subjects; Anderson et al. (2002) recorded abnormal transverse relaxation time in the cerebellar vermis of adults sexually abused in childhood; 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; and Ito et al. (1993) found increased electrophysiological abnormalities in sexually abused children.Some studies indicate that sexual or physical abuse in children can lead to the overexcitation of an undeveloped limbic system. Teicher et al. (1993) 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.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.

Incest
Incest between a child or adolescent and a related adult is known as child incestuous abuse, and has been identified as the most widespread form of child sexual abuse with a highly significant capacity to damage the young person. One researcher stated that more than 70% of abusers are immediate family members or someone very close to the family. 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. 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.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. 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. Similarly, some argue that sibling incest may be as common, or more common, than other types of incest: Goldman and Goldman reported that 57% of incest involved siblings; Finkelhor reported that over 90% of nuclear family incest involved siblings; while Cawson et al. show that sibling incest was reported twice as often as incest perpetrated by fathers/stepfathers.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.

Types
Child sexual abuse includes a variety of sexual offenses, including:

sexual assault – a term defining offenses in which an adult uses a minor for the purpose of sexual gratification; for example, rape (including sodomy), and sexual penetration with an object. Most U.S. states include, in their definitions of sexual assault, any penetrative contact of a minors body, however slight, if the contact is performed for the purpose of sexual gratification.
sexual exploitation – a term defining offenses in which an adult victimizes a minor for advancement, sexual gratification, or profit; for example, prostituting a child, live streaming sexual abuse, and creating or trafficking in child pornography.
sexual grooming – a term defining the social conduct of a potential child sex offender who seeks to make a minor more accepting of their advances, for example in an online chat room.

Commercial sexual exploitation
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)." 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. In recent years, new innovations in technology have facilitated the trade of Internet child pornography.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. Prior to 2009, the term commonly used to describe child sexual exploitation was child prostitution. 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. 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.

Disclosure
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. In general, studies have found that children need support and stress-reducing resources after disclosure of sexual abuse. Negative social reactions to disclosure have been found to be harmful to the survivors well-being. 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.  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. Non-validating and otherwise non-supportive responses to disclosure by the childs 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.The American Academy of Child and Adolescent Psychiatry provides guidelines for what to say to the victim and what to do following the disclosure. Asa 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 childrens issues too long will negatively impact their recovery. Therefore, the parental caregiver teaches the child to mask his or her issues."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 childs 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, although some researchers consider the dolls too explicit and overstimulating, which might contribute to non-abused children behaving with the dolls in one or more ways that suggest they were sexually abused.  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.

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

Age at the time of presentation
Circumstances of presentation for treatment
Co-morbid conditionsThe goal of treatment is not only to treat current mental health issues, and trauma related symptoms, but also to prevent future ones.

Children and adolescents
Children often present for treatment in one of several circumstances, including criminal investigations, custody battles, problematic behaviors, and referrals from child welfare agencies.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. In a 2012 systematic review, cognitive behavior therapy showed potential in treating the adverse consequences of child sexual abuse.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 childs 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.

Adults
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.Generally, the approach is to focus on the present problem, rather than the abuse itself. Treatment is highly varied and depends on the persons 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.Although there is no known cure for pedophilia, 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.The evidence for cognitive behavioral therapy is mixed. A 2012 Cochrane Review of randomized trials found that CBT had no effect on risk of reoffending for contact sex offenders. Meta-analyses in 2002 and 2005, which included both randomized and non-randomized studies, concluded that CBT reduced recidivism. There is debate over whether non-randomized studies should be considered informative. More research is needed.Sexual abuse is associated with many sub-clinical behavioral issues as well, including re-victimization in the teenage years, a bipolar-like switching between sexual compulsion and shut-down, and distorted thinking on the subject of sexual abuse (for instance, that it is common and happens to everyone).  When first presenting for treatment, the patient can be fully aware of their abuse as an event, but their appraisal of it is often distorted, such as believing that the event was unremarkable (a form of isolation). Frequently, victims do not make the connection between their abuse and their present pathology.

Prevention
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 and group work. Programmes delivered to parents were developed in the 1980s and took the form of one-off meetings, two to three hours long. 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.

Offenders
Demographics
Offenders are more likely to be relatives or acquaintances of their victim than strangers. 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%).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%. Studies of sexual misconduct in US schools with female offenders have shown mixed results with rates between 4% to 43% of female offenders. Maletzky (1993) found that, of his sample of 4,402 convicted child sex offenders, 0.4% were female.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 relatives. Male relatives were found to be the most relevant predators in the case of both gender.In U.S. schools, educators who offend range in age from "21 to 75 years old, with an average age of 28".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, 14.58% of the victims are boys and "most victims were abused by a family member, friend or acquaintance." One in six perpetrators are underage.

Typology
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". 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.Later work (Holmes and Holmes, 2002) expanded on the types of offenders and their psychological profiles.  They are divided as follows:
Situational – does not prefer children, but offend under certain conditions.
Regressed – Typically has relationships with adults, but a stressor causes them to seek children as a substitute.
Morally Indiscriminate – All-around sexual deviant, who may commit other sexual offenses unrelated to children.
Naive/Inadequate – Often mentally disabled in some way, finds children less threatening.
Preferential – has true sexual interest in children.
Mysoped – Sadistic and violent, target strangers more often than acquaintances.
Fixated – Little or no activity with own age, described as an "overgrown child".

Causal factors
Causal factors of child sex offenders are not known conclusively. 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.Offenders may use cognitive distortions to facilitate their offenses, such as minimization of the abuse, victim blaming, and excuses.

