Abstract

BACKGROUND/AIMS

This study aimed to investigate the socio-demographic characteristics of children and adolescents who were victims of sexual abuse (SA) admitted to the child psychiatry clinic by the judicial authorities, to examine the characteristics of the abuse and the perpetrator, and to compare these characteristics in terms of age and gender.

MATERIALS AND METHODS

Our study included 388 cases of SA referred for a forensic report. Data were obtained retrospectively from the forensic files and outpatient clinic registration files of the cases.

RESULTS

Of 388 sexually abused cases, 357 (92%) were girls. The mean age of the cases was 13.41±2.99 years, and the mean age of the boys was lower than that of the girls. It was found that the rate of abuse was higher among adolescent girls. It was found that 99.2% of the perpetrators were male. One person was responsible for 93.5% of all instances of abuse. 50.4% of the victims experienced abuse more than once, and the victim’s statement was responsible for revealed 44.8% of the abuse cases. It was found that in 44.4% of cases, the perpetrator was the victim's boyfriend, 14.9% of cases were married at an early age, 20.6% had a pregnancy after abuse, and 65.4% of cases had no psychiatric diagnosis.

CONCLUSION

Our findings showed that the majority of SA victims were girls, the frequency of abuse increased with age, the majority of perpetrators were the victims’ boyfriends, and the reporting rate of abuse incidents by victims was low. Starting education about sexual health and SA at a very young age will be beneficial in protecting individuals from becoming victims of abuse, reporting abuse, and seeking help.

INTRODUCTION

Child abuse and neglect, known to be as old as human history and one of humanity’s most significant social wounds, is a health problem whose extent is not well known in societies, tends to be hidden, and has victims who are afraid to speak out.^{1, 2} Sexual abuse (SA), which is a subset of child maltreatment, is defined in two ways: (1) any act that occurs as a result of coercion, threat, deception, or fraud without the consent of the child or adolescent; (2) the involvement of a child under the age of consent in an act that results in the sexual gratification of a sexually mature adult or the condoning of such a situation.^{3, 4} Sexual behavior can take the form of sexual intercourse, attempted sexual intercourse, oral-genital contact, and fondling of the genitals directly or through clothing. Non-contact behaviors, such as sexually explicit language, exhibitionism, and voyeurism, are also included in the concept of SA.⁵ In recent years, the view has prevailed that all behavior with sexual content should be considered within the scope of sexual activity in a broad sense.⁶ Many factors, such as the variable nature of SA, the time lag between abuse and examination, the experience of the examiner, and the lack of standardization of examinations, make detecting physical signs of abuse difficult. While it has been reported that in most cases of SA, there are no physical findings⁷, Green found that SA had more psychiatric effects.⁸ 

In many societies, SA is concealed by the victim of abuse, and therefore, a large proportion of SA cases are not reported to the judicial authorities.⁹ It is difficult to obtain accurate statistical data about the prevalence of SA because only 15% of SA victims report.¹⁰ It has been reported that the prevalence of SA is between 10-40% in children, 3-17% in boys and 8-31% in girls. Females are at two to three times the risk of experiencing SA during childhood compared to males.¹¹ In a meta-analysis by Pereda et al.¹² in which 38 articles from 21 countries were evaluated, it was reported that girls were sexually abused 1.5-5.5 times more than boys in all age groups except 2 studies. It is known that the abuser may be a stranger to the child or an acquaintance, relative, or family member.^13-15

It has been reported, that 47% of people who have been sexually abused in childhood have psychiatric disorders that begin in childhood. In comparison, 26-32% have psychiatric disorders that begin in adulthood.^{16, 17} In a retrospective study conducted among adults in Türkiye, the rate of childhood SA was found to be 2.5%.¹⁸ It has been highlighted suicide attempts following childhood SA are more common in girls.¹⁹

Although the number of studies on childhood SA is gradually increasing in Türkiye^{4,6,9,13-15,20-30}, data from different years and different regions are important to increase knowledge about the incidence, pattern, and impact of SA. This study aimed to determine the socio-demographic characteristics, psychiatric diagnoses, and characteristics related to abuse and perpetrator of SA victims referred to Trakya University Faculty of Medicine, Child Psychiatry Outpatient Clinic for forensic evaluation. 

MATERIALS AND METHODS

The sample of our study consisted of victims of SA abuse who were referred for forensic evaluation to Trakya University Faculty of Medicine, Child and Adolescent Mental Health Outpatient Clinic between June 2008 and June 2013. In this retrospective descriptive study, the principles of confidentiality were respected, and no details could reveal the children, their families, or the judicial process.

