J Forensic Sci, January 2015, Vol. 60, No. 1 doi: 10.1111/1556-4029.12566 Available online at: onlinelibrary.wiley.com
PAPER
GENERAL; PSYCHIATRY AND BEHAVIORAL SCIENCES Berna Aydin,1 M.D.; Seher Akbas,2 M.D.; Ahmet Turla,1 M.D.; Cihad Dundar,3 M.D.; Murat Yuce,2 M.D.; and Koray Karabekiroglu,2 M.D.
Child Sexual Abuse in Turkey: An Analysis of 1002 Cases
ABSTRACT: This study investigated the characteristics of abuse suffered by children, the dimensions of the psychiatric effects associated
with abuse, and the factors affecting these. One thousand two cases aged under 18, exposed to sexual abuse, and referred over a 7-year period were assessed. Girls represented 80.8% of cases, and the numbers rose with age. The aggressors were all male, and 88.2% were known to their victim. Approximately half the children were exposed to sexual abuse involving penetration. Psychological pathology was identified in 62.1%. Female gender, the presence of penetration, physical violence, and incest significantly increased the development of psychological pathology. Levels of awareness in people close to and trusted by the child must be raised to minimize the adverse effects of trauma in the long term, preventive measures must be taken, and medical and social support units from which victims can receive assistance need to be established.
KEYWORDS: forensic science, child abuse, child sexual abuse, sexual assault, psychopathology, Turkey Abuse and neglect, which damage children’s psychological and physical health and hinder their development, are a serious public health problem everywhere in the world (1–3). Sexual abuse is a serious, insidious, and persistent form of child abuse that is difficult to identify, is often not reported, and therefore often remains hidden (3–6). It is difficult to come by realistic data regarding the prevalence of sexual abuse (5). It is generally stated that more than 80% of cases go unreported and that the true incidence is much higher than the number of reported cases (7). The “Child Maltreatment 2011” report, which contains national statistics, published by the “U.S. Department of Health & Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau Department,” states that 676,569 victims of child abuse were reported (unique count) for 2011 by 51 States. The report cited a unique victim rate of 9.1 per 1000 children in the population, with 9.1% of unique victims (61,472 victims) were sexually abused (8). Additionally, some studies have reported that approximately 1% of children are exposed to some form of sexual abuse every year (6,9). Various numerical data regarding “child sexual abuse” in Turkey in the Justice Statistics published by the Ministry of Justice are shown in Fig. 1. The way these statistics are arranged has changed as of 2008, and no data concerning the number of victims or complainants have appeared since 2009
1
Department of Forensic Medicine, Faculty of Medicine, Ondokuz Mayis University, Atakum/Samsun, 55139-Turkey. 2 Department of Child and Adolescent Psychiatry, Faculty of Medicine, Ondokuz Mayis University, Atakum/Samsun, 55139-Turkey. 3 Department of Public Health, Faculty of Medicine, Ondokuz Mayis University, Atakum/Samsun, 55139-Turkey. Received 8 July 2013; and in revised form 21 Oct. 2013; accepted 28 Oct. 2013. © 2014 American Academy of Forensic Sciences
(10–15). According to these statistics, cases of child sexual abuse in Turkey are increasing annually. We attribute this rise to increasing awareness and reporting of sexual abuse in Turkey. Nonetheless, as in the rest of the world, it is unclear to what extent the number of cases officially reported in Turkey reflects reality. Child sexual abuse may have adverse psychological effects in both the short term and in the long term as far as adulthood (5,16,17). Several studies have emphasized that a number of psychiatric disorders may develop, such as behavioral problems, compromised interpersonal relations, sexually oriented behavior, sexual dysfunction, engagement in high-risk sexual behavior, substance dependence, suicidal thoughts or behavior, personality disorders, eating disorders, anxiety disorders, depression, dissociation, and post-traumatic stress disorder (PTSD) (17–26). This study, which we think will contribute to the literature due to its relatively high case numbers compared to other studies in Turkey, was intended to investigate the characteristics of abuse suffered by children, the dimensions of the psychiatric impact developing in association with abuse, and the factors influencing the development of psychiatric disorder by analyzing data for children exposed to sexual abuse. Materials and Methods Victims said by judicial authorities to have been to sexual abuse are referred to the Ondokuz Mayis University Faculty of Medicine Forensic Medicine Department for examination and reports to establish the severity of the physical and psychiatric damage resulting from such sexual abuse. One thousand two cases referred for this reason from several provinces of Turkey between January 01, 2006, and December 31, 2012, and aged under 18 were included in the study and their patient files examined. General physical examinations were performed by forensic medicine specialists at the Forensic Medicine Department. 61
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FIG. 1––-Numbers of victims and accused persons in cases of sexual abuse by year.
