This post will soon also be available as a podcast as part of the Meer e Karwan series.
Zainab Ansari, a 7 year old child was on her way to Quran recitation classes in Kasur, Pakistan, when she was abducted, raped, strangled and left in a dumpster. Her body was discovered on the 9th January 2018. Autopsy has yielded that she was most likely held in captivity, where she was tortured. Criminal proceedings are underway and someone has yet to be charged for this.
Child sexual abuse is a horrific reality of the society we live in and Zainab’s case is just one of the few most recent reminders of this. Today’s podcast will focus on definitions, the extent of the problem, signs exhibited by children and further complications secondary to the abuse as well as a brief reflection on prevention and control strategies.
Child sexual has differing dynamics to those of adult sexual abuse in many parameters ranging from disclosure differences to the symptoms exhibited. Lets begin by defining the problem. The World Health Organisation’s definition of child sexual abuse is:
- The involvement of a child in sexual activity that he or she does not fully comprehend
- Is unable to give informed consent to
- For which the child is not developmentally prepared for
- Or that violates the laws or social taboos of a society
Sexual abuse in the case of minors is evidenced by any of the above activity between a child and an adult, or another child who by age or development is in a relationship of responsibility, trust or power with the activity being intended to gratify or satisfy the needs of the other people. This may include but is not limited to 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.”
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. 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. A meta-analysis conducted in the year 2009 analysed 65 studies in 22 countries and estimated an “overall international figure.” The main findings of the study were:
- An estimated 7.9% of males and 19.7% of females universally faced sexual abuse before the age of 18 years
- The highest prevalence rate of CSA was seen in Africa (34.4%)
- Europe, America, and Asia had prevalence rate of 9.2%, 10.1%, and 23.9%, respectively.
CSA has found to be associated with physical abuse at both younger and older ages and 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.
India has a huge problem of child sexual abuse, in fact, it is home to 19% of the world’s children as well as home to the worlds largest number of abused children. 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. 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 labour, and crime.
It would be false to believe that the problem exists in poor and developing countries only. Unfortunately, child sexual abuse is found across international borders as well delving deep within all socioeconomic boundaries.
- 1 in 20 children in the UK have been sexually abused
- 54,000 sexual offences against children recorded in 2015/6
- Over 90% of the abused children’s perpetrator was someone they knew
- Over 2900 children were identified as needing protection from sexual abuse in 2015
Risk factors have been identified, which can make children more vulnerable to abuse. These include:
- Unaccompanied children
- Children in foster or adopted care
- Physically or mentally less abled children
- Armed conflict
- Social isolation
- Dysfunctional family life e.g. alcohol, drug dependency
The aftermath of child sexual abuse includes physical and mental complications. The physical issues range from genital injury, genital discharge, bedwetting/soiling, anal complaints (e.g. fissures, pain, bleeding), UTIs and STIs. Psychological and behavioural issues can include behavioural regression, delayed developmental milestones, sleep disturbances, depression, PTSD, poor self-esteem and/or inappropriate sexualised behaviours.
So what is the cause of the problem? Child sexual abuse is multi-dimensional in its cause and complexity, however, cultural and social norms supporting violence are a major issue. These can include the following:
- Sexual violence being an acceptable way of punishment/power assertion
- Sexual activity (including rape) being a marker of masculinity
- Sex and sexuality being taboo as well as shameful for the victim, thus preventing disclosure
- Perpetrators having had a history of longstanding sexual abuse
Prevention and control of child sexual abuse
Management of victims of sexual abuse is also, therefore, quite complex and multidimensional. It is important to remember, however, that sexual abuse is preventable and there are a number of steps that can be taken to keeping children safe. On individual levels this includes giving safe spaces to children (online and offline), equipping adults with knowledge and understanding to take action and empowering children to speak out about sexual abuse.
For children already having a history of abuse, there needs to be adequate support. This includes the treatment of physical injuries, STI treatment, HIV prophylaxis, long term counselling and/or psycho-educational intervention. Similarly, the frontline health staff need training in order to pick up the signs of sexual abuse, ask about it in a non-threatening setting and be competent enough to carry out the basic investigations and treatment. Disclosure in children is a multi step process and often is not easy for them to narrate. The health and forensic services must therefore work hand in hand to allow for sensitive information to be gathered from the child.
Education is a key element of control and prevention of child sexual abuse. The learning is imperative for children and families. The children need to be taught in safe environments, which touching and other behaviours are inappropriate and who to report to. They need to be reassured and mentally equipped so that they have a safe person with whom they can communicate.
Implementation of laws and policies is another minefield, which has to be taken into consideration. Control and prevention of abuse cannot work if the laws and policies are not in place, and if society as a whole does not believe in the legal enforceability of these.
Guidelines for medico-legal care for victims of sexual abuse. World Health Organisation. http://apps.who.int/iris/bitstream/10665/42788/1/924154628X.pdf
Changing social and cultural norms that support violence. World Health Organisation. http://www.who.int/violence_injury_prevention/violence/norms.pdf
Child sexual abuse. National Society for the Prevention of Cruelty to Children. https://www.nspcc.org.uk/preventing-abuse/child-abuse-and-neglect/child-sexual-abuse/
Singh et al. An epidemiological overview of child sexual abuse. J Family Med Prim Care 2014; 3(4): 430-435.