Physical, Psychological and Sexual Abuse of the Minor in the Families from the Northwestern Region of Romania- Social and Medical Forensics.

BACKGROUND: In Romania, the abuse within the family of the minor child is a widespread phenomenon, its extent is insufficiently known because of ignorance/not reporting all the existing cases.
METHODS: The participants of the research are represented by two independent groups from the NW Romania 2007-2011, one for sociological study (1544 parents and 1283 children) and another for forensic statistical study (2761 cases of abused children). The sociological study was carried out by analyzing questionnaires applied in schools located in Bihor County, both to children and parents. The statistical analysis was carried out by studying the cases of the physically, sexually, and psychologically abused minors, recorded at Bihor County Forensic Service.
RESULTS: Physical neglect and physical abuse are the most common forms of child abuse. The forensic analysis highlight that most of the victims are male from urban areas. Physical abuse is more common in the 16-18 age group, psychological abuse in children aged between 6-10 yr, and sexual abuse in children under the age of 14 years. Girls were subject to sexual abuse, neglect, and emotional abuse, more frequently in rural areas; boys were most often victims of exploitation, physical, and emotional abuse in both urban and rural areas.
CONCLUSION: The results of the study led to the formulation of general guidelines on this phenomenon and highlight the need for proposals to improve the current situation of child abuse within the family.

Introduction

Intra-familial abuse of the minor child is a negative social phenomenon, frequent and with worrying growth rates in many civilized countries around the world, including Romania. Abuse against minors is still an important issue in developed countries both from the social-welfare and public-health points of view (1–4). The Child Protective Services (CPS) data recorded that in 2011 about 9.1/1000 minors were subjects of abuse in the United States (5). Community surveys show even a gather occurrence of abuses, 15% or above (6–8). There are extreme cases when neglect and abuse against minors can be fatal. About 1,590 minors died in 2012 after being submitted to neglect or abuse (9).

According to WHO abuse against minors is “all forms of physical and/or emotional maltreatment, sexual abuse, neglect or negligent treatment or commercial or other exploitation, resulting in actual or potential harm to the child’s health, survival, development or dignity in the context of a relationship of responsibility, trust or power” (10, 11). Another definition formulated by The Centers for Disease Control and Prevention (CDC) presents abuse against minors as being “any act or series of acts of commission or omission by a parent or other caregiver that results in harm, potential for harm, or threat of harm to a child” (7, 12).

There is no clear statistical data on parental abuse on children in Romania so that the magnitude of this phenomenon can be measured. Due to the lack of information about these cases, the phenomenon is considered by the specialists to be incorrectly evaluated and insufficiently publicized. At the same time, in Romania, normative acts and laws on child protection are still incomplete.

The risk factors (Table 1) of abuse against a minor are multiple; they have cumulative effects and can multiply, being grouped into common and specific factors (13–23).

Table 1:

Risk factors for child abuse (13–23)

Social and environnemental factors	Factors related to the aggressor	Particularities related to the abused child
Low socio-economic level	Chronic alcoholism	Prematurity
Unemployment	Violence within the family	Unwanted child (from concubinage /adultery)
Promiscuity	Psychic diseases
Conflicts within the family	Drug consumption	Child with physical or mental disability
Low educational level	Educational deficiencies	Unwanted child gender
Legislative gaps	A history of abuse / domestic violence	The existence of adverse childhood experiences (ACEs)
Separated parents (divorce, death, etc.)
Overburdened parents
Alcohol and drug consumption
Antecedents of the child		Family environment
Multiple and long postnatal hospitalizations		Large family
Institutionalized child		Young parents
Irregular parental presence		Single parent family
Disordered way of life		Maternal sociopathy and youth

Starting from the complexity of the phenomenon on the one hand and from the lack of the forensic literature on this phenomenon, on the other hand, the research we have designed is aimed at an insight into the complexity of the phenomenon from a sociological and medical-legal point of view.

Materials and Methods

The present study has two major components:

Sociological analysis of the phenomenon of abuse against a minor;

The retrospective statistical study of the cases of minors physically and sexually abused, examined in the legal department of Bihor County Medical Service.