Consultations were requested from the Gynecology and Obstetrics, Pediatric Surgery, Pediatric Infectious Diseases, and other departments when necessary. Additionally, psychiatric interviews were conducted with these patients, and their parents if available, by child and adolescent psychiatry specialists at the Department of Child and Adolescent Psychiatry. During these interviews, information was obtained regarding children’s sociodemographic characteristics and the abuse experienced. Children’s psychological state was assessed using DSM-IV diagnostic criteria, and the presence of psychological disorder was investigated. Data from the patient files were assessed using IBM SPSS Statistics (Version 20.0; IBM Corp., Armonk, NY). The chisquare test was used in comparisons between groups and logistic regression analysis for the purpose of determining factors affecting the development of psychological pathology after sexual abuse. Significance was set at p < 0.05. Results Girls represented 810 (80.8%) and boys 192 (19.2%) of the 1002 cases constituting the study group. Mean age of cases was 12.3 3.2 (2–17) years, 10.7 3.1 (2–17) years for boys, and 12.7 3.1 (3–17) for girls. Of the cases shown distributed by age-groups in Table 1, 11.1% (111 cases) were the children of broken families. The level of cases aged 12 or above in abused girls was statistically significantly higher compared to the same age-group in boys (v2 = 51.9; p < 0.001). All those perpetrating abuse were male, with a mean age of 26.8 12.5 (11–80 years). The child was previously known to the aggressor in 88.2% of cases, and incest was determined in 102 (10.2%) cases. Approximately half of children (47.9%) were subjected to abuse in the home environment, and abuse was recurrent in 476 (47.5%) cases. Recurrent abuse was significantly higher among victims of incest compared to other children (v2 = 94.5; p < 0.001). TABLE 1––Gender distributions by age-group. Male N (%)
Age-Group 0–6 7–11 12–17 Total
27 74 91 192
v2 = 51.9; p < 0.001.
(14.1) (38.5) (47.4) (100)
Female N (%) 38 181 591 810
(4.7) (22.3) (73.0) (100)
Total N (%) 65 255 682 1002
(6.5) (25.4) (68.1) (100)
Vaginal, anal, and/or oral penetration was determined in 41.1% of cases, and 6.9% of cases were exposed to physical violence in addition to sexual abuse. Events came to light as a result of direct disclosure to family, teacher, or a person such as a friend in 61.8% of cases; 53.3% of children first told a member of their family, with 36.9% issuing a legal complaint on the same or the following day and 14.3% 1 year afterward. Legal complaints were issued significantly later in cases of incest compared to the others (v2 = 228.1; p < 0.001). Assessments revealed that psychological pathology associated with sexual abuse developed in 62.1% of cases. The most common diagnoses were depressive disorder (37.5%) and PTSD (36.9%). Sexual abuse-related data are given in Table 2. Model compatibility at logistical regression analysis performed to examine factors influencing the development of psychological pathology after sexual abuse is 66.6%. Analysis revealed that female gender, presence of penetration, exposure to physical violence, and presence of incest highly significantly affected development of psychological pathology (p < 0.01). Female gender and exposure to penetration increased the risk of development of psychological pathology twofold, while exposure to physical violence increased the risk 13-fold. Prevalence of psychological pathology increased with age and repetition of abuse, although the difference was not statistically significant (p > 0.05) (Table 3). Discussion Sexual abuse affects children of all ages, of all races and cultures, of all socioeconomic levels, and in all countries (6,7,27,28). Epidemiological studies show that sexual abuse is a major threat to 5–20% of all children and that girls are at 2–3 times higher risk than boys (18,29–31). In this study, too, in agreement with previous similar research, the great majority of victims were girls (80.8%) (6,32–39). The number of cases rose with age, with 6.5% of children in the study group aged 0–6, 25.4% aged 7–11, and 68.1% aged 12–17. Some studies have reported that the risk in childhood sexual abuse increases with age, while others have suggested the case numbers decrease with age (18,33,35,39). This discrepancy may be attributed to prevalence of exposure weighted by age, calculating the victim age-group as a proportion of the age-group in its own population, not being expressed. However, all these
AYDIN ET AL. TABLE 2––Data regarding sexual abuse to which children were exposed.
