An epidemiological overview of child sexual abuse.

Child sexual abuse (CSA) is a universal problem with grave life-long outcomes. The estimates vary widely depending on the country under study, the definitions used, the type of CSA studied, the extent of coverage, and quality of data. This study intended to assess the magnitude and the issues related to CSA. We searched databases such as PubMed, Google scholar, web (newspaper reports), and government websites. The relevant data was extracted from these sources for gathering evidence on CSA and secondary data analysis was done. The prevalence of CSA was found to be high in India as well as throughout the world. CSA is an extensive problem and even the lowest prevalence includes a huge number of victims. It also has various adverse effects on the psychological, physical, behavioral, and interpersonal well-being of the victim. Hence, stringent measures should be taken for the prevention and control of this hidden public health issue.

Introduction

Child sexual abuse (CSA) is a universal problem with grave life-long outcomes.[1] The World Health Organisation (WHO) defines CSA as “the involvement of a child in sexual activity that he or she does not fully comprehend and is unable to give informed consent to, or for which the child is not developmentally prepared, or else that violate the laws or social taboos of society.”[2] The term CSA includes a range of activities like “intercourse, attempted intercourse, oral-genital contact, fondling of genitals directly or through clothing, exhibitionism or exposing children to adult sexual activity or pornography, and the use of the child for prostitution or pornography.”[3]

The issue of CSA is intricate and challenging to study. The estimates vary widely depending on the country under study, the definitions used, the type of CSA studied, the extent of coverage, and the quality of data.[1456] However, sexual violence is seen to occur in all ages, in all socioeconomic classes, and nearly in all countries with differences in the magnitude.[4] Hence, this study intended to provide a brief overviewof CSA to enhance the awareness of primary care physicians, policy makers, counsellors, police personnel, teachers, and the community.

We searched databases such as PubMed, Google scholar, web (newspaper reports), and government websites. The relevant data was extracted from these sources for gathering evidence on CSA and secondary data analysis was done.

Global Scenario of the Problem

The WHO in 2002 estimated that 73 million boys and 150 million girls under the age of 18 years had experienced various forms of sexual violence.[1] The Center's for Disease Control and the US Department of Justice conducted a study in the US and reported prevalence of being forced to have sex at some point of time in their lives as 11% and 4% of the high-school girls and boys, respectively.[7] A meta-analysis conducted in the year 2009 analyzed 65 studies in 22 countries and estimated an “overall international figure.” The main findings of the study were:[7]

An estimated 7.9% of males and 19.7% of females universally faced sexual abuse before the age of 18 years[7]

The highest prevalence rate of CSA was seen in Africa (34.4%)[78]

Europe, America, and Asia had prevalence rate of 9.2%, 10.1%, and 23.9%, respectively[7]

With regards to females, seven countries reported prevalence rates as being more than one fifth i.e., 37.8% in Australia, 32.2% in Costa Rica, 31% in Tanzania, 30.7% in Israel, 28.1% in Sweden, 25.3% in the US, and 24.2% in Switzerland[7]

The lowest rate observed for males may be imprecise to some extent because of under reporting.[7]

The 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.[7]

A review of studies from 21 high- and middle-income nations showed that seven to 36% of females and three to 29% of males reported being victims of sexual abuse during their childhood.[9] Evidence from the National Child Abuse and Neglect Data System found that in 2006, 8.8% children were abused sexually in the US.[10] In a report by Advocates for Youth, it was estimated that per year 1-3% of youth from the US experience CSA.[11]

Review conducted by Collin-Vezina et al. reported that CSA is a major issue which affects more than one out of five females and one in 10 males globally.[12] In a study conducted in Brazil in 2009, the prevalence of CSA was 5.6% among girls and 1.6% among boys. It was also reported that boys had been sexually abused at younger ages in comparison to girls. More than half (60%) of the sexual abuse cases reported that the incident took place before the age of 12. CSA was found to be associated with physical abuse at both younger and older ages. The study also reported that CSA alone is accountable for about one per cent of the global burden of disease, but it is likely to be a risk factor for several other conditions like alcohol consumption, illegal drug usage, development of mental disorders, and spread of sexually transmitted diseases, which when pooled, are accountable for over 20% of the global burden.[5]