Clinical interviews were conducted with all cases of SA, and an anamnesis form containing socio-demographic data was completed by the research assistants who conducted the interviews. The information form used for each case admitted to the outpatient clinic asked about the socio-demographic characteristics of the child and parents, including the age and educational status of the cases and parents, psychiatric diagnoses of the cases and drug treatments, if any, and family structure, as well as the characteristics of the abuse and the perpetrator. A psychometric test (Stanford Binet, Cattell 2A) was administered to the cases whose language development was complete and whose cooperation could be established.  The data related to the abuse incident in the cases were obtained by analysing the diagnoses received in the outpatient clinic follow-up and in the forensic committee according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) diagnostic criteria, the number of outpatient clinics related to the follow-up, the data associated with the use of drug treatment, the outpatient clinic files and the forensic committee reports. As the DSM-IV-TR was the version in effect during the years the study data were collected, this version was used. This study was approved by the Non-Interventional Clinical Research Ethics Committee of Trakya University Faculty of Medicine (approval number: 17/14, date: 31.07.2013).

Statistical Analysis

Statistical data analysis was performed using SPSS 15.0 for Windows, at a 95% confidence level. Mean, standard deviation, median, minimum, maximum, frequencies, and ratios were used in the descriptive statistics of the data. A one-sample Kolmogorov-Smirnov test was used to measure the conformity of variables to the normal distribution. Pearson chi-square was used to compare categorical data between groups, and Mann-Whitney U statistical analyses were used to compare continuous data that did not have a normal distribution between groups. p<0.05 was considered statistically significant.

RESULTS

The cases evaluated in the study consisted of girls and boys aged 3-18 years, of whom 357 (92.0%) were girls. Most cases (43.6%) were aged between 15 and 18 years, and the mean age was 13.41±2.99 years. The sociodemographic data of the cases are shown in Table 1. The majority of female subjects (45.7%) were aged 15-18 years, while the majority of male subjects (41.9%) were aged 7-11 years. It was found that the rate of abuse increased with increasing age in girls and in the total group, whereas it decreased with increasing age in boys. The mean age of the cases by sex was compared and showed that the male cases had a lower female cases (p=0.001). Similarly, the mean maternal age of the male cases was lower than that of the female cases (p=0.012) (Table 2).

The average age of the parents of the victims of SA was 37.42 and 42.22 years for mothers and fathers, respectively; the ratio of working mothers and fathers was 27.7% and 88.3%, respectively; 60.6% of the mothers and 67.4% of the fathers had completed primary school, and 66.8% of the cases lived in a nuclear family.

The characteristics of the abuse and the perpetrators were analyzed. In terms of the type of abuse, only 44.8% of the victims reported the incident; vaginal penetration was the most common type of abuse; 53.9% of the abuse involved coercion; and 50.4% of the victims were victimized more than once (Table 3).

The analyzed cases included those that were “married” by their definition. These cases were young people younger than 18 who were married with the consent of their families but they were not officially married. When the cases were analyzed in terms of early marriage, pregnancy after abuse, and suicide, it was found that 14.9% had an early marriage, 20.6% had a pregnancy after abuse, and 6.7% had attempted suicide following abuse.

The analysis of age groups among children (3-11 years) and adolescents (12-18 years) revealed that in both groups, the perpetrator was someone outside the family (p<0.001).

Gender and age were compared regarding the number and type of abuse, perpetrator information, penetration during abuse, and psychiatric diagnosis. These comparisons are presented in Tables 2, 4.

DISCUSSION

This study investigated the sociodemographic and clinical characteristics of SA cases referred to the Child and Adolescent Psychiatry Clinic of a University Hospital in Edirne province as forensic cases with a report request within 5 years. Comparisons were made according to gender and age factors. In our study, the mean age of the 388 cases evaluated for SA was 13.41±2.99 years. The mean age of female patients was higher than that of male patients. Our findings were similar to the results of studies in the literature.^{4, 20-24} In previous studies, girls were found to undergo SA more frequently than boys.^{6, 12, 25-27}

Studies on gender differences in the reporting of SA have found that girls report more cases of abuse, while boys tend to under-report. Factors contributing to this under-reporting include the fear of being perceived as homosexual in the presence of a male perpetrator. In the presence of a female perpetrator, boys perceive the experience as a sexual relationship, do not feel victimized, and do not report the abuse. It is also emphasized that male victims are usually threatened with more violence and power and are, therefore, reluctant to report. The effect of these factors leads to the conclusion that boys are more hesitant to report abuse than girls.³¹