Both studies were conducted simultaneously, from 2007–2011. The sociological study was conducted in six schools in Bihor County. Questionnaires were prepared, completed during working sessions with parents and children. The study lot consists of 1544 parents and 1283 children aged between 6–18 yr, of which 720 female and 563 males. The analysis of the cases from forensic point of view was carried out in two main directions: the analysis of the cases of abuse and sexual exploitation of children, respectively the analysis of cases of physical and emotional violence against children. The study group consisted of 2761 cases of children with medical-legal expertise, of whom 623 cases of sexually abused children, 1490 cases of physically assaulted children (785 victims of domestic violence) and 648 cases of psychologically/emotionally abused children.

Results

Phenomenon of abuse against a minor. Sociological analysis

As a result of questionnaire analysis, we obtained the data presented in Table 2. The results of the study allowed us to assess the forms of abuse and their magnitude, as resulted from the answers given by parents and children.

Table 2:

Data obtained from the questionnaire analysis

Indices of abuse and neglect within the family	Parents’ statements (N=1544)		Children’s statements (N=1283)
	No. of cases	%	No. of cases	%
Physical abuse	285	18.4	312	24.4
Physical neglect	1053	67.8	591	45.8
Exploitation of the child in the family	104	6.8	107	8.4
Educational neglect	886	57.1	439	34.1
Psychological abuse	396	25.6	116	21.2
Psychological neglect	706	45.5	562	43.6
Sexual Abuse	1	0.1	116	9.1

Thus, physical, psychological and educational neglect have been declared both by parents and by children as major forms of abuse. The results of questionnaires on the parent group show slightly higher data compared to the group of questioned children (surveyed parents: physical neglect 67.8%, psychological 45.5% and educational 57.1%, questioned children: physical neglect 45.8%, psychological 43.6% and educational 34.1%). Physical and psychological abuses are declared as forms of abuse, also important, both by children and parents. Thus, over 24% of children and over 18% of parents consider physical abuse to be the most common form after neglect compared to over 25% of parents and over 21% of children who appreciate psychological abuse as a form of abuse following neglect. The highest incidence of physical and mental neglect, physical, psychological, and sexual abuse, as well as child exploitation by the family, is particularly prevalent in rural areas. One of the significant findings of the study, which resulted from questioning the children, is the physical punishment applied by parents: 84% of the children included in the study group stated that their parents physically punish them by hand beatings. One in five children declared he was beaten with various objects for a particular error (with belt – 24%; stick – 29.3%, wooden spoon – about 11%, etc.) or when the parent is angry (7.5%). Approximately 16% of children said they were afraid to go home because of the beating, and 10% felt physical abuse as severe, with severe beatings that left traces. 33.1% of the children felt they did not deserve the penalty, compared to 22.7% who felt they deserved the punishment.

Regarding the last form of abuse that the children were questioned about (meaning sexual abuse by one of the parents), 9.1% of the group surveyed said they had been subjected to this kind of abuse; 5.7% said they were subjected to indecent actions by one of the parents (under the influence of alcohol), 2.2% responded they were forced to accept being touched/caressed on certain parts of the body and 3% answered they were asked to undress in front of/in the presence of a person, to have sexual intercourse against their will, and to pose naked in exchange for money.

Analyzing cases from the forensic point of view

For this analysis, the following parameters were used: the type of abuse, the age, the gender and the background of the abused child. Analysis of cases of physical, psychological/emotional, and sexual abuse on children according to the parameter age of the victims is presented in Table 3.

Table 3:

Analysis of 2761 cases of physical and emotional violence against children according to the parameter age of the victims, during 2007–2011 period

Type of violence/abuse	No. of cases	Age group (yr)	%
Physical abuse	1490	10–14	18
		14–16	19
		16–18	30
Psychological/emotional	648	<6	15.9
		6–10	17.14
		10–14	16.4
		14–16	15.4
Sexual	623	10–14	31.4
		14–16	42.3
		16–18	25.3

Case of physical abuse

Data obtained from the study show that physical abuse (whose tendency decreases with age) is more common among older age groups (about 30% of children aged 16–18 yr, over 19% of children aged 14–16 yr and 18% of all children aged 10–14 yr old are subjected to this form of abuse). The study of violence in the three age groups showed that for all three age groups, rape or other violence and bodily injuries are the most common bad treatments applied. The high percentage (around 7%) of the killings and deadly hits within the age group under 14, is alarming. Comparatively, differentiated by each type of violence and per age group, the most victimized group is the age group of 16–18 yr of age, which is more intensely submitted than other age groups to body injuries (including those of a serious nature), attempted murder or other forms of violence. Next, in order, is the age group under 14 yr, which is subject mostly to murders and hits causing death (the latter affect equally the group under 14 yr, and the 16–18 yr group). The age group of 14–16 yr appears less affected than the other age groups by the different forms of violence mentioned, the highest percentage being in this group the rape or other violence and serious body injuries.