In a study conducted in Ethiopia among boys studying in high schools, the lifetime burden of sexual abuse was 68.2% and that of rape was 4.3%.[13] A study conducted in Hong Kong among college students on recall of sexual abuse before 17 years of age reported the prevalence of various forms of CSA to be 6%; these rates were higher in females. Majority of the participants reported being abused during their teens; the average age being 11 years.[14]

Another study conducted in Mexico, reported prevalence of CSA to be 18.7% (58% in girls and 42% in boys). Physical abuse was involved in 75% of the cases.[15] In a study done in Croatia, 10.8% of the children reported as having faced some form of CSA during childhood.[16] Review conducted by Martin et al. reported that nearly 4% and 2% of girls and boys, respectively, experience CSA every year. In the age-group of 2–17 years, nearly 15% of girls and 6% of boys face severe consequences of CSA.[6]

A study by Song et al. in China, found that about 33% of the participants reported sexual abuse. The lifetime burden of which was 41% for girls and 29.5% for boys.[17] Another study among urban Chinese population reported the prevalence of CSA before the age of 14 years to be 4.2% (males: 5%, females: 3.3%).[18] In a study done in Boston, the burden of CSA was 26.7% and 16.7% in girls and boys, respectively.[19] Review conducted by Townsend et al. reported burden of CSA to be 7.5–11.7% (girls: 10.7–17.4%, boys: 3.8–4.6%).[20] A study conducted by Verelst et al. reported more than one third of the participants experienced sexual violence.[21]

It is a challenging task to find out the actual number of sexually victimized children due to the fact that the prevalence reported varies across studies and data sources.[10]

Indian Scenario of the Problem

India is home to 19% of the world's children. As per the 2001 census, about 440 million individuals in India were below 18 years of age and constitute 42% of total population. A total of 33,098 cases of sexual abuse in children were reported in the nation during the year 2011 when compared to 26,694 reported in 2010 which increased by 24%. A total of 7,112 cases of child rape were reported during 2011 as equated to 5,484 in 2010 depicting a growth by 29.7%.[922] India has the world's largest number of CSA cases: For every 155th minute a child, less than 16 years is raped, for every 13th hour child under 10, and one in every 10 children sexually abused at any point of time.[23] Studies propose that over 7,200 children, including infants, are raped every year and it is believed that several cases go unreported. It is estimated by the government that 40% of India's children are susceptible to threats like being homeless, trafficking, drug abuse, forced labor, and crime.[24] In India, every second child is being exposed to one or the other form of sexual abuse and every fifth child faces critical forms of it.[22]

A survey by United Nations International Children Education Fund (UNICEF) on demographic and health was conducted in India from 2005 to 2013, which reported that ten per cent of Indian girls might have experienced sexual violence when they were 10–14 years of age and 30% during 15–19 years of age. Overall, nearly 42% of Indian girls have gone through the trauma of sexual violence before their teenage.[25]

The first study on CSA in India was conducted by Recovery and Healing from Incest, an Indian non-government organization (NGO) in 1998. Majority (76%) of the participants reported being abused during childhood or adolescence.[24]

Save the Children, the international organization, and, Tulir–Center for Healing and Prevention of Child Sex Abuse, an Indian NGO, conducted a study in 2005 among 2,211 school going children in Chennai. About 48% and 39% of the boys and girls, respectively, reported as being sexually abused, while more than one-tenth (15%) of the participants stated as having faced severe forms of sexual abuse.[9]

A study was conducted in 2007 by Ministry of women and child development in India covering 13 states.[9] The study reported that about 21% of the participants were exposed to extreme forms of sexual abuse. Among the participants who reported being abused, 57.3% were boys and 42.7% were girls, about 40% were 5–12 years of age. About half of the participants were exposed to other forms of sexual abuse. The data reported by the study on prevalence of various forms of sexual abuse are depicted in the [Table 1].[9]

Table 1

Prevalence of various forms of child sexual abuse in India[9]

According to Carson et al. the detection of new cases of CSA is high in India: One-fifth to half of the country's population might have faced some form of sexual abuse at least once in their life, but these may not include the children (1 in 5) who do not reveal their sexual abuse from within or outside their family.[26]

Ministry of home affairs, Karnataka reported age-wise distribution of CSA among females, and it was seen that there was rise in number of cases from 2010 to 2012 which is presented in [Table 2].[27]