When we analyzed the number of cases by age group, we found that most of our cases (43.6%) were in the 15-18 age group. When analyzed by gender, the majority of male cases (41.9%) were in the 7-11 age group, and the majority of female cases (45.7%) were in the 15-18 age group. In our study, the 3-6 age group accounted for only 3.9% of cases. It was found that the rate of abuse was higher in boys in the 3-6 and 7-11 age groups, whereas the rate of abuse was higher in girls in the 12-14 and 15-18 age groups (p<0.001). Similar to the results of our study, Cengel-Kültür et al.²³ found that boys were most often sexually abused during the school years (7-11 years) and girls during adolescence (12 years and older). The literature suggests that the risk of SA increases with age.^{4, 32} In another study, the frequency of abuse was found to have a bimodal age distribution, with abuse concentrated in children aged 5 and 14 years, and rates of abuse increasing with age beyond 14 years.³³ A study by Bassani et al.³⁴ in a community-based sample reported that prevalence decreased with age in boys and increased in girls. Abuse is often observed in prepubertal boys because male cases may become more suitable for self-protection with increasing age. In contrast, adolescent girls are seen as more vulnerable sexual objects due to the development of secondary sexual characteristics.³⁵

Our results showed that the number of cases was low in the age group of 3-6 years. This finding is consistent with studies in the literature. It is thought that the low number of cases in the 3-6 year age group may be due to the inability of this age group to understand or express the occurrence of SA.³⁵Another reason may be that families are skeptical about the narratives of cases at this age, or want to protect the child from possible trauma that may develop in the forensic process. It may not, therefore, be responsive to the forensic process or the physician.

Studies investigating the prevalence of intellectual disability in victims of SA have reported rates ranging from 13.2% to 35.4% in different sources.^{20, 21, 24, 25, 28} It has been reported that children with intellectual disabilities are vulnerable to deception, and this is considered a risk factor for abuse.²⁰ It has been reported that the risk of abuse is higher in children with intellectual disability and borderline intelligence because their perception and reasoning skills are limited, and children with intellectual disability may have difficulty  assessing the incident and reporting it to  authorized persons.³⁶ It is noted that the rate of cases with intellectual disability was low in our study. The rates in our study may have been low because individuals with borderline intelligence or mental retardation had difficulty reporting their victimization and were exposed to abuse that did not cause physical findings. When they shared this situation with their families, the families viewed the incident with suspicion and did not report it. On the other hand, the proportion of cases with mental retardation may have been lower, as 14.9% of the cases were due to early marriage.

The maternal and paternal ages of the subjects maternal and paternal ages were analyzed according to gender. The mean maternal age of male subjects was lower than that of female subjects, and this difference was statistically significant. No comparison can be made because there aren’t enough studies evaluating parental age. However, our results should be interpreted with caution. The mean age of male subjects may be younger because our sample was predominantly female and mainly in the 15-18 age range, whereas the male cases were mostly in the 7-11 age range.

Another issue analyzed in studies of SA is the relationship between age and the number of incidents of abuse. When we examined the relationship between age and repeated abuse, we found that abuse was mainly repeated once in the 3-11 age group, whereas it was mostly repeated in the 12-18 age group (p<0.001). It has been reported in the literature that the risk of being a victim of repeat abuse is higher in adolescence than in childhood.^{37, 38} It was observed that the rates of SA reoccurrence, reported in the studies, varied from 25% to 89.6%. Consistent with our findings, the rates of abuse reoccurrence increased with advancing age.^{13, 22, 23, 25, 29, 39-43}

In studies where the forms of abuse were assessed, the most common were vaginal penetration, anal penetration, fondling, and interfemoral intercourse.^{35, 41, 44} When analyzed by gender, vaginal penetration and fondling were reported to be the most common forms of abuse in girls. Anal penetration and frictional abuse were the most common forms of abuse in boys.^{4, 21, 35} In studies of non-clinical samples, touching and rubbing were found to be the most common forms of abuse.^{45, 46} Two studies from Sweden and Australia reported that non-contact abuse was more common than contact abuse.^{47, 48} It has been noted in the literature that the penetration rate found in the non-clinical sample is lower than that in the clinical sample. It is thought that non-contact forms of abuse, such as touching, are more common in some studies in the literature, whereas genital penetration is more common in studies in Türkiye, because the low level of reporting of touching forms of abuse may explain this discrepancy.³⁵ Similar to the literature, the results of our study found that abuse involving penetration was most prevalent in the adolescent age group and among girls, and the rate of vaginal penetration was 49.0%. In addition, the fact that 14.9% of our sample were assessed for “early marriage” impacted the higher rate of these findings. 