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CHILD SEXUAL ABUSE
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TABLE 3––Logistic regression analysis of factors affecting development of psychological pathology.
N (%) Scene of event Home Area open to the public School Inside vehicle Other isolated, closed area Workplace Victim/aggressor relationship Acquaintance Boyfriend Neighbor Friend Family member Other relative Teacher Local trader Friend of family member Other* Stranger Form of abuse Touching, kissing, or fondling Vaginal penetration Anal penetration Oral penetration Vaginal and anal penetration Anal and oral penetration Physical violence Yes No First person informed Family member Police Teacher Friend Relative Other† How the event was revealed Direct disclosure by victim Disclosure when asked as a result of suspicions Statement to police Statements by witnesses As a result of medical examination Time of judicial complaint Same or next day Within 1 month 1 month–1 year After more than 1 year Psychiatric diagnosis Depressive disorder PTSD PTSD and depressive disorder Acute stress disorder Depressive disorder and acute stress Anxiety disorder None
480 218 140 59 58 47
(47.9) (21.7) (14.0) (5.9) (5.8) (4.7)
884 207 139 123 102 90 53 35 30 105 118
(88.2) (20.6) (13.9) (12.3) (10.2) (8.9) (5.3) (3.5) (3.0) (10.5) (11.8)
590 282 91 12 22 5
(58.9) (28.1) (9.1) (1.2) (2.2) (0.5)
69 (6.9) 933 (93.1) 532 265 92 65 34 14
(53.1) (26.4) (9.2) (6.5) (3.4) (1.4)
619 155 89 70 69
(61.8) (15.4) (8.9) (7.0) (6.9)
370 162 327 143
(36.9) (16.2) (32.6) (14.3)
215 213 157 30 4 3 380
(21.4) (21.3) (15.7) (3.0) (0.4) (0.3) (37.9)
*Previous acquaintances of some kind. † Neighbor, doctor attended, and boyfriend.
data still support the idea that sexual abuse affects children of all ages. Several studies have reported that the majority of attackers are male and generally (63.2–83.3%) known to or acquainted with the victim and that 16.4–27% of assailants are members of the family (9,16,17,32,33,35,36,38–42). In agreement with this, all the attackers in this study were male and 88.2% were known to the victim, while 10.2% were family members. This may be attributed to people who are known and related having easier access to children, and to children not suspecting such people and trusting them more easily.
Variables Female Presence of penetration Presence of physical violence Presence of incest Repetition of abuse Age-group 0–6 years 7–11 years 12–17 years
SE
Wald
d.f.
Sig.
Exp (B)
0.826 0.749 2.570
0.176 0.150 0.601
22.039 24.775 18.314
1 1 1
0.000 0.000 0.000
2.285 2.114 13.064
0.885 0.073
0.284 0.143
9.744 0.264
1 1
0.002 0.607
2.423 0.929
– 0.139 0.210
– 0.293 0.279
4.361 0.225 0.566
2 1 1
0.113 0.635 0.452
– 1.149 0.811
B
Approximately half the children in this study were abused in the home environment. K€ ußc€ uker (34) reported that 64.5% of children were abused in the home, while Sharma and Gupta (36) cited 63.39% and Bahali et al. (33) suggested 50%. Bearing in mind that the majority of children are sexually abused by people they know and who are close to them, then it is to be expected that the site of abuse will be the home, which requires no special efforts and raises no suspicions. Studies report varying levels regarding types of abuse to which children are exposed. One study in Italy reported that 33.9% of children under 14 subjected to abuse were exposed to anal or vaginal penetration or attempted penetration by the penis and 6.1% with other objects (39). One study in Turkey evaluating 101 cases of child sexual abuse in the 4–17 age-group reported abuse involving penetration at a level of 48.5% (33). Another study of 83 cases in the 0–17 age-group reported abuse involving penetration at a level of 35% and that additional physical violence was also present in 10.8% of these 83 cases (35). In our study, too, 41.1% of sexual abuse victims were subjected to abuse including penetration and 6.9% of cases were also subjected to physical abuse. Sharma and Gupta (36) reported that child victims of sexual abuse most commonly (47.2%) disclosed this abuse to their mothers at home and that outside the family; disclosure was most commonly (33.3%) made to health workers. They also reported that 44.4% of children made disclosure when asked by parents or close friends and that 36.1% disclosed sexual abuse because of pain in their private parts. In our study, 53.1% of child victims of sexual abuse first disclosed the event to members of the family; 61.8% disclosed the event directly without being asked, while 15.4% reported abuse after being asked when family or close friends became suspicious. These levels are significant; more than half of victims of abuse sought help from families