A cross-sectional observational study on child sexual abuse

INTRODUCTION

Child sexual abuse (CSA) has been a serious unexposed threat due to the fear of revealing. It has been observed that sexually transmitted infections (STI) are in increasing trend among adolescents due to early sexual maturity, increased promiscuity, and sexual offenses.¹ A wide variety of adult psychiatric conditions like major depression, borderline personality disorder, substance abuse disorders and bulimia nervosa are known to be associated with CSA.^2,3 The World Health Organisation (WHO) has reported that about 20 percent of girls and 5 to 10 percent of boys are victims of sexual abuse all over the world.⁴ Child sexual offenses can be categorized into touching and non-touching. Interestingly, evidence of physical violence is less in child abuse cases as it might reveal the offence and the identity of the perpetrator.⁵ Disclosures of the sexual abuse are mostly delayed in these cases and it should also be remembered that even a male child attending STD clinic should be suspected of sexual abuse. Protection of Children from sexual offences (POCSO) Act was implemented by the government of India in 2012 to address the crimes of sexual abuse and exploitation of children. It’s main objective is to ensure the healthy physical, emotional, intellectual and social development of the child. This act prescribes stringent punishment graded as per the gravity of the offence, with a maximum term of rigorous imprisonment for life and fine.⁶

Media in the form of newspaper and channels continue reporting about various children sexual abuse cases in India whereas an exact figure of the incidents could not be obtained from any legitimate source or scientific publication. Most of these incidents go unreported and fails to receive adequate attention by the society unless it is a rape. There is a need to understand that every unreported form of sexual abuse is paving steps gradually into becoming a rape in the future.

Aims

The primary objective of the study was to estimate the level of unreported child sexual abuse incidents among school children and to know the awareness level, the need for sex education and prevention measures.

METHODS

This was a single centre, cross-sectional observational study conducted at Department of STD, Government Stanley medical college, Chennai from July 2018 to December 2018. This study was carried out at a private school present in South Chennai after obtaining consent from the management and institutional ethical clearance. A total of 774 school children between the age group of 14-17 years were included in the study. Semi-structured written questionnaires were given to them to fill for duration of 20 minutes. The study populations were instructed not to reveal their identity in the form of name or address in any part of the questionnaire. The questionnaire included five sections like basic information about their age, sex and family details, general health state elaborating the details of any medical illness and menstrual history, sex education and awareness about sexual abuse elaborating details of personal sexual abuse incidents including penetrative and non-penetrative abuse and prevention aspect in the form of POCSO law awareness.

Statistical analysis

Descriptive statistical analysis was carried out in this study. The values were presented as range, mean, median, ratio and percentage in this cross-sectional study.

RESULTS

On analysis, it was observed that 5.5% (43) children had been abused in different forms. 37.3% (16) and 62.7% (27) were males and females among the affected individuals. Mean age of victims in males was 15.43 years and in females was 15.5 years. Among female victims, 11.1% (3) and 59.25% (16) were abused in penetrative and non-penetrative forms, respectively and 29.65% (8) did not mention the details (Figure 1a). Among male victims, 6.25% (1) and 43.75% (7) were abused in penetrative and non-penetrative forms respectively and 50% (8) did not mention the details (Figure 1b). 75% (12) of male victims and 96.2% (26) of female victims were abused by males and none reported about female abusers.

Figure 2 represents the relationship of perpetrators to children. Abusers were mainly family and friends (25.5%), strangers (23.2%), neighbours (18.6%), teachers (6.9%) and not mentioned (25.8%).

Sex education level was 29.7%, mainly contributed by school and teachers (37.3%), parents (24%) and others (38.7%). 25.3% of unaffected (731) and 27.9% of affected (43) individuals were aware of POCSO law. 88.3% of affected and 62.3% of unaffected children rated good and above for the questionnaire.

