INTRODUCTION
Sexual abuse is defined as the involvement of a child younger than the age of consent by means of force, threat, cheat or deception in every kind of act resulting in the sexual satisfaction of a sexually adult person in the absence of the consent and equality or conniving at its occurrence (1,2). In the section of sexual offenses comprising the articles 102-105 of the Turkish Penal Code, while the sexual abuse was defined as “any act of a sexual nature committed against a minor who has not reached fifteen years of age or who in spite of having reached fifteen years of age, lacks the competence to understand the legal significance and consequences of such acts” and in respect of the other children it is defined as “sexual acts against other minors by means of force, threat, deception or any other means that influences the will of the child”. If the child or adolescent is abused by the biological relatives and by the persons who are forbidden by law to marry, the abuse is called incest (3).
Sexual abuse is divided into two groups according to whether the physical contact is included in the act or not. Exhibitionism, voyeurism, dirty talks, sexual intercourse, attempted intercourse, oral-genital contact, fondling the genital area of the child directly or through clothing, interfemoral sex, exposure of the child to adult sexual activity or pornography, sexual exploitation (using the child in prostitution or in pornography) are the types of sexual abuse (4). Since sexual abuse is reported by only 15% of the victims, the actual epidemiological data on sexual abuse of children are of sexual abuse in females ranged from 7% to 36% and ranged from 3% to 29% in males (6). While the prevalence of sexual abuse in girls was reported as three times higher than that of the boys, sexual abuse exposure has been reported more frequently in younger children (7-10). The studies revealed that the incidence of sexual abuse peaked between the age of 8 and 12 and significantly reduced after the age of 12 (11-13).
Although the sexual abuse offender may be a stranger to the child, mostly a person from the environment of the child or respectable and popular person in the society is the abuser. The studies revealed that 40.7% to 66.7% of the abusers are acquainted with their victims (14,15). The sexual abuse offenders are usually male (16). In addition, it is estimated that 30-40% of the acts of abuse were carried out by adolescents (17).
It is known that the frequent and long term abuse, the act committed by using force, the occurrence of penetration and being acquainted with the abuser may result in more destructive and permanent effects on the child (18). While 20-50% of the victims of sexual abuse do not reveal any psychological symptoms, the development of the psychiatric disorders such as anxiety, depression, substance addiction, suicidal behavior, borderline personality disorder and post traumatic stress syndrome have been reported in the later periods following the abuse (19,20).
The most commonly accepted explanation concerning the children and adolescents revealing the act of abuse is the “learning theory” based on many factors such as being exposed to sexuality and violence, sexual abuse exposure, early exposure to pornographic publications and living in an aggressive family model (21).
In this study the sociodemographic data from the cases of sexual abuse victims or perpetrators admitted to our university were assessed in the light of literature and it was aimed at determining the characteristics of the sexual abuse cases in the East Black Sea Region.
METHOD
This study is a retrospective review of the personal psychiatric files of 6721 children and adolescents admitted to Child and Adolescent Mental Health and Diseases Outpatient clinic of the Medical School of the Karadeniz Technical University between January 1, 2008 and December 31, 2010. In this study the act of child sexual abuse was assessed from the perspectives of the victimized and victimizer children and the demographic data (age, sex, educational level, family status etc.), the reason for admission, diagnoses and the results of the reports were evaluated in detail.
The Study Sample
A total of 118 (82 girls and 36 boys) sexual abuse files were reached and while 104 out of 118 cases were sexual abuse victims, 14 cases were the children and adolescents who were the perpetrators of sexual abuse. The persons accompanying the cases on the admission were classified as “parent” and the “other” and the other referred to the individuals such as a close relative, a neighbor, a police officer or an attendant of the nursery. In this study, the types of the sexual abuse act are classified as sexual intercourse, attempted intercourse, oral-genital contact, anal-genital contact, fondling directly or through clothing, exhibition and make the victim watch, sexual intercourse, pregnancy and verbal harassment. The presence of the pregnancy was included in the act of sexual intercourse in the descriptive and comparative analyses. The victimized cases were divided into three groups according to the age groups; aged between 4 and 6 years, aged between 7 and 11 years and aged 12 years and over. In this study the term of a fragmented family referred to the children with divorced parents and children who had lost his/her mother or father.