Pedophilia
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. 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); however, not all child sexual offenders are pedophiles and not all pedophiles engage in sexual abuse of children. For these reasons, researchers recommend against imprecisely describing all child molesters as pedophiles.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 and the Council of Europe to refer to child sexual abuse and sexual violence used against children, child prostitution, child trafficking and the use of child pornography. The term "cyber-pedocriminality" has been used to refer to the activities of viewers of child pornography online.

Recidivism
Although reconviction data suggest that not many sex offenders reoffend, OJP reported that observed recidivism rates of sex offenders are underestimated of actual reoffending. 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. 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.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.

Other children
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, 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.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.

Teachers
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. 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. A survey by Promundo found that 16% of girls in North Kivu said they had been forced to have sex with their teachers. 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. According to Plan International, 16% of children in Togo, for instance, named a teacher as responsible for the pregnancy of a classmate.

Prevalence
Global
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:
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%.

Africa
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.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, Zambia and Nigeria and is being blamed for the high rate of sexual abuse against young children.Child rape is on the rise in the war-ravaged eastern Democratic Republic of the Congo.  Aid workers blame combatants on all sides, who operate with much impunity, for a culture of sexual violence. 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). A survey by CIET found around 11% of boys and 4% of girls admitted to forcing someone else to have sex with them. 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. 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."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. 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 infants injuries were so extensive, increased attention on prosecution has occurred.

Asia
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.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 countrys legalized brothels use the drug. According to social activists, the steroid can cause diabetes and high blood pressure and is highly addictive.In 2007, the Ministry of Women and Child Development published the "Study on Child Abuse: India 2007." 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 studys 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.In Pakistan, sexual abuse of children is a problem in some madrassas. Child sexual abuse has also been reported in Madrassas across Bangladesh and India.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 Pakistans history.In 2019, Pakistans Human Rights Minister, Shirin Mazari has said that Pakistan was ranked as the country with the largest numbers of child pornography viewers.  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."In Taiwan, a survey of adolescents reported 2.5% as having experienced childhood sexual abuse.In Uzbekistan, the UK Ambassador Craig Murray wrote that the government, under president Islam Karimov, used child rape to force false confessions from prisoners.

Pacific
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 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.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. 57·5% (587/1022) of men who raped a non-partner committed their first rape as teenagers.

United States and Europe
Child sexual abuse occurs frequently in Western society, although the rate of prevalence can be difficult to determine. 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. In the UK, a 2010 study estimated prevalence at about 5% for boys and 18% for girls (not dissimilar to a 1985 study that estimated about 8% for boys and 12% for girls). 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. Barnardos charity estimates that two thirds of victims in the United Kingdom are girls and one third are boys. Barnardos is concerned that boy victims may be overlooked. A firm of solicitors that acts in many cases of child abuse has published a list of over twenty Childrens Homes and group actions that they have an interest in or for which they are lead solicitors.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, while a statistical analysis based on 16 cross-sectional studies estimated the rate to be 7.2% for males and 14.5% for females. The US Department of Health and Human Services reported 83,600 substantiated reports of sexually abused children in 2005, while state-level child protective services reported 63,527 sexual abuse incidents in 2010. Including incidents which were not reported would make the total number even larger. 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".Surveys have shown that one fifth to one third of all women reported some sort of childhood sexual experience with a male adult.
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." 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. 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."  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.Child marriage is often considered to be another form of child sexual abuse. 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. 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.In US schools, according to the United States Department of Education, "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%. 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"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. Sexual victimization of boys by their mothers or other female relatives is especially 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. This underreporting has been attributed to cultural denial of female-perpetrated child sex abuse, because "males have been socialized to believe they should be flattered or appreciative of sexual interest from a female." 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".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.

International law
Child sexual abuse is outlawed nearly everywhere in the world, generally with severe criminal penalties, including in some jurisdictions, life imprisonment or capital punishment.  An adults sexual intercourse with someone below the legal age of consent is defined as statutory rape, 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 childrens 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.  As of November 2008, 193 countries are bound by the CRC, including every member of the United Nations except the United States and South Sudan.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. This directive deals with several forms of sexual abuse of children, especially commercial sexual exploitation of children.

History
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. 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. Up until the 1930s, the psychological impact of sexual abuse was not emphasized, instead emphasis was placed on the physical harm or the childs reputation. Widespread public awareness of childrens sexual abuse did not occur until the 1970s in the West.

Early writings
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.

Public concern
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. 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.
Second wave feminism brought greater awareness of child sexual abuse and violence against women, and made them public, political issues. 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.  Her second book Trauma and Recovery coined the term complex post-traumatic stress disorder and included child sexual abuse as a cause.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. Megans Law which was enacted in 1996 gives the public access to knowledge of sex offenders nationwide.Anne Hastings described these changes in attitudes towards child sexual abuse as "the beginning of one of historys largest social revolutions."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."

Media reporting and its quality
Media reporting plays a crucial role in tackling the word-wide problem of child sexual abuse because it puts the issue on the public and political agenda. 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.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. When media reporting on child sexual abuse is investigated, usual methodological approaches are the media content analysis and the media quality analysis. 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. 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. Future media content and media quality analyses will show if and how the quality of news reporting on child sexual abuse will be improving over time in different countries and across different media systems.

Civil lawsuits
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.  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.
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 plaintiffs 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.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 $45million 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.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."