DISCUSSION

WHO has defined child sexual abuse as, “the involvement of a child sexual activity that he or she does not fully comprehend, is unable to give informed consent to or for which child is not developmentally prepared and cannot give consent, or that violates the laws or social taboos of society.⁷ Sexual abuse has been described as an insidious and persistent problem, knowing the prevalence varies within the population studied and definitions used.⁴ Our study correlates with Finkelhor et al retrospective study with a prevalence rate of 1-16% in men and 2-45% in women.⁸ The social class distribution in CSA varies upon the level of exposure with predominance in the lower and middle class than higher social class probably due to underreporting.⁹ We conducted our study in a private school where the level of exposure is relatively high compared to government institutions. This emphasises that our approach through awareness programmes about child sexual abuse must be streamlined according to the differences in socio-economic, education and exposure level. A study from literature has quoted that 61% of the child abuse cases studied were found to be normal on examination and other cases presented with atypical findings such as erythema, fissures, and vulvovaginitis.¹⁰

In our study, it was observed that 5.5% children had been abused in different forms like they were forced by someone to look at his/her private parts or fondled (caresses, rubs, kisses, touches whole body or private parts); shown pornographic pictures or movies and fingers or objects were inserted into their private parts.¹¹ Among victims, 37.5% (6) of males and 62.9% (17) of females had shared about the incident to someone. Although most of the studies suggest that girls experience sexual abuse more than boys, there is one study done on 311 cases of child sexual abuse which reported that there is an increasing trend in male child victims.^12,13 They also reported that perpetrators were male in 100% cases, acquaintances in 70% of the cases and family members in 22 cases. Though child sexual abuse is viewed as a social phenomenon, the exact aetiology is not known. Preconditions and inhibiting factors by Finkelhor and family systems theories have been postulated. Still, considerable research needed in evaluating pedophiles.^14-16 With the advent of technology exposure to the younger generation, the special category of “internet sex offenders” should also be considered.¹⁷

Literature from the past highlights that the prevalence of sexually transmitted infections among CSA ranges from 2 to 7% in girls and 0.5% to 1% in boys.^1,18 Infections like wart and molluscum contagiosum could spread by both sexual abuse and autoinoculation in children. Another study has stated that chlamydial infections, genital warts and gonorrhoea being more common among STI in child abuse cases.¹⁹ In order to avoid missing identification of any child abuse incident without any delay, sexual abuse must be ruled out in all children attending STD out-patient department.²⁰ Most of the sexual abuse cases get revealed only when symptoms develop or any mishap happens. This time gap could be reduced by conducting a similar questionnaire session at periodic intervals maybe twice in a year by schools. Parents and teachers play a major role in children learning about sexual development and relationships. There is a need to create awareness among caretakers about the risk of association of CSA with psychological disorders like emotional disturbances, sexually inappropriate behaviour, suicidal behaviour, anxiety and somatoform complaints.^21,22 Instead of conducting a general awareness programme about sexual abuse, schools can conduct a tailored sexual awareness programme highlighting the real-time data of their locality about the number, source, and form of abuse and alert parents accordingly. This could create a greater impact and prevent any untoward incidents happening at an earlier stage.²³ It was also noted that even the majority of the study population were under the impression that only girls are victims of sexual abuse there is a rise in male sexual victims. Although, schools play a vital role in creating awareness about sexual abuse, they lack proper channel to address these issues. Despite having known about POCSO law by 27.9% of the affected children in our study, they failed to reveal or share about the incident to anyone. This emphasises the need to create a proper channel for them to report their issues. The major portion of the study population rated well and above for the questionnaire which highlights the need to conduct similar sessions as it serves as a medium to express their emotional distress in addition to the identification of abuse trend.

CONCLUSION

Variation in risk factors, source and form of abuse could be due to the differences in socio-economic, education and exposure level. Unreported and silent victims have to be identified and addressed to prevent crimes and provide a safer environment for children. Implementation of POCSO law at the root level with sex education must be strengthened. Our study concluded that CSA is an extensive problem and even the lowest prevalence includes a huge number of victims who still need to be considered.

Limitation

Clinical examination and serological testing were not done to identify asymptomatic STI diseases.

ACKNOWLEDGEMENTS

The authors are grateful to the school management to conduct the study.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the institutional ethics committee

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