An SPSS 13.0 version of statistical package program was used for the analysis of the obtained data. In the statistical assessment, descriptive analyses were used including the percentage, mean, standard deviation. Pearson, Chi- Square or Fisher’s exact test were used in the analyses of nominal data. In addition Mann-Whitney U test was used in the analyses of the interval data noncomplying with the normal distribution. ANOVA analysis was performed for comparison of 3 and more groups complying with the normal distribution. In the analyses of non homogeneous variance, a Tamhane’s post hoc pairwise comparison was performed; statistically, a p-value of <0.05 was considered as significant.
RESULTS
In the review of 118 sexual abuse files of the cases admitted to child psychiatry outpatient clinic, it was determined that 82.2% (97) of the cases were referred from the judicial authorities at the victim’s position and 11.9% (n=14) of the cases were children and adolescents referred to our department at the perpetrator’s position. 5 out of the remaining 7 cases were taken into hospital for the complaints such as introversion, decreased school success, bad temper and encopresis and the child abuse exposure was determined in the phychiatric examination. The other 2 cases were presented as judicial cases due to the various reasons such as narcotic drug possession or psychiatric examination as a precautionary measure and sexual abuse exposure was determined during the assessment of the patients. The families of these children having a history of sexual abuse were informed by the physician and they were oriented for a legal application. It was determined that 21.1% of the overall cases (n=25) applied to the outpatient clinic in 2008, 38.1% (n=45) of the cases applied in 2009 and 40.7% (48) of the cases applied to the outpatient clinic in 2010. The sociodemografic data concerning these cases were presented in Table 1 (Table 1).
The mean age of the girls exposed to sexual abuses was found as 11.1±3.3 years and the mean age of the boys was found as 9.6±2.8 and a significant difference was detected between the mean ages (Z=-2.123, p=0.034). When the distribution according to the age groups was assessed, it was determined that the highest number of the cases were in the age group of 12 years and over in girls (56.1%, n= 46); this rate was found as 31.8% (n=7) in boys (p=0.043) (Table 2) and the difference was found statistically significant. In the assessment of school attendance in 19 victims who had left the school, it was found that 18 of these children were female and 50% (n=9) of these cases were at the age of 14.
While 71.2% (n=74) of the 104 cases who were in the position of the victim, were accompanied by their families on the admission, only 28.8% (n=4) of the 14 cases at the position of perpetrators were accompanied by their family and the difference between the two groups was found statistically significant (p=0.005). 7.6% (n=9) of the overall cases, were the children of the divorced parents and 3.4% (n=4) of the cases were the children who had lost his/her mother or father. When these cases were examined, 8 out of the 9 (88.9%) cases and 2 out of the 4 cases (50%) were presented as the victims of sexual abuse. No statistically significant difference was found between being an abuse offender or being abused in the fragmented structure of the families (p=0.211). Since no adequate information was obtained about the families, 5 cases who had been taken into care due to incest and living in the nursery and 2 cases living in the nursery were excluded from this analysis. The cases who were at the position of victims were assessed according to the act that had been exposed and their gender, the act of fondling directly or through clothing in girls and anal genital contact in males were significantly higher compared to the opposite sex (p=0.029 and p<0.001, respectively) (Table 3).
The mean ages of the victims according to the form of the act of abuse were assessed and the “sexual intercourse” group was found to have the highest mean age as 13.7 years. A statistically significant difference was found in the comparison of the mean ages of the groups (F=3.121, p<0.001). In the paired comparisons, this difference was found to be generated by the mean age of the “sexual intercourse” group. 19 out of 20 victims involved in sexual intercourse were over the age of 12 and 3 of them were pregnant at the admission.
While 95.2% (n=99) of the victims were found to be exposed to an act including contact, only in 18.3% (n=19) of the cases, the abuse offender was not acquainted with the victim. 14.4% (n=15) of the cases involved in an incestuous relationship (Table 4). 5 (5.9% of the overall cases) out of 7 cases staying in a nursery were taken from their families due to the incestuous relationship. In 4 (66.7%) out of 6 incest victims abused by their own father, alcohol dependence was detected in the abuser.
Forensic reports of the victims and perpetrators were examined separately and these reports pointed out that 12 (85.8%) out of 14 cases at the position of perpetrators were competent with the legal meaning and the consequences of the crime that they had committed and 2 of them were not competent with the meaning and consequences of the committed crime.