See also
References
Further reading
Abagnalo, George (2001). Boy on a Pony. Moreland Press. ISBN 978-0-970-667700 (a groundbreaking novel exploring the subject of privileged sexual abuse of children within the healthcare system).
Lew, Mike (2004). Victims No Longer: The Classic Guide for Men Recovering from Sexual Child Abuse (2nd ed.). Perennial Currents. ISBN 978-0-06-053026-6.
Cynthia Crosson-Tower (2008). Understanding child abuse and neglect. Boston: Pearson/Allyn & Bacon. ISBN 978-0-205-50326-1.
Asa Don Brown (2009). "Posttraumatic stress disorder in childhood". Family and Marriage Counseling.
Lascaratos, J; Ascaratos J; Poulakou-Rebelakou, E (2000). "Child Sexual abuse: Historical cases in the Byzantine Empire (324–1453 A.D.)". Child Abuse & Neglect. 24 (8): 1085–1090 </s>


<s> [INST] <<SYS>> You are a responsible assistant committed to providing accurate and helpful responses. Avoid sharing harmful or biased content. Clarify any unclear or incorrect questions rather than providing false or misleading information. <</SYS>> What is Suicidal ideation and can you explain it in depth? [/INST] Suicidal ideation, or suicidal thoughts, means having thoughts, ideas, or ruminations about the possibility of ending ones own life. It is not a diagnosis but is a symptom of some mental disorders and can also occur in response to adverse events without the presence of a mental disorder.On suicide risk scales, the range of suicidal ideation varies from fleeting thoughts to detailed planning. Passive suicidal ideation is thinking about not wanting to live or imagining being dead.  Active suicidal ideation is thinking about different ways to die or forming a plan to die.Most people who have suicidal thoughts do not go on to make suicide attempts, but suicidal thoughts are considered a risk factor. During 2008–09, an estimated 8.3 million adults aged 18 and over in the United States, or 3.7% of the adult U.S. population, reported having suicidal thoughts in the previous year, while an estimated 2.2 million reported having made suicide plans in the previous year. In 2019, 12 million U.S. adults seriously thought about suicide, 3.5 million planned a suicide attempt, 1.4 million attempted suicide, and more than 47,500 died by suicide. Suicidal thoughts are also common among teenagers.Suicidal ideation is associated with depression and other mood disorders; however, many other mental disorders, life events, and family events, can increase the risk of suicidal ideation. Mental health researchers indicate that healthcare systems should provide treatment for individuals with suicidal ideation, regardless of diagnosis, because of the risk for suicidal acts and repeated problems associated with suicidal thoughts. There are a number of treatment options for people who experience suicidal ideation.

Definitions
The ICD-11 describes suicidal ideation as "thoughts, ideas, or ruminations about the possibility of ending ones life, ranging from thinking that one would be better off dead to formulation of elaborate plans".The DSM-5 defines it as "thoughts  about  self-harm, with deliberate consideration or planning of possible techniques of causing ones own death".The Centers for Disease Control and Prevention defines suicidal ideation "as thinking about, considering, or planning suicide".

Terminology
Another term for suicidal ideation is suicidal thoughts.When someone who has not shown a history of suicidal ideation experiences a sudden and pronounced thought of performing an act which would necessarily lead to their own death, psychologists call this an intrusive thought. A commonly experienced example of this is the high place phenomenon, also referred to as the call of the void.Euphemisms related to mortal contemplation include internal struggle, voluntary death, and eating ones gun.

Risk factors
The risk factors for suicidal ideation can be divided into three categories: psychiatric disorders, life events, and family history.

Psychiatric disorders
Suicidal ideation is a symptom for many mental disorders and can occur in response to adverse life events without the presence of a mental disorder.There are several psychiatric disorders that appear to be comorbid with suicidal ideation or considerably increase the risk of suicidal ideation. For example, many individuals with borderline personality disorder exhibit recurrent suicidal behavior and suicidal thoughts. One study found that 73% of patients with borderline personality disorder have attempted suicide, with the average patient having 3.4 attempts. The following list includes the disorders that have been shown to be the strongest predictors of suicidal ideation. These are not the only disorders that can increase risk of suicidal ideation. The disorders in which risk is increased the greatest include:
Anxiety disorders
Autism spectrum disorder
Major depressive disorder: 162
Dysthymia
Bipolar disorder
Attention deficit hyperactivity disorder (ADHD)
Premenstrual Dysphoric Disorder (PMDD)
Post-traumatic stress disorder (PTSD) and complex post-traumatic stress disorder (C-PTSD): 278
Personality disorders
Psychosis (detachment from reality)
Paranoia
Schizophrenia: 104
Substance use disorders, inhalant use disorder: 538
Body dysmorphic disorder: 245
Nightmare disorder: 405
Gender dysphoria: 454
Conduct disorder: 473
Specific learning disorder: 70

Medication side effects
Antidepressant medications are commonly used to decrease the symptoms in patients with moderate to severe clinical depression, and some studies indicate a connection between suicidal thoughts and tendencies and taking antidepressants, increasing the risk of suicidal thoughts in some patients.Some medications, such as selective serotonin re-uptake inhibitors (SSRIs), can have suicidal ideation as a side effect.  Moreover, these drugs intended effects, can themselves have unintended consequence of an increased individual risk and collective rate of suicidal behavior: Among the set of persons taking the medication, a subset feel bad enough to want to attempt suicide (or to desire the perceived results of suicide) but are inhibited by depression-induced symptoms, such as lack of energy and motivation, from following through with an attempt.  Among this subset, a "sub-subset" may find that the medication alleviates their physiological symptoms (such as lack of energy) and secondary psychological symptoms (e.g., lack of motivation) before or at lower doses than it alleviates their primary psychological symptom of depressed mood. Among this group of persons, the desire for suicide or its effects persists even as major obstacles to suicidal action are removed, with the effect that the incidences of suicide and suicide attempts increase.In 2003, the U.S. Food and Drug Administration (FDA) issued the agencys strictest warning for manufacturers of all antidepressants (including tricyclic antidepressants [TCAs] and monoamine oxidase inhibitors) due to their association with suicidal thoughts and behaviors. Further studies disagree with the warning, especially when prescribed for adults, claiming more recent studies are inconclusive in the connection between the drugs and suicidal ideation.Individuals with anxiety disorders who self-medicate with drugs or alcohol may also have an increased likelihood of suicidal ideation.