by disclosing events directly, while the families and friends of only 15.4% of children suffering sexual became suspicious and asked children whether they had been abused. In addition, 53.1% of children reported abuse to the judicial authorities within the first month and 49.9% after more than 1 month. This reveals that there is still a great need for society, families, and children to be informed about child abuse and for protective approaches to be developed if children are to be protected. Child victims of incest generally do not disclose their experiences, usually due to feelings of shame, fear guilt, and other causes. In addition, families that are aware of abuse suffered by children prefer to cover the matter up, again from a variety of concerns. In cases of incest, which generally remains hidden for such reasons, the abuse lasts longer and is recurrent, and judicial complaints are made later compared to other cases (43–45). In
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this study, too, abuse was repeated significantly more in victims of incest compared to other children, and judicial complaints were again made later. The effect of sexual abuse of the child’s psychological life is extremely complex. Child sexual abuse is associated with various psychiatric disorders that begin in childhood and persist in adulthood (46). In a review in which they investigated the longterm effects of child sexual abuse, Polusny and Follette (47) reported prevalence levels of PTSD of between 33% and 86% in child abuse cases and prevalences of major depression of between 13% and 88%. In the first clinical assessment, when standard instruments were used, approximately 40% of children exposed to sexual abuse have been reported to have few or no psychiatric symptoms (18,20,48). However, long-term studies have reported that problems may begin later in 12–18 months in 10–20% of asymptomatic children and that initially asymptomatic children may experience severe problems at more advanced ages (18,20,48). In accordance with these studies, psychiatric pathologies were determined in 62.1% of the victims of sexual abuse in our study. Most frequent were depressive disorder (37.5%) and PTSD (36.9%). In addition, if the cases constituting the study group will be reassessed over time with long-term observation, we presume that the number of cases in which psychiatric pathologies were seen could be higher. The psychological impact of the event on children may vary depending on the child’s age and sex, type of abuse, its duration and severity, involvement of penetration, the relationship between the child and the abuser, and the use of force or violence (19–21,46). Impact of sexual abuse rises from the age of 6–7 and becomes significant from the age of 10 (49). Two metaanalyses reported that the adverse effects in cases of child sexual abuse were not equivalent for males and females and that adverse effects were observed at a much lower level in boys (50,51). Abuse being prolonged and frequent, its involving penetration, the use of violence, and the assailant being someone closely related to the child all lead to a much more negative psychological impact and determine the degree of symptomatology (20,21). In our study, logistic regression performed to reveal the factors affecting the development of psychological pathology showed that, in agreement with the literature, female gender, presence of penetration, exposure to physical violence, and the presence of incest statistically significantly increased the development of psychological pathology. Prevalence of psychological pathology increased with age and in the event the abuse was recurrent, although the differences were not statistically significant. Our inability to determine duration of abuse and time to disclosure are limitations of the study. Nonetheless, this evaluation of data for 1002 children subjected to abuse over a 7-year period contributes to the determination of the characteristics of sexual abuse experienced by children in Turkey, the dimension of the resulting damage and the factors affecting development of psychological pathology. The fact that very few children make disclosure when asked also reveals the need for levels of consciousness among people the child trusts, such as families and teachers, to be raised and for preventive measures to eventually be taken. As it is known that for the child to believe that he/she is safe after the event and to be able to describe his/her experiences will reduce the adverse effects of the trauma in the long term, cases of abuse not remaining hidden but being reported to the appropriate authorities are very important in terms of treatment and rehabilitation. For that reason, medical and social support units