In 87 out of the 97 sexual abuse who were referred by judicial authorities to the outpatient clinic, it was questioned that whether the mental health of the victim was disturbed. In 5 of them, the final mental status examination was requested and in 3 of them the assessment of whether their statement was reliable and in 2 cases, it was questioned that whether the legal meaning and consequences of the committed crime were perceived. While it was reported that the mental health was not disturbed in 11.3% (n=11) of the cases, in 81 (77.9%) out of 104 cases who were at the position of victims, a psychiatric diagnosis was made. The anxiety disorder was the most common psychiatric disorder with a percentage of 26.9%. This was followed by the post traumatic stress disorder (23.1%) and depressive disorders (19.2%). While 17.3% of the cases who were at the victim position revealed nail biting behavior, this finding was not observed in any of the perpetrators. In the assessment of the diagnosis according to the age group, posttraumatic stress syndrome was the most common diagnosis in the age group of 4-6 years with a percentage of 47.1% (n=8). This diagnosis was replaced by the diagnosis of anxiety with a percentage of 35.3% (n=12) , in the age group of 7-11. In the age group of 12 years and over, having the highest number of cases, the most common diagnosis was the major depressive disorder with a percentage of 30.2%. At the same time the substance abuse was only observed in this group. In addition in the assessment of 37 victims who had experienced vaginal penetration or anal penetration/rubbing, it was detected that 27% (n=10) of them were diagnosed with depression.
Following the legal application, 28.9% (n=28) of 97 victims kept their outpatient followup however 71.1% (69) of them were only examined during the legal application process. In these cases the the length of the period of time from the act to the hospital admission was calculated and it was determined that this period of time varied from less than one month to 5 years. Most of the cases (86,5%, n=84) were admitted to the outpatient clinic within one year after the act. In a more detailed examination, only 8.2% of the overall group could be assessed within one month after the act.
DISCUSSION
Among the cases assessed in the outpatient clinic during the last 3 years, 78.8% of the cases of sexual abuse victims were female, 21.1% were male. These data, supported the previous studies in our country and around the World indicating that the girls were abused more commonly than boys (14,22,23). However it was reported that sexual abuse in boys might be revealed less (24).
The data of 2009 of the General Directorate of Judicial Records and Statistics of Turkey pointed out that in 721 out of 1398 prosecuted cases in the juvenile court and in the juvenile heavy criminal courts within the scope of sexual offenses, the offenses were committed by children-adolescents in the age group of 12 and 15 and while 701 of the perpetrators were male, 20 were female (25). In our study, all of the 14 (100%) perpetrators of sexual abuse were male.
A significant increase in the number of the legal cases related sexual abuse attracted the attention. This condition suggested that the awareness of the families on child sexual abuse had increased and consequently the number of the legal applications had been increased. However another outstanding condition was that only 71.1% (n=69) of the 97 cases of sexual abuse were admitted to the child psychiatry outpatient clinic and although it was recommended, they discontinued the treatment and followup. This condition indicates that, while the families look for their legal rights, they are still unaware of the importance and the necessity of the continuity of child psychiatry followups.
In our study, the mean age of the cases at the position of victim was calculated as 10.8±3.3 years . In two similar studies recently conducted in our country, the mean ages were reported as 11.4 and 10.8 years (22,26). In another study, it was reported that 71.3% of the sexual abuse victims were under the age of 12 (23). In our study the mean age of the girls was 11.1±3.3 years and the mean age of the boys was 9.6±2.8 years This difference of age suggested that boys were abused at younger ages than the girls. This condition may be related to the customary independence of the boys compared to the girls and their upbringing that is more open to be abused.