Life events
Life events are strong predictors of increased risk for suicidal ideation. Furthermore, life events can also lead to or be comorbid with the previous listed psychiatric disorders and predict suicidal ideation through those means. Life events that adults and children face can be dissimilar and for this reason, the list of events that increase risk can vary in adults and children. The life events that have been shown to increase risk most significantly are
Alcohol use disorder
Studies have shown that individuals who binge drink, rather than drink socially, tend to have higher rates of suicidal ideation
Certain studies associate those who experience suicidal ideation with higher alcohol consumption
Not only do some studies show that solitary binge drinking can increase suicidal ideation, but there is a positive feedback relationship causing those who have more suicidal ideation to have more drinks per day in a solitary environment
Minoritized gender expression and/or sexuality
Unemployment
Chronic illness or pain
Death of family members or friends
End of a relationship or being rejected by a romantic interest
Major change in life standard (e.g. relocation abroad)
Other studies have found that tobacco use is correlated with depression and suicidal ideation
Unplanned pregnancy
Bullying, including cyberbullying and workplace bullying
Previous suicide attempts
Having previously attempted suicide is one of the strongest indicators of future suicidal ideation or suicide attempts
Military experience
Military personnel who show symptoms of PTSD, major depressive disorder, alcohol use disorder, and generalized anxiety disorder show higher levels of suicidal ideation
Community violence
Undesired changes in body weightWomen: increased BMI increases chance of suicidal ideation
Men: severe decrease in BMI increases chance of suicidal ideation
In general, the obese population has increased odds of suicidal ideation in relation to individuals that are of average-weight
Exposure and attention to suicide related images or words

Family history
Parents with a history of depression
Valenstein et al. studied 340 adult offspring whose parents had depression in the past. They found that 7% of the offspring had suicidal ideation in the previous month alone
AbuseChildhood: physical, emotional and sexual abuse
Adolescence: physical, emotional and sexual abuse
Family violence
Childhood residential instability
Certain studies associate those who experience suicidal ideation with family disruption.

Relationships with parents and friends
According to a study conducted by Ruth X. Liu of San Diego State University, a significant connection was found between the parent–child relationships of adolescents in early, middle and late adolescence and their likelihood of suicidal ideation. The study consisted of measuring relationships between mothers and daughters, fathers and sons, mothers and sons, and fathers and daughters. The relationships between fathers and sons during early and middle adolescence show an inverse relationship to suicidal ideation. Closeness with the father in late adolescence is "significantly related to suicidal ideation". Liu goes on to explain the relationship found between closeness with the opposite sex parent and the childs risk of suicidal thoughts. It was found that boys are better protected from suicidal ideation if they are close to their mothers through early and late adolescence; whereas girls are better protected by having a close relationship with their father during middle adolescence.
An article published in 2010 by Zappulla and Pace found that suicidal ideation in adolescent boys is exacerbated by detachment from the parents when depression is already present in the child. Lifetime prevalence estimates of suicidal ideation among nonclinical populations of adolescents generally range from 60% to 75% and in many cases its severity increases the risk of suicide.

Prevention
Early detection and treatment are the best ways to prevent suicidal ideation and suicide attempts. If signs, symptoms, or risk factors are detected early then the individual might seek treatment and help before attempting to take their own life. In a study of individuals who did commit suicide, 91% of them likely had one or more mental illnesses. However, only 35% of those individuals were treated or being treated for a mental illness. This emphasizes the importance of early detection; if a mental illness is detected, it can be treated and controlled to help prevent suicide attempts. Another study investigated strictly suicidal ideation in adolescents. This study found that depression symptoms in adolescents early as 9th grade is a predictor of suicidal ideation. Most people with long-term suicidal ideation do not seek professional help.The previously mentioned studies point out the difficulty that mental health professionals have in motivating individuals to seek and continue treatment. Ways to increase the number of individuals who seek treatment may include:

Increasing the availability of therapy treatment in early stage
Increasing the publics knowledge on when psychiatric help may be beneficial to them
Those who have adverse life conditions seem to have just as much risk of suicide as those with mental illnessA study conducted by researchers in Australia set out to determine a course of early detection for suicidal ideation in teens stating that "risks associated with suicidality require an immediate focus on diminishing self-harming cognitions so as to ensure safety before attending to the underlying etiology of the behavior". A Psychological Distress scale known as the K10 was administered monthly to a random sample of individuals. According to the results among the 9.9% of individuals who reported "psychological distress (all categories)" 5.1% of the same participants reported suicidal ideation. Participants who scored "very high" on the Psychological Distress scale "were 77 times more likely to report suicidal ideation than those in the low category".In a one-year study conducted in Finland, 41% of the patients who later committed suicide saw a health care professional, most seeing a psychiatrist. Of those, only 22% discussed suicidal intent on their last office visit. In most of the cases, the office visit took place within a week of the suicide, and most of the victims had a diagnosed depressive disorder.There are many centers where one can receive aid in the fight against suicidal ideation and suicide. Hemelrijk et al. (2012) found evidence that assisting people with suicidal ideation via the internet versus more direct forms such as phone conversations has a greater effect. In a 2021 research study, Nguyen et al. (2021) propose that maybe the premise that suicidal ideation is a kind of illness has been an obstacle to dealing with suicidal ideation. They use a Bayesian statistical investigation, in conjunction with the mindsponge theory, to explore the processes where mental disorders have played a very minor role and conclude that there are many cases where the suicidal ideation represents a type of cost-benefit analysis for a life/death consideration, and these people may not be called "patients".