The beaten child syndrome or “The Battered Child Syndrome” (Silverman Syndrome) was found, according to the data obtained from the study, in 21% of the cases of physical aggression. The age of children with Silverman Syndrome was between 1–5 yr old. These children had been forensically examined before, and along with the examination multiple lesions on different parts of the body, of different lengths of time were revealed. The severity of the injuries found was not important in any of cases, being given under 20 d of medical care, fact that allowed the legal incidence of the aggressor’s deed to light-to-medium severity hits. These children, however, were taken out of the family environment and admitted to special centers for minors. In the course of forensic examination, no investigations for sexual abuse were conducted for any of these minors.

Case of psychological/emotional abuse

For these children, the forensic examination did not reveal any body injury, although the story reported by the child or adult person accompanying the child was each time about verbal and physical aggression from the part of an adult in the family.

Cases of sexual abuse and sexual exploitation

Our data show the following: 54.7% (341 children) were examined as being victims of rape, 21.8% (136 children) of sexual intercourse with a minor, 9% (56 children) of sexual perversion, 12% (75 children) of sexual corruption, 2.5% (15 children) of incest. However, in analyzing the results obtained from the study, we must to consider the fact that, regarding the acts of sexual abuse committed by parents against their children, the information are incomplete or insufficient, given the extremely intimate nature of these acts/deeds. There is no relevant data in this respect, and there is a complete lack of investigations concerning the victims. Although we consider this information to be incomplete, given the limits of the study, the results obtained show that rape and sexual intercourse of underage girls with an adult are predominant in all sexual offenses. The trend observed in our study was a year-on-year increase in sexual perversions and other sexual abuses, especially rape and sexual intercourses between a minor and an adult.

Highlighting the distribution of different forms of abuse in the studied period, based on the three age groups (under 14, 14–16, 16–18 yr), it shows that: in case of younger age groups (under 14 and 14 –16 yr), the hierarchy of these forms is relatively similar: 1st place - rapes; 2nd place - sexual intercourses between a minor and an adult, and 3rd place - sexual corruption. In contrast, for the group of those aged between 16 and 18 yr, although rape persists, seduction and sexual intercourse between a minor and an adult are ranked (almost equal) in second place. A clearer picture of the victimization of each of the three age groups is shown in Table 4.

Table 4:

The percentage distribution of cases of child sexual abuse and sexual exploitation according to the parameter age of the victims

Age (yr)	Rape	Intercourse with a minor	Sexual perversion	Sexual Corruption	Seduction	Incest
Under 14	32.4	39.5	56.3	67.1	12.5	48.6
14–16	23.0	54.3	10.4	18.8	35	24.3
16–18	44.6	6.2	33.3	14.1	52.5	27.1
Total cases	100	100	100	100	100	100

Thus, the highest risk of being subjected to rape and seduction is specific to the 16–18 age group, while for the 14–16 age group, the highest risk is to have sexual intercourse with an adult; for the youngest age group (under the age of 14) the highest risk is to face acts of sexual corruption and perversion.

The analysis of cases of physical, sexual and emotional violence against children according to the gender and the area of origin (rural, urban) of the victims is presented in Table 5. Our results confirm the findings of other studies in the literature that sexual abuse and neglect are the most common forms of abuse on girls; boys are subjected, in a greater extent, to all other forms of abuse, especially to physical abuse (22). The various forms of abuse characterize in relatively similar proportions children from both urban and rural environments, however, children from urban area are subject, in a higher proportion than those from rural areas. Physical abuse is manifested in equal proportions (approximately 54.0% of all forms of child abuse) in both urban and rural areas.