One of the important issues in the assessment of sexual activity is voluntary sexual intercourse before the age of 18. This issue has been analyzed in different countries, and a study conducted in Australia reported that about 50% of Australian adolescents had voluntary sexual intercourse before the age of 17 or 18. A study conducted in a non-clinical sample in Sweden found that most cases involved voluntary sexual intercourse.^{39, 49} In our study, 35.7% of the cases were found to have had sexual intercourse voluntarily. In a study conducted in Mersin, this rate was found to be 24.8%.³⁵ In another study, the rate of SA without the use of coercion and physical violence was reported to be 45.7%.⁵⁰. As sexual intercourse before the age of 18, even before marriage, is generally not approved in our country, it is not surprising that the majority of the group who said they did not consent actually did not consent. According to the Convention on the Rights of the Child, everyone under the age of 18 is considered a child, so it seems problematic to talk about the consent of a child. It is assumed that all kinds of interactions in which the child is used to satisfy the sexual desires of the adult should be accepted as SA, whether they involve consent or not.³⁵

Another significant finding of our study was that the perpetrator in the “child” and “adolescent” age groups was someone outside the family (p<0.001). the study by Alikasifoglu et al.⁴⁶ reported that when analyzing the relationship between age and whether the perpetrator was inside or outside the family, cases of abuse under the age of 12 were mostly by someone outside the family. One study suggested that reasons for the high incidence of out-of-family abuse include cultural factors that allow abuse to remain a secret within the family.³⁵ Although the results of our study are similar to those of previous studies, there is not sufficient research in the literature.

In our study, penetration was assessed according to four age groups. In most of the cases in the 3-6 age/7-11 age group, a form of abuse without penetration was found. In contrast, forms of abuse with penetration were found in the 12-14 age/15-18 age group.  This difference between the rates was statistically significant. A study conducted by Metin et al.³⁵in Mersin reported findings consistent with those of our study. A survey by Akbaş et al.²² in Samsun found that older children were often exposed to multiple forms of abuse, and the rate of abuse involving vaginal penetration increased with age in girls. It has been reported in the literature, that cases exposed to penetrative SA were in the older age group compared to those exposed to non-penetrative SA.⁵¹

Our study found that the pregnancy rate after confidence interval was 20.6%. In a study conducted in Mersin, the rate of pregnancy history after SA was found to be 8.6%, while in a study conducted in Samsun, this rate was 4.2%.^{22, 35} In their meta-analyses, Noll et al.⁵² found that the presence of SA increased the risk of adolescent pregnancy by a factor of 2.21 and that approximately 5 out of 10 pregnant adolescents may have a history of SA. In our study, the rates of pregnancies were higher than those reported in the literature. We believe that the high rate (14.9%), of cases, referred to our outpatient clinic by forensic units as victims of SA due to unofficial marriages performed with the consent of the families, influenced the results of our study.

Our study found no psychopathology in 65.4% of cases assessed according to the DSM-IV-TR diagnostic and classification system. In 4 studies that evaluated the status of receiving a psychiatric diagnosis in victims of sexual assault in our country, the rates ranged from 76.4% to 91.7%, and it was reported that most cases were diagnosed with post-traumatic stress disorder (PTSD), acute stress disorder, and depression.^{4, 21, 25, 30, 35} In studies of children and adolescents exposed to SA, PTSD has been reported in 44-71%. Although some children do not meet all the diagnostic criteria for PTSD, they may show symptoms of re-experiencing, fear, anxiety, and difficulty concentrating.⁵³ There are studies in the literature, reporting that 21-36% of child victims of SA have no symptoms in the short term and 64-79% have a variable spectrum of symptoms. Additionally, there are studies reporting that approximately 40% of children exposed to SA have very few or no symptoms.^{5, 53} It has been reported that 10-20% of asymptomatic cases may show symptoms within 12-18 months. It is thought that the reason why undiagnosed cases do not show symptoms may be that they have been exposed to milder abuse, are more resilient children, or have a coping style that masks their distress.⁵ A review of the literature related to the outcomes of SA suggests that SA does not have a single and universal effect. Therefore, not every child who has been exposed to SA may show a post-traumatic response to abuse.³⁵ For these reasons, we believe the diagnosis rate was lower in our study.

Study Limitations

The limitations of our study include the inability to use a scale because it was conducted using the retrospective file review method, the lack of a control group, and the fact that the psychological evaluation was conducted during the forensic process. However, as it represents a single region and a high number of cases, our results make an essential contribution to the literature.

CONCLUSION

Our study found that the majority of victims of SA were girls, males were abused in childhood and girls in adolescence, the frequency of abuse generally increased with age, the victim was exposed to more than one abuse with increasing age, the number of abuses involving penetration also increased with increasing age, the number of “early marriages” was 14.9% and the rate of pregnancy was 20.6%. On the other hand, the fact that incidents were reported where the victim consented at a rate of 35.7% and that 44.4% of perpetrators were the victim’s boyfriend suggests that it is important to assess the need for increased sexual health education in adolescence. Starting education about SA which is an important public health problem at a very young age may encourage victims to report abuse. Although the number of studies addressing SA and evaluating victims of SA is increasing, there is still a need for studies on prevention, treatment, and aftercare in this area.