Assessment
Assessment seeks to understand an individual by integrating information from multiple sources such as clinical interviews; medical exams and physiological measures; standardized psychometric tests and questionnaires; structured diagnostic interviews; review of records; and collateral interviews.

Interviews
Psychologists, psychiatrists, and other mental health professionals conduct clinical interviews to ascertain the nature of a patient or clients difficulties, including any signs or symptoms of illness the person might exhibit. Clinical interviews are "unstructured" in the sense that each clinician develops a particular approach to asking questions, without necessarily following a predefined format. Structured (or semi-structured) interviews prescribe the questions, their order of presentation, "probes" (queries) if a patients response is not clear or specific enough, and a method to rate the frequency and intensity of symptoms.

Standardized psychometric measures
Beck Scale for Suicide Ideation
Nurses Global Assessment of Suicide Risk
Suicidal Affect–Behavior–Cognition Scale (SABCS)
Columbia Suicide Severity Rating Scale

Treatment
Treatment of suicidal ideation can be problematic due to the fact that several medications have actually been linked to increasing or causing suicidal ideation in patients. Therefore, several alternative means of treating suicidal ideation are often used. The main treatments include: therapy, hospitalization, outpatient treatment, and medication or other modalities.

Therapy
In psychotherapy a person explores the issues that make them feel suicidal and learns skills to help manage emotions more effectively.

Hospitalization
Hospitalization allows the patient to be in a secure, supervised environment to prevent the suicidal ideation from turning into suicide attempts. In most cases, individuals have the freedom to choose which treatment they see fit for themselves. However, there are several circumstances in which individuals can be hospitalized involuntarily. These circumstances are:

If an individual poses danger to self or others
If an individual is unable to care for oneselfHospitalization may also be a treatment option if an individual:

Has access to lethal means (e.g., a firearm or a stockpile of pills)
Does not have social support or people to supervise them
Has a suicide plan
Has symptoms of a psychiatric disorder (e.g., psychosis, mania, etc.)

Outpatient treatment
Outpatient treatment allows individuals to remain at their place of residence and receive treatment when needed or on a scheduled basis. Being at home may improve quality of life for some patients, because they will have access to their personal belongings, and be able to come and go freely. Before allowing patients the freedom that comes with outpatient treatment, physicians evaluate several factors of the patient. These factors include the patients level of social support, impulse control and quality of judgment. After the patient passes the evaluation, they are often asked to consent to a "no-harm contract". This is a contract formulated by the physician and the family of the patient. Within the contract, the patient agrees not to harm themself, to continue their visits with the physician, and to contact the physician in times of need. There is some debate as to whether "no-harm" contracts are effective. These patients are then checked on routinely to assure they are maintaining their contract and avoiding dangerous activities (drinking alcohol, driving fast and not wearing a seat belt, etc.).

Medication
Prescribing medication to treat suicidal ideation can be difficult. One reason for this is that many medications lift patients energy levels before lifting their mood. This puts them at greater risk of following through with attempting suicide. Additionally, if a person has a comorbid psychiatric disorder, it may be difficult to find a medication that addresses both the psychiatric disorder and suicidal ideation.
Antidepressants may be effective. Often, SSRIs are used instead of TCAs as the latter typically have greater harm in overdose.Antidepressants have been shown to be a very effective means of treating suicidal ideation. One correlational study compared mortality rates due to suicide to the use of SSRI antidepressants in certain counties. The counties which had higher SSRI use had a significantly lower number of deaths caused by suicide. Additionally, an experimental study followed depressed patients for one year. During the first six months of that year, the patients were examined for suicidal behavior including suicidal ideation. The patients were then prescribed antidepressants for the six months following the first six observatory months. During the six months of treatment, experimenters found suicide ideation reduced from 47% of patients down to 14% of patients. Thus, it appears from current research that antidepressants have a helpful effect on the reduction of suicidal ideation.
Although research is largely in favor of the use of antidepressants for the treatment of suicidal ideation, in some cases antidepressants are claimed to be the cause of suicidal ideation. Upon the start of using antidepressants, many clinicians will note that sometimes the sudden onset of suicidal ideation may accompany treatment. This has caused the Food and Drug Administration (FDA) to issue a warning stating that sometimes the use of antidepressants may actually increase suicidal ideation. Medical studies have found antidepressants help treat cases of suicidal ideation and work especially well with psychological therapy. Lithium reduces the risk of suicide in people with mood disorders. Tentative evidence finds clozapine in people with schizophrenia reduces the risk of suicide.