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40. Welch J, Mason F. Rape and sexual assault. BMJ 2007;334(7604):1154– 8. 41. Tardif M, Auclair N, Carpentier J. Sexual abuse perpetrated by adult and juvenile females: an ultimate attempt to resolve a conflict associated with maternal identity. Child Abuse Negl 2005;29:153–67. 42. Sarkar SC, Lalwani S, Rautji R, Bhardwaj DN, Dogra TD. A study of victims of sexual offences in South Delhi. J Fam Welf 2005;52(1):60–6. 43. Pintello D, Zuravin S. Intrafamilial child sexual abuse: predictors of postdisclosure maternal belief and protective action. Child Maltreat 2001;6 (4):344–52. 44. Gunduz T, Karbeyaz K, Ayranci U. Evaluation of the adjudicated incest cases in Turkey: difficulties in notification of incestuous relationships. J Forensic Sci 2011;56(2):438–43. 45. Crisma M, Bascelli E, Paci D, Romito P. Adolescents who experienced sexual abuse: fears, needs and impediments to disclosure. Child Abuse Negl 2004;28(10):1035–48. 46. Hornor G. Child sexual abuse: consequences and implications. J Pediatr Health Care 2010;24(6):358–64. 47. Polusny MA, Follette VM. Long-term correlates of child sexual abuse: theory and review of the empirical literature. Appl Prev Psychol 1995;4 (3):143–66. 48. Finkelhor D, Berliner L. Research on the treatment of sexually abused children: a review and recommendations. J Am Acad Child Adolesc Psychiatry 1995;34(11):1408–23. 49. Finkelhor D. Epidemiological factors in the clinical identification of child sexual abuse. Child Abuse Negl 1993;17(1):67–70. 50. Rind B, Tromovitch P. A meta-analytic review of findings from national samples on psychological correlates of child sexual abuse. J Sex Res 1997;34(3):237–55. 51. Rind B, Tromovitch P, Bauserman R. A meta-analytic examination of assumed properties of child sexual abuse using college samples. Psychol Bull 1998;124(1):22–53. Additional information and reprint requests: Berna Aydin, M.D. Associate Professor Department of Forensic Medicine Faculty of Medicine Ondokuz Mayis University Atakum/Samsun 55139 Turkey E-mail: [email protected]
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PAPER
GENERAL; PSYCHIATRY AND BEHAVIORAL SCIENCES Berna Aydin,1 M.D.; Seher Akbas,2 M.D.; Ahmet Turla,1 M.D.; Cihad Dundar,3 M.D.; Murat Yuce,2 M.D.; and Koray Karabekiroglu,2 M.D.
Child Sexual Abuse in Turkey: An Analysis of 1002 Cases
ABSTRACT: This study investigated the characteristics of abuse suffered by children, the dimensions of the psychiatric effects associated
with abuse, and the factors affecting these. One thousand two cases aged under 18, exposed to sexual abuse, and referred over a 7-year period were assessed. Girls represented 80.8% of cases, and the numbers rose with age. The aggressors were all male, and 88.2% were known to their victim. Approximately half the children were exposed to sexual abuse involving penetration. Psychological pathology was identified in 62.1%. Female gender, the presence of penetration, physical violence, and incest significantly increased the development of psychological pathology. Levels of awareness in people close to and trusted by the child must be raised to minimize the adverse effects of trauma in the long term, preventive measures must be taken, and medical and social support units from which victims can receive assistance need to be established.
KEYWORDS: forensic science, child abuse, child sexual abuse, sexual assault, psychopathology, Turkey Abuse and neglect, which damage children’s psychological and physical health and hinder their development, are a serious public health problem everywhere in the world (1–3). Sexual abuse is a serious, insidious, and persistent form of child abuse that is difficult to identify, is often not reported, and therefore often remains hidden (3–6). It is difficult to come by realistic data regarding the prevalence of sexual abuse (5). It is generally stated that more than 80% of cases go unreported and that the true incidence is much higher than the number of reported cases (7). The “Child Maltreatment 2011” report, which contains national statistics, published by the “U.S. Department of Health & Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau Department,” states that 676,569 victims of child abuse were reported (unique count) for 2011 by 51 States. The report cited a unique victim rate of 9.1 per 1000 children in the population, with 9.1% of unique victims (61,472 victims) were sexually abused (8). Additionally, some studies have reported that approximately 1% of children are exposed to some form of sexual abuse every year (6,9). Various numerical data regarding “child sexual abuse” in Turkey in the Justice Statistics published by the Ministry of Justice are shown in Fig. 1. The way these statistics are arranged has changed as of 2008, and no data concerning the number of victims or complainants have appeared since 2009