Table 2

Age wise distribution of child sexual abuse among females

In the year 2010 in Karnataka, 107 cases of child rape, 125 cases of kidnapping and abduction, and 21 cases of procuring minor girls were reported which steeply increased to 142, 471, and 45, respectively in the year 2012.[27]

Bengaluru, Karnataka accounted for 26.76% of the total child rapes reported in the year 2012. About 27 cases were reported in 2010, which increased to 47 in the year 2011.[2728]

It was reported that more than 2,000 school-going children have been sexually abused in the Bengaluru.[29] According to Bangalore City Police, 38 cases of rape were reported in 2012, 34 in 2013, and 47 in 2011.[30]

As per the data obtained from Kerala, between April 2011 to March 2012, 157 cases of CSA were reported.[31]

The research on the issue of CSA has not received much importance in India because of lack of reporting/disclosure.[22] Although considerable attention has been brought about sexual abuse among females, there is dearth of information on CSA in India.[24]

Who are More Vulnerable to CSA?

The rates of sexual abuse tends to rise after commencement of menarche though children in the younger age-group also face several forms of it.[346912] The overall prevalence is seen to be high among both gendersthough studies suggest girls are more prone than boys[346910111219203132], few studies report that there is no difference[16], while some others report males to be more prone.[18] In most (95%) of the cases, the perpetrator is known to the child (relatives, neighbors, step parents, highly trusted people).[48911132224323334] Physical debilities like deafness, blindness, and mental retardation have found to be associated with increased risk of being sexually abused.[31112] In a study conducted by Romero et al. among bipolar disorder patients, 7% had history of CSA,[35] while in a study done by Schudlich et al. the prevalence was 20%.[36] Children belonging to the lower socio-economic status are at higher risk.[42127] The absence of one or both biological parents,[31334] marital conflicts, and/or parental substance abuse increases the vulnerability.[31112] Children under the influence of alcohol/drugs are more susceptible.[4] Customs such as child marriages,[4937] devadasi system,[38] and ngozi[4] makes some children more prone to be victims of CSA. Lesbian, gay, bisexual, transgender (LGBT) are more prone to CSA.[11]

Reported adverse effects of CSA

The adverse effects of CSA can be grouped into psychological, physical, behavioral, and interpersonal[10] which is depicted in [Table 3].

Table 3

Adverse effects of child sexual abuse

CSA: A hidden issue

The issue of CSA is still a taboo in India. In India, majority of the people remain numb about this issue. This silence is due to the fear of indignity, denial from the community,[412] social stigma,[132139] not being able to trust government bodies,[1024] and gap in communication between parents and children about this issue.[9] Majority of the healthcare professionals do not have the abilities and are not trained to examine and manage cases of CSA. A chief concern in India is the dearth of good monitoring of various juvenile residential institutes and there is no punishment for institutes that do not follow the laws. Institutions fear they will lose their dignity if incorrect information is disclosed. Hence cases are not reported and are settled within the institution. A number of factors confound the identification a CSA victim. Some of them do not reveal characteristic signs and symptoms. Many instances of CSA don’t include penetrant sex, victims usually clean themselves following attack, and hence the medical investigation does not provide any evidence of rape.[24] CSA victims and their families experience the panorama of legal proceedings that can continue for several years.[824] Adding to the problem, the execution of laws and initiatives in India is a challenge and there is lack of funding for programs for child safety.[2441]

Control and prevention of child sexual abuse

Control and prevention of CSA should be done using a multi centric and an integrated approach which is depicted in [Figure 1].

Figure 1

Control and prevention of child sexual abuse (CSA)

Conclusion

This paper was intended to understand the magnitude and issues related to child sexual abuse. The prevalence of CSA was found to be high in India as well as throughout the world. CSA is an extensive problem and even the lowest prevalence includes a huge number of victims. Three main issues have been identified that makes it difficult to estimate exactly how many children are victims of CSA. Firstly, the way abuse is defined plays an important role. Secondly, the cases reported by the official organizations usually underrate the number of victims as many cases never get reported to them. Thirdly, different studies report the prevalence for different time periods, for e.g., few give data on number of children abused in one year, others give numbers based on children ever abused in their lifetime, and few others involve adults who recall and report their childhood abuses. The prevalence of CSA is alarming; hence, stringent measures should be taken for its prevention and control.