In this study, while 32.6% (n=34) of the cases at the position of victims were student at the primary school, 18.4 of them had left the school. In a study published by Oztop and Ozcan (22) in 2010, 33.9% of the cases were unschooled children in the adolescent age group and 27.5% of them were reported as students at primary school. In our study, 18 out of 19 cases who had left the school were female and 9 (50%) of these cases were at the age of 14. In conclusion, these data were consistent with those of the previous studies indicating that sexual abuse peaked between the ages 12 and 14 and was more frequent among the adolescent females who had left the school (11,27). Withdrawing from the school and spending more time with their peers revealing problematic behavior were reported to increase juvenile delinquency (28). In this study in the assessment of school attendance among the children dragged into crime, non attendance was determined in 57.1% (n=8) of these children. This result supported the higher rates of school withdrawal among the children and adolescents revealing anti-social behaviors and dragged into crime, regardless the nature of the crime. In our study, the position of the children and adolescents as perpetrators in a case of sexual abuse, expelled the family out of the legal procedure. The majority (71.4%) of these children, were taken to the child psychiatry outpatient clinic by somebody other than their parents. This situation might be related to the unwillingness of the families to be apparent in this dimension of the crime or lack of interest and support of families to the children. When the abuse act is revealed once, the recurrence rate of abusive act rate is as low as 10-15%, and this is interpreted as that these behaviors partakes of the transition to adulthood and the lesser occurrence of perverted sexual behavior patterns is reported in adolescents (29,30). One thought that the solution of the inner conflicts of the children and adolescents in this group should be inquired in collaboration with the families. It is obvious that these children who are left alone by their families, do not have any sexual education.
In addition, it was observed that 71.2% of the cases of victims in this study were not left alone by their families at the admission. This situation appears quite important for the early improvement of mental health of the child because the most important factor that may prevent the development of adaptation problems in the sexually abused children are defined as their relationships with their peers and their environment as well as with their family (31). The reasons leading to the fragmentation of the family such as the loss of mother or father were defined as an important risk factor for the sexual abuse (32). Although no significant difference was found among the fragmented family and being at the position of a sexual abuse victim or at the position of a perpetrator, the rates of being a sexual abuse victim were high among the cases of divorced family children, or cases who had lost mother or father (89% and 50% respectively). This situation may be related to decreased interest on the child or the gap due to the lack of authority. It was reported that the majority of the children dragged into crime lived in the cities (33). However, in our study the majority of cases both at the position of the victim or perpetrator, were from rural areas. The population in the rural areas in our country gradually decreases day by day (34). However, the educational levels and socioeconomic levels are lower in the families living in the rural areas. It is possible to say that the children living in the rural areas have a very limited source of sexual education and they receive inadequate information on this subject. From this point of view, living in rural areas may be considered as a factor that may increase both being a victim or perpetrator of sexual abuse. Apart from the other types of child abuse, sexual abuse was reported to occur at every socioeconomic level (35). In this study, the economical level of 84.5% of the cases was determined as low and intermediate level. While the relationship between the socioeconomic level and child sexual abuse is not clear, a significant relationship was reported between the child sexual abuse and maternal educational level (11). In a study conducted by Akbaş et al. (14) maternal education was mostly found at the level of primary school. In a similar way, the educational levels of a large part (%69.1, n=62) of the mothers in our study were found at primary school. The prevalence of penetration in the cases of sexual abuse was reported to vary between 0.8% and 31.9% in the literature (36,37). In this study, while the vaginal penetration was reported in 19.5% (n=20) of the cases, anal penetration or rubbing was detected in 16.3% of the cases. Overall, an act including contact was observed in 95.2% of the cases. This ratio was similar to that of the previous studies conducted in our country (14,22). In addition, 19 out of 20 cases of sexual intercourse were 12 years old and over and this may suggest that as the age increases, the risk of vaginal penetration also increases. As is seen, the rates of acts including contact were fairly high in the cases of sexual abuse referred for assessment. Worse long term outcomes were reported in the sexual abuse which included contact (38,39). This situation reveals once again the importance of health services that should be presented to these children along with preventive measures. 3 out of 82 female cases who were at the position of the victim, were determined as married with children. In addition, these victims aged 14 and 15 years had left the school. Individuals who have children in spite of their an age group that can be considered as children and need to be at school, constitute a great irony in today’s conditions. The article 124 of the Turkish Civil Code determines the age of 17 as the minimum age of marriage for both men and women according to the consent of the parents (40). However, according to the data of TNSA-2008, 5% of the women in reproductive age marry before the age of 15. In addition while unschooled women begin to give birth children during the period of puberty, this rate is 4% in women who are at least high school graduate (34). These data indicate that the continuation of the education protects girls from being married at an early age and associated problems. In our study, 14.4% (n=15) of the victim cases were the incest cases. In a study conducted among university students, the incest rate was reported as 1.4% (41). Many risk factors were defined in incest cases. The presence of previous incest in the maternal or paternal families, the lack of a mother or a mother who is not able to be a protective power, authoritarian and fanatic father or alcoholic father are some of the risk factors (42). In our study, adequate information about the families of the incest cases could not be obtained; however, in 4 (66.7%) out of 6 incests cases abused by their own father, incestuous fathers were alcoholics.