See also
Existential angst
Existential crisis
Existential nihilism
Finno-Ugrian suicide hypothesis
Mental health first aid
Suicide attempt
Suicide crisis

References
Further reading
Beck, AT; Steer, RA; Kovacs, M; Garrison, B (1985). "Hopelessness and eventual suicide: a 10-year prospective study of patients hospitalized with suicidal ideation". Am J Psychiatry. 142 (5): 559–563. CiteSeerX 10.1.1.462.6328. doi:10.1176/ajp.142.5.559. PMID 3985195.
Uncapher, H (2000–2001) </s>


<s> [INST] <<SYS>> You are a responsible assistant committed to providing accurate and helpful responses. Avoid sharing harmful or biased content. Clarify any unclear or incorrect questions rather than providing false or misleading information. <</SYS>> What is Process and can you explain it in depth? [/INST]  </s>


<s> [INST] <<SYS>> You are a responsible assistant committed to providing accurate and helpful responses. Avoid sharing harmful or biased content. Clarify any unclear or incorrect questions rather than providing false or misleading information. <</SYS>> What is Osteochondrosis and can you explain it in depth? [/INST] Osteochondrosis is a family of orthopedic diseases of the joint that occur in children, adolescents and rapidly growing animals, particularly pigs, horses, dogs, and broiler chickens. They are characterized by interruption of the blood supply of a bone, in particular to the epiphysis, followed by localized bony necrosis, and later, regrowth of the bone. This disorder is defined as a focal disturbance of endochondral ossification and is regarded as having a multifactorial cause, so no one thing accounts for all aspects of this disease.Osteochondrosis is a developmental disease. It usually occurs in an early stage of life. It has personified features as focal chondronecrosis and confinement of growth cartilage due to a failing of endochondral ossification. Fissures can develop from lesions over the top articular cartilage and form a cartilage flap and an osteochondral fragment. It is diagnosed as osteochondritis dissecans.

In animals
In dogs osteochondrosis is seen in elbow, shoulder, knee, and ankle joints. Elbow osteochondrosis is also known as "elbow dysplasia". There are three types of elbow dysplasia:  fragmented medial coronoid process, ununited anconeal process and Osteochondritis dissecans of the medial humeral condyle.
Breeds that have the predisposition to these are Basset Hound, Labrador, Golden Retriever, and Rottweiler. Other breeds can also be diagnosed with this condition but it is not common.One of the leading factors to some elbow osteochondrosis is that the radius and ulna are growing at different rates. In this situation, the stress to the joint surface is not even and can cause some form of osteochondrosis in the elbow when the puppy grows or make already existing elbow dysplasia even worse. Some of the breeds that are susceptible to that are for example Dachshunds, Corgis, Pugs, Bulldogs, and Beagles.

Signs and symptoms
These conditions nearly all present with an insidious onset of pain referred to the location of the bony damage. Some, notably Kienbocks disease of the wrist, may involve considerable swelling, and Legg-Calvé-Perthes disease of the hip causes the victim to limp. The spinal form, Scheuermanns disease, may cause bending, or kyphosis of the upper spine, giving a "hunch-back" appearance.

Symptoms in animals
The most common symptoms are lameness and pain in the affected joints. Animals may try to ease the pain and walk differently and the pain can be noticed by the change in animals walking style. The condition affects both sides (right and left leg). On most occasions, the other leg is worse. This can result that the dog starts encumbering the other leg and the healthier leg becomes more strained. Sometimes the symptoms are so mild or there are no symptoms which can make it hard to detect that there is something wrong with that dog.

Cause
The ultimate cause for these conditions is unknown, but the most commonly cited cause factors are rapid growth, heredity, trauma (or overuse), anatomic conformation,  and dietary imbalances; however, only anatomic conformation and heredity are well supported by scientific literature. The way that the disease is initiated has been debated. Although failure of chondrocyte differentiation, formation of a fragile cartilage, failure of blood supply to the growth cartilage, and subchondral bone necrosis all have been proposed as the starting point in the pathogenesis, recent literature strongly supports failure of blood supply to growth cartilage as most likely. Osteochondrosis can be usually inherited.

Factors
There are four factors: genetics, environment, diet, and exercise.
Environment is found to be a key factor in osteochondrosis occurring. The environment is related to diet and exercise. If the dog has good facilities to live a healthy life, meaning having a good diet and enough and the right kind of exercise, osteochondrosis may never occur even if there would be genetic susceptibility. Sometimes even if the environmental conditions are optimal there is still a chance that osteochondrosis will occur in the animal.Dogs are very susceptible to calcium when they are growing up </s>


<s> [INST] <<SYS>> You are a responsible assistant committed to providing accurate and helpful responses. Avoid sharing harmful or biased content. Clarify any unclear or incorrect questions rather than providing false or misleading information. <</SYS>> What is Vaginismus and can you explain it in depth? [/INST] Vaginismus is a condition in which involuntary muscle spasm interferes with vaginal intercourse or other penetration of the vagina. This often results in pain with attempts at sex. Often, it begins when vaginal intercourse is first attempted.The formal diagnostic criteria specifically requires interference during vaginal intercourse and a desire for intercourse. However, the term vaginismus is sometimes used more broadly to refer to any muscle spasms occurring during the insertion of some or all types of objects into the vagina, sexually motivated or otherwise, including the usage of speculums and tampons.The underlying cause is generally a fear that penetration will hurt. Risk factors include a history of sexual assault, endometriosis, vaginitis, or a prior episiotomy. Diagnosis is based on the symptoms and examination. It requires there to be no anatomical or physical problems and a desire for penetration on the part of the woman.Treatment may include behavior therapy such as graduated exposure therapy and gradual vaginal dilatation. Surgery is not generally indicated. Botulinum toxin (botox), a muscle spasm treatment, is being studied. Estimates of how common the condition is vary. One textbook estimates that 0.5% of women are affected. Outcomes are generally good with treatment.

Signs and symptoms
Severity and pain during vaginal penetration varies.