1
Department of Forensic Medicine, Faculty of Medicine, Ondokuz Mayis University, Atakum/Samsun, 55139-Turkey. 2 Department of Child and Adolescent Psychiatry, Faculty of Medicine, Ondokuz Mayis University, Atakum/Samsun, 55139-Turkey. 3 Department of Public Health, Faculty of Medicine, Ondokuz Mayis University, Atakum/Samsun, 55139-Turkey. Received 8 July 2013; and in revised form 21 Oct. 2013; accepted 28 Oct. 2013. © 2014 American Academy of Forensic Sciences
(10–15). According to these statistics, cases of child sexual abuse in Turkey are increasing annually. We attribute this rise to increasing awareness and reporting of sexual abuse in Turkey. Nonetheless, as in the rest of the world, it is unclear to what extent the number of cases officially reported in Turkey reflects reality. Child sexual abuse may have adverse psychological effects in both the short term and in the long term as far as adulthood (5,16,17). Several studies have emphasized that a number of psychiatric disorders may develop, such as behavioral problems, compromised interpersonal relations, sexually oriented behavior, sexual dysfunction, engagement in high-risk sexual behavior, substance dependence, suicidal thoughts or behavior, personality disorders, eating disorders, anxiety disorders, depression, dissociation, and post-traumatic stress disorder (PTSD) (17–26). This study, which we think will contribute to the literature due to its relatively high case numbers compared to other studies in Turkey, was intended to investigate the characteristics of abuse suffered by children, the dimensions of the psychiatric impact developing in association with abuse, and the factors influencing the development of psychiatric disorder by analyzing data for children exposed to sexual abuse. Materials and Methods Victims said by judicial authorities to have been to sexual abuse are referred to the Ondokuz Mayis University Faculty of Medicine Forensic Medicine Department for examination and reports to establish the severity of the physical and psychiatric damage resulting from such sexual abuse. One thousand two cases referred for this reason from several provinces of Turkey between January 01, 2006, and December 31, 2012, and aged under 18 were included in the study and their patient files examined. General physical examinations were performed by forensic medicine specialists at the Forensic Medicine Department. 61
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FIG. 1––-Numbers of victims and accused persons in cases of sexual abuse by year.
Consultations were requested from the Gynecology and Obstetrics, Pediatric Surgery, Pediatric Infectious Diseases, and other departments when necessary. Additionally, psychiatric interviews were conducted with these patients, and their parents if available, by child and adolescent psychiatry specialists at the Department of Child and Adolescent Psychiatry. During these interviews, information was obtained regarding children’s sociodemographic characteristics and the abuse experienced. Children’s psychological state was assessed using DSM-IV diagnostic criteria, and the presence of psychological disorder was investigated. Data from the patient files were assessed using IBM SPSS Statistics (Version 20.0; IBM Corp., Armonk, NY). The chisquare test was used in comparisons between groups and logistic regression analysis for the purpose of determining factors affecting the development of psychological pathology after sexual abuse. Significance was set at p < 0.05. Results Girls represented 810 (80.8%) and boys 192 (19.2%) of the 1002 cases constituting the study group. Mean age of cases was 12.3 3.2 (2–17) years, 10.7 3.1 (2–17) years for boys, and 12.7 3.1 (3–17) for girls. Of the cases shown distributed by age-groups in Table 1, 11.1% (111 cases) were the children of broken families. The level of cases aged 12 or above in abused girls was statistically significantly higher compared to the same age-group in boys (v2 = 51.9; p < 0.001). All those perpetrating abuse were male, with a mean age of 26.8 12.5 (11–80 years). The child was previously known to the aggressor in 88.2% of cases, and incest was determined in 102 (10.2%) cases. Approximately half of children (47.9%) were subjected to abuse in the home environment, and abuse was recurrent in 476 (47.5%) cases. Recurrent abuse was significantly higher among victims of incest compared to other children (v2 = 94.5; p < 0.001). TABLE 1––Gender distributions by age-group. Male N (%)
Age-Group 0–6 7–11 12–17 Total
27 74 91 192
v2 = 51.9; p < 0.001.