In the cases other than incests, while the abuse offender was generally an acquaintance (81,7%) mostly he was a boyfriend (22.1%, n=23). In a study conducted in the Child Protection Center of Gazi University, when the relationship between the abuser and the child was assessed, a close boyfriend ranked first (13). When the changing society and the increasing sexual curiosity in the puberty are considered, one may say that improper friendships dragg the child into sexual abuse. Many children and adolescents who do not share anything with their family and exhibiting emotional problems such as guilt, fear and regret are repeatedly exposed to abuse (2). In our study, the detection of an incest victim abused by her own brother, who was also repeatedly abused by her teacher and by a next-door boy, supported these data.
In a study conducted in 2008, post traumatic stress disorder was observed in 63.8%, and depression was observed in 33% of the children exposed to sexual abuse (43). In the assessment of the cases from a psychiatric view, 77.9% (n=81) of the overall cases were diagnosed with a psychiatric disorder and the most common disorder was depression with a rate of 26.9%. However the increasing age and increasing rate of penetration- rubbing were associated with increasing rates of the diagnosis of major depression. These findings indicate that the distribution of the psychiatric diagnoses changes according to the age and the kind of the act.
Fear, depression, attention deficit/hyperactivity disorder, secondary enuresis and encopresis, thumb sucking, nail biting, problems in school success and behavior, conversive pictures or panic attacks were reported to be experienced following the sexual abuse act (5,44). Problems such as encopresis, bad temper and decreased school success had attracted the attention of the families in cases that we examined before the legal application process and nail biting was observed in 17.3% (n=18) of the victim cases as an indicator of anxiety.
In this study, the length of the period of time from the abusive act to the outpatient clinic admission may be prolonged up to 5 years. Even though 86.5% of the cases were examined within the first year, the assessment of the rest of the cases was delayed. In a survey conducted in our country, it was demonstrated that any of the sexual abuse cases met the diagnosis criteria of DSM-IV in terms of depression following two years of regular treatment. However, although the diagnosis of anxiety or depressive disorder is not made at the beginning due to the traumatic dynamics of sexual abuse, behavioral problems such as social introversion, destructive behaviors, distractibility, and somatization were reported to develop in the long term in these children along with these disorders (45). From this point of view, keeping these cases on regular followup and treatment is very important.
CONCLUSION
Although child sexual abuse is a significant public health problem, when the short term and long term consequences are taken into consideration, it is considered as a serious crime from the legal and psychosocial perspectives. Nevertheless, it is well known that there are quite a number of unreported cases. This situation may be related to the fear of explaining the sexual abuse as well as the long and complicated structure of the legal process. In this study it was demonstrated that girls were more commonly abused compared to the boys, the sexual abuse exposure was more prevalent at the ages of puberty and particularly at the end of the primary school and the tendency to crime was higher in children who left the school. The factors that push the children and adolescents to be a perpetrator of sexual abuse, should be assessed in a more detailed manner. Whether the legal meaning of the crime is perceived or not, starting a treatment procedure for the behavioral disorder of the children is as important as it is in the victims.
In this study, it was observed that the age of the sexual abuse exposure was higher in girls than the boys and the increased age was associated with the increased rate of vaginal penetration. In addition, while the symptoms related to anxiety were in the foreground at a younger age, the increased age and the act committed in the form of penetration-rubbing led the depression to the foreground. The assessment of the child within a short term after the act of abuse and keeping him/her on a regular outpatient followup, providing adequate family and environmental support may positively affect the acute effects of trauma. However it is well known that these children may experience social problems in the long term. Our target should be an effective treatment following the event as well as preventing the occurrence of such events. From this point of view developing new programs with the contributions of physicians, national education, judicial authorities, and media, informing the children and parents in a more detailed manner are considered as important. In addition, increasing the extensiveness of the child protection units of the university hospitals and providing at least regional access to these units, is considered as necessary for the protection and treatment programs.