Causes
Primary vaginismus
Vaginismus occurs when penetrative sex or other vaginal penetration cannot be experienced without pain. It is commonly discovered among teenage girls and women in their early twenties, as this is when many girls and young women first attempt to use tampons, have penetrative sex, or undergo a Pap smear. Awareness of vaginismus may not happen until vaginal penetration is attempted. Reasons for the condition may be unknown.A few of the main factors that may contribute to primary vaginismus include:

chronic pain conditions and harm-avoidance behaviour
negative emotional reaction towards sexual stimulation, e.g. disgust both at a deliberate level and also at a more implicit level
strict conservative moral education, which also can elicit negative emotionsPrimary vaginismus is often unknown cause.Vaginismus has been classified by Lamont according to the severity of the condition. Lamont describes four degrees of vaginismus: In first degree vaginismus, the person has spasm of the pelvic floor that can be relieved with reassurance. In second degree, the spasm is present but maintained throughout the pelvis even with reassurance. In third degree, the person elevates the buttocks to avoid being examined. In fourth degree vaginismus (also known as grade 4 vaginismus), the most severe form of vaginismus, the person elevates the buttocks, retreats and tightly closes the thighs to avoid examination. Pacik expanded the Lamont classification to include a fifth degree in which the person experiences a visceral reaction such as sweating, hyperventilation, palpitations, trembling, shaking, nausea, vomiting, losing consciousness, wanting to jump off the table, or attacking the doctor.Although the pubococcygeus muscle is commonly thought to be the primary muscle involved in vaginismus, Pacik identified two additionally-involved spastic muscles in people who were treated under sedation. These include the entry muscle (bulbocavernosum) and the mid-vaginal muscle (puborectalis). Spasm of the entry muscle accounts for the common complaint that people often report when trying to have intercourse: "Its like hitting a brick wall".

Secondary vaginismus
Secondary vaginismus occurs when a person who has previously been able to achieve penetration develops vaginismus. This may be due to physical causes such as a yeast infection or trauma during childbirth, while in some cases it may be due to psychological causes, or to a combination of causes. The treatment for secondary vaginismus is the same as for primary vaginismus, although, in these cases, previous experience with successful penetration can assist in a more rapid resolution of the condition. Peri-menopausal and menopausal vaginismus, often due to a drying of the vulvar and vaginal tissues as a result of reduced estrogen, may occur as a result of "micro-tears" first causing sexual pain then leading to vaginismus.

Mechanism
Specific muscle involvement is unclear, but the condition may involve the pubococcygeus muscle, levator ani, bulbocavernosus, circumvaginal, or perivaginal muscles.

Diagnosis
The diagnosis of vaginismus, as well as other diagnoses of female sexual dysfunction, can be made when "symptoms are sufficient to result in personal distress." The DSM-IV-TR defines vaginismus as "recurrent or persistent involuntary spasm of the musculature of the outer third of the vagina that interferes with sexual intercourse, causing marked distress or interpersonal difficulty".

Treatment
A Cochrane review found little high quality evidence regarding the treatment of vaginismus in 2012. Specifically it is unclear if systematic desensitisation is better than other measures including nothing.

Psychological
According to a 2011 study, those with vaginismus are twice as likely to have a history of childhood sexual interference and held less positive attitudes about their sexuality, whereas no correlation was noted for lack of sexual knowledge or (nonsexual) physical abuse.

Physical
Often, when faced with a person experiencing painful intercourse, a gynecologist will recommend reverse Kegel exercises and provide some additional lubricants. Although vaginismus has not been shown to affect a persons ability to produce lubrication, providing additional lubricant can be helpful in achieving successful penetration. This is due to the fact that women may not produce natural lubrication if anxious or in pain. Achieving sufficient arousal during foreplay is crucial for the release of lubrication which can contribute to the ease of sexual penetration and pain-free intercourse.
Though strengthening exercises such as Kegel exercises were previously considered to be a helpful intervention for pelvic pain, new research suggests that these exercises, which function to strengthen the pelvic floor, may not be helpful or may make conditions that are caused by over-active muscles such as vaginismus worse. Exercises that stretch or relax the pelvic floor may be a better treatment option for vaginismus.To help develop a treatment plan that best fits the needs of their patient, a gynecologist or general practitioner may refer a person experiencing painful intercourse to a Pelvic floor physical therapist or occupational therapist. These therapists specialize in the treatment of disorders of the pelvic floor muscles such as vaginismus, dyspareunia, vulvodynia, constipation, and fecal or urinary incontinence. After performing a manual exam both internally and externally to assess muscle function and to isolate possible trigger points for pain or tightness on the muscles, pelvic floor physical or occupational therapists develop a treatment plan consisting of muscle exercises, muscle stretches, dilator training, electrostimulation, and/or biofeedback interventions. Treatment of vaginismus often involves the use of Hegar dilators (sometimes called vaginal trainers), progressively increasing the size of the dilator inserted into the vagina. The technique is used to practice conscious diaphragmatic breathing (breathing in deeply allowing ones belly to expand) and allowing the pelvic floor muscles to lengthen during inhale; then exhale, bringing belly in and repeat. Research suggests pelvic floor physical or occupational therapy is one of the safest and most effective treatments for vaginismus.