(14.1) (38.5) (47.4) (100)
Female N (%) 38 181 591 810
(4.7) (22.3) (73.0) (100)
Total N (%) 65 255 682 1002
(6.5) (25.4) (68.1) (100)
Vaginal, anal, and/or oral penetration was determined in 41.1% of cases, and 6.9% of cases were exposed to physical violence in addition to sexual abuse. Events came to light as a result of direct disclosure to family, teacher, or a person such as a friend in 61.8% of cases; 53.3% of children first told a member of their family, with 36.9% issuing a legal complaint on the same or the following day and 14.3% 1 year afterward. Legal complaints were issued significantly later in cases of incest compared to the others (v2 = 228.1; p < 0.001). Assessments revealed that psychological pathology associated with sexual abuse developed in 62.1% of cases. The most common diagnoses were depressive disorder (37.5%) and PTSD (36.9%). Sexual abuse-related data are given in Table 2. Model compatibility at logistical regression analysis performed to examine factors influencing the development of psychological pathology after sexual abuse is 66.6%. Analysis revealed that female gender, presence of penetration, exposure to physical violence, and presence of incest highly significantly affected development of psychological pathology (p < 0.01). Female gender and exposure to penetration increased the risk of development of psychological pathology twofold, while exposure to physical violence increased the risk 13-fold. Prevalence of psychological pathology increased with age and repetition of abuse, although the difference was not statistically significant (p > 0.05) (Table 3). Discussion Sexual abuse affects children of all ages, of all races and cultures, of all socioeconomic levels, and in all countries (6,7,27,28). Epidemiological studies show that sexual abuse is a major threat to 5–20% of all children and that girls are at 2–3 times higher risk than boys (18,29–31). In this study, too, in agreement with previous similar research, the great majority of victims were girls (80.8%) (6,32–39). The number of cases rose with age, with 6.5% of children in the study group aged 0–6, 25.4% aged 7–11, and 68.1% aged 12–17. Some studies have reported that the risk in childhood sexual abuse increases with age, while others have suggested the case numbers decrease with age (18,33,35,39). This discrepancy may be attributed to prevalence of exposure weighted by age, calculating the victim age-group as a proportion of the age-group in its own population, not being expressed. However, all these
AYDIN ET AL. TABLE 2––Data regarding sexual abuse to which children were exposed.
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CHILD SEXUAL ABUSE
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TABLE 3––Logistic regression analysis of factors affecting development of psychological pathology.
N (%) Scene of event Home Area open to the public School Inside vehicle Other isolated, closed area Workplace Victim/aggressor relationship Acquaintance Boyfriend Neighbor Friend Family member Other relative Teacher Local trader Friend of family member Other* Stranger Form of abuse Touching, kissing, or fondling Vaginal penetration Anal penetration Oral penetration Vaginal and anal penetration Anal and oral penetration Physical violence Yes No First person informed Family member Police Teacher Friend Relative Other† How the event was revealed Direct disclosure by victim Disclosure when asked as a result of suspicions Statement to police Statements by witnesses As a result of medical examination Time of judicial complaint Same or next day Within 1 month 1 month–1 year After more than 1 year Psychiatric diagnosis Depressive disorder PTSD PTSD and depressive disorder Acute stress disorder Depressive disorder and acute stress Anxiety disorder None
480 218 140 59 58 47
(47.9) (21.7) (14.0) (5.9) (5.8) (4.7)
884 207 139 123 102 90 53 35 30 105 118
(88.2) (20.6) (13.9) (12.3) (10.2) (8.9) (5.3) (3.5) (3.0) (10.5) (11.8)
590 282 91 12 22 5
(58.9) (28.1) (9.1) (1.2) (2.2) (0.5)
69 (6.9) 933 (93.1) 532 265 92 65 34 14
(53.1) (26.4) (9.2) (6.5) (3.4) (1.4)
619 155 89 70 69
(61.8) (15.4) (8.9) (7.0) (6.9)
370 162 327 143
(36.9) (16.2) (32.6) (14.3)
215 213 157 30 4 3 380
(21.4) (21.3) (15.7) (3.0) (0.4) (0.3) (37.9)
*Previous acquaintances of some kind. † Neighbor, doctor attended, and boyfriend.
data still support the idea that sexual abuse affects children of all ages. Several studies have reported that the majority of attackers are male and generally (63.2–83.3%) known to or acquainted with the victim and that 16.4–27% of assailants are members of the family (9,16,17,32,33,35,36,38–42). In agreement with this, all the attackers in this study were male and 88.2% were known to the victim, while 10.2% were family members. This may be attributed to people who are known and related having easier access to children, and to children not suspecting such people and trusting them more easily.
Variables Female Presence of penetration Presence of physical violence Presence of incest Repetition of abuse Age-group 0–6 years 7–11 years 12–17 years
SE
Wald
d.f.
Sig.