Table 5:

The analysis of 2761 cases of physical, sexual, and emotional violence against children according to the gender and the area of origin of the victims

Parameter	Total cases	Type of abuse	%
Sex of the victims	1651 male	Exploitation for committing crimes	75
		Labor exploitation	62
		Physical	52
		Emotional	51
	1110 female	Sexual	56
		Neglect and emotional	56
Area of origin	1721 urban	Exploitation for committing crimes	88
		Sexual	69
		Labor	75
		Emotional	60
	1040 rural	Sexual	56
		Neglect	56

Discussion

The forensic physician plays an important role in detecting and examining minors physically or sexually abused and the psychiatric traumas remaining after such aggressions (17). Thus, in the forensic expertise a role as important as the traumatological forensic expertise must be given to the psychiatric-legal expertise.

Any type of abuse in the early life of a minor determines psychopathology, sexual misconduct, low self-esteem and communication difficulties (24–26). Subjection too many types of abuse and repeated situations of abuse determine the growth of the risks of serious abuse and psychological consequences (27–29). Emotional abuse had the most powerful impact of abuses against minors on psychological disorders later in life, then in order of severity, emotional neglect, sexual and physical abuse (10). Because the most common cause of emotional deficiency is intra-family violence, we are witnessing a vicious circle in which violence inevitably generates violence (30). Thus, a child lacking affection, victim of domestic violence, will become the promoter of future intra-family violence and even of social violence (31). Emotional abuse during childhood especially emotionally abusive acts, determine diagnoses of many Axis I and Axis II mental illness for life (3). The existence of psychiatric disorders can make these future young adult perfect candidates for suicide acts (32, 33).

Even if the risk of physical maltreatment is greater with age, fatal injuries are predominant to young children mostly under 2 yr old (21, 34). “The Battered Child Syndrome” is a particular, serious abuse against a minor, of relatively high frequency (21% of the cases studied) characterized by a multi-layered aspect with posttraumatic lesions disseminated to several parts of the body at different lengths of time, which demonstrates repeated violence against the child over time. This syndrome does not include the minor’s sexual abuse. According to our study, the two aggressions (physical and sexual) can be associated, the forensic examination being considered complete only by conducting and consulting in the genito-anal area. In cases of sexual assault against the minor, even if the serological confirmation of the identification/presence of sperm in the vagina/rectum cannot be achieved, the sexual abuse in its various forms (fetishism, forcing the child to undress, and masturbation) remains possible. That is why we consider that in the forensic expertise these cases need to be thoroughly examined and thoroughly investigated.

At present, few of the cases of minors, victims of intra-family aggression, have at the time of forensic examination the confirmation of such aggression from the legal authorities. Specialists in child health, social services, schools, primary care, law-enforcement services, and mental health have to identify and act against abuses on minors. All these fields of activity register cases of abuse not reported to authorized agencies (2). The causes for not reporting the abuse cases are: the idea that reporting the case could be harmful for the minor rather than beneficial, the multitude of formalities needed for reporting and not recognizing the signs of child abuse (2).

In Romania, the forensic expertise of the minor “victim” of some acts of violence is very important in order that the offender’s deed to be fitted correctly into legal framework. It would be extremely helpful the participation of some sociologists at the forensic examination and applying sociological questionnaires, in order to obtain a real social image of the phenomenon of intra-familial aggression against minors. At the same time, there is a need for closer collaboration between the forensic and other medical fields, especially the pediatric fields, for the early detection of aggression cases against minors, many them being problematic (35, 36).

Improving parenting abilities and identifying risk groups are the prevention measures on which the specialists in the field are relying on in Romania so that adults better manage the situations that can trigger such behaviors. Evidence-based guidelines for who should be evaluated by child protection specialists, training and use of questionnaires to ask children or parents for information about abuse are also strategies for recognizing the phenomenon that should be improved (2, 37).

Essential elements for preventing child abuse are the improvement of problem-solving skills and the management of role sharing within the family with the help of training programs and spreading the information (38).

Conclusion

The multidisciplinary approach of the cases, the collaboration of the investigating institutions with those competent for the protection of the minor, the careful analysis of the social investigation as an important part of the case file are essential for the legal framing of the aggressor’s deed and for taking measures to protect the minor and prevent acts of violence against him.

Ethical considerations

Ethical issues (Including plagiarism, informed consent, misconduct, data fabrication and/or falsification, double publication and/or submission, redundancy, etc.) have been completely observed by the authors.