Neuromodulators
Botulinum toxin A (Botox) has been considered as a treatment option, under the idea of temporarily reducing the hypertonicity of the pelvic floor muscles </s>


<s> [INST] <<SYS>> You are a responsible assistant committed to providing accurate and helpful responses. Avoid sharing harmful or biased content. Clarify any unclear or incorrect questions rather than providing false or misleading information. <</SYS>> What is Peripartum cardiomyopathy and can you explain it in depth? [/INST] Peripartum cardiomyopathy (PPCM) is a form of dilated cardiomyopathy that is defined as a deterioration in cardiac function presenting typically between the last month of pregnancy and up to six months postpartum.  As with other forms of dilated cardiomyopathy, PPCM involves systolic dysfunction of the heart with a decrease of the left ventricular ejection fraction (EF) with associated congestive heart failure and an increased risk of atrial and ventricular arrhythmias, thromboembolism (blockage of a blood vessel by a blood clot), and even sudden cardiac death.  In essence, the heart muscle cannot contract forcefully enough to pump adequate amounts of blood for the needs of the bodys vital organs.PPCM is a diagnosis of exclusion, wherein patients have no prior history of heart disease and there are no other known possible causes of heart failure. Echocardiogram is used to both diagnose and monitor the effectiveness of treatment for PPCM.The cause of PPCM is unknown.  Currently, researchers are investigating cardiotropic viruses, autoimmunity or immune system dysfunction, other toxins that serve as triggers to immune system dysfunction, micronutrient or trace mineral deficiencies, and genetics as possible components that contribute to or cause the development of PPCM.The process of PPCM begins with an unknown trigger (possibly a cardiotropic virus or other yet unidentified catalyst) that initiates an inflammatory process in the heart. Consequently, heart muscle cells are damaged; some die or become scar tissue. Scar tissue has no ability to contract; therefore, the effectiveness of the pumping action of the heart is decreased. Also, damage to the cytoskeletal framework of the heart causes the heart to enlarge, stretch or alter in shape, also decreasing the hearts systolic function or output. The initial inflammatory process appears to cause an autoimmune or immune dysfunctional process, which in turn fuels the initial inflammatory process. Progressive loss of heart muscle cells leads to eventual heart failure.

Signs and symptoms
Symptoms usually include one or more of the following: orthopnea (difficulty breathing while lying flat), dyspnea (shortness of breath) on exertion, pitting edema (swelling), cough, frequent night-time urination, excessive weight gain during the last month of pregnancy (1-2+ kg/week; two to four or more pounds per week),  palpitations (sensation of racing heart-rate, skipping beats, long pauses between beats, or fluttering), and chest pain.The shortness of breath is often described by PPCM patients as the inability to take a deep or full breath or to get enough air into the lungs.  Also, patients often describe the need to prop themselves up overnight by using two or more pillows in order to breathe better.  These symptoms, swelling, and/or cough may be indications of pulmonary edema (fluid in the lungs) resulting from acute heart failure and PPCM.Diagnosis may be delayed or dismissed as early symptoms may be interpreted as being typical of normal pregnancy. Delays in diagnosis and treatment of PPCM are associated with increased morbidity and mortality.It is also quite common for women to present with evidence of having an embolus (clot) passing from the heart to a vital organ, causing such complications as stroke, loss of circulation to a limb, even coronary artery occlusion (blockage) with typical myocardial infarction (heart attack).For these reasons, it is paramount that clinicians hold a high suspicion of PPCM in any peri- or postpartum patient where unusual or unexplained symptoms or presentations occur.

Diagnosis
The following screening tool may be useful to patients and medical professionals in determining the need to take further action to diagnose symptoms:

Ultrasound
Treatment
Early detection and treatment are associated with higher rates of recovery and decreased morbidity and mortality.Treatment for PPCM is similar to treatment for congestive heart failure. Conventional heart failure treatment includes the use of diuretics, beta blockers (B-B), and angiotensin-converting enzyme inhibitors (ACE-I) after delivery.  Diuretics, preferably furosemide, help the body to get rid of excess water weight and also lower blood pressure.  ACE-I and B-B improve blood circulation and contribute to the reversal of the immune system dysfunction associated with PPCM.  If ACE-I is not well tolerated by the patient, it can be replaced by angiotensin receptor blockers (ARB).    Hydralazine with nitrates may replace ACE-I in breastfeeding mothers or before delivery; however, evidence suggests that this course of treatment may not be as effective as ACE-I but beneficial when necessary.If EF is less than 35%, anticoagulation is indicated, as there is a greater risk of developing left ventricular thrombi (blood clots).  Sometimes implantation of a left ventricular assist device (LVAD) or even heart transplant also becomes necessary.It is important that the patient receives regular follow-up care including frequent echocardiograms to monitor improvement or the lack thereof, particularly after changes of medical treatment regimes.
Patients who do not respond to initial treatment, defined as left ventricular EF remaining below 20% at two months or below 40% at three months with conventional treatment may merit further investigation, including cardiac magnetic resonance imaging (MRI), cardiac catheterization, and endomyocardial biopsy for special staining and for viral polymerase chain reaction (PCR) analysis. Antiviral therapy, immunoabsorption, intravenous gamma globulin, or other immunomodulation therapy may then be considered accordingly, but following a controlled research-type protocol.Since no one knows for sure exactly when to discontinue treatment, even when recovery occurs quickly, it is still recommended that both ACE-I and B-B be continued for at least one year after diagnosis.PPCM patients have an increased risk for sudden death and it is seen that they benefit from implantable cardioverter defibrillator (ICD) and cardiac resynchronization therapy to prevent sudden cardiac death. However, in view of reversible cardiomyopathy, sometimes Implantable cardioverter-defibrillator (ICD) or Cardiac resynchronization therapy (CRT) are not routinely used and reserved for severe LV dysfunction or high risk cases.

Prognosis
The most recent studies indicate that with newer conventional heart failure treatment consisting of diuretics, ACE inhibitors and beta blockers, the survival rate is very high at 98% or better, and almost all PPCM patients improve with treatment.  In the United States, over 50% of PPCM patients experience complete recovery of heart function (EF 55% or greater) </s>