Exp (B)
0.826 0.749 2.570
0.176 0.150 0.601
22.039 24.775 18.314
1 1 1
0.000 0.000 0.000
2.285 2.114 13.064
0.885 0.073
0.284 0.143
9.744 0.264
1 1
0.002 0.607
2.423 0.929
– 0.139 0.210
– 0.293 0.279
4.361 0.225 0.566
2 1 1
0.113 0.635 0.452
– 1.149 0.811
B
Approximately half the children in this study were abused in the home environment. K€ ußc€ uker (34) reported that 64.5% of children were abused in the home, while Sharma and Gupta (36) cited 63.39% and Bahali et al. (33) suggested 50%. Bearing in mind that the majority of children are sexually abused by people they know and who are close to them, then it is to be expected that the site of abuse will be the home, which requires no special efforts and raises no suspicions. Studies report varying levels regarding types of abuse to which children are exposed. One study in Italy reported that 33.9% of children under 14 subjected to abuse were exposed to anal or vaginal penetration or attempted penetration by the penis and 6.1% with other objects (39). One study in Turkey evaluating 101 cases of child sexual abuse in the 4–17 age-group reported abuse involving penetration at a level of 48.5% (33). Another study of 83 cases in the 0–17 age-group reported abuse involving penetration at a level of 35% and that additional physical violence was also present in 10.8% of these 83 cases (35). In our study, too, 41.1% of sexual abuse victims were subjected to abuse including penetration and 6.9% of cases were also subjected to physical abuse. Sharma and Gupta (36) reported that child victims of sexual abuse most commonly (47.2%) disclosed this abuse to their mothers at home and that outside the family; disclosure was most commonly (33.3%) made to health workers. They also reported that 44.4% of children made disclosure when asked by parents or close friends and that 36.1% disclosed sexual abuse because of pain in their private parts. In our study, 53.1% of child victims of sexual abuse first disclosed the event to members of the family; 61.8% disclosed the event directly without being asked, while 15.4% reported abuse after being asked when family or close friends became suspicious. These levels are significant; more than half of victims of abuse sought help from families by disclosing events directly, while the families and friends of only 15.4% of children suffering sexual became suspicious and asked children whether they had been abused. In addition, 53.1% of children reported abuse to the judicial authorities within the first month and 49.9% after more than 1 month. This reveals that there is still a great need for society, families, and children to be informed about child abuse and for protective approaches to be developed if children are to be protected. Child victims of incest generally do not disclose their experiences, usually due to feelings of shame, fear guilt, and other causes. In addition, families that are aware of abuse suffered by children prefer to cover the matter up, again from a variety of concerns. In cases of incest, which generally remains hidden for such reasons, the abuse lasts longer and is recurrent, and judicial complaints are made later compared to other cases (43–45). In
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this study, too, abuse was repeated significantly more in victims of incest compared to other children, and judicial complaints were again made later. The effect of sexual abuse of the child’s psychological life is extremely complex. Child sexual abuse is associated with various psychiatric disorders that begin in childhood and persist in adulthood (46). In a review in which they investigated the longterm effects of child sexual abuse, Polusny and Follette (47) reported prevalence levels of PTSD of between 33% and 86% in child abuse cases and prevalences of major depression of between 13% and 88%. In the first clinical assessment, when standard instruments were used, approximately 40% of children exposed to sexual abuse have been reported to have few or no psychiatric symptoms (18,20,48). However, long-term studies have reported that problems may begin later in 12–18 months in 10–20% of asymptomatic children and that initially asymptomatic children may experience severe problems at more advanced ages (18,20,48). In accordance with these studies, psychiatric pathologies were determined in 62.1% of the victims of sexual abuse in our study. Most frequent were depressive disorder (37.5%) and PTSD (36.9%). In addition, if the cases constituting the study group will be reassessed over time with long-term observation, we presume that the number of cases in which psychiatric pathologies were seen could be higher. The psychological impact of the event on children may vary depending on the child’s age and sex, type of abuse, its duration and severity, involvement of penetration, the relationship between the child and the abuser, and the use of force or violence (19–21,46). Impact of sexual abuse rises from the age of 6–7 and becomes significant from the age of 10 (49). Two metaanalyses reported that the adverse effects in cases of child sexual abuse were not equivalent for males and females and that adverse effects were observed at a much lower level in boys (50,51). Abuse being prolonged and frequent, its involving penetration, the use of violence, and the assailant being someone closely related to the child all lead to a much more negative psychological impact and determine the degree of symptomatology (20,21). In our study, logistic regression performed to reveal the factors affecting the development of psychological pathology showed that, in agreement with the literature, female gender, presence of penetration, exposure to physical violence, and the presence of incest statistically significantly increased the development of psychological pathology. Prevalence of psychological pathology increased with age and in the event the abuse was recurrent, although the differences were not statistically significant. Our inability to determine duration of abuse and time to disclosure are limitations of the study. Nonetheless, this evaluation of data for 1002 children subjected to abuse over a 7-year period contributes to the determination of the characteristics of sexual abuse experienced by children in Turkey, the dimension of the resulting damage and the factors affecting development of psychological pathology. The fact that very few children make disclosure when asked also reveals the need for levels of consciousness among people the child trusts, such as families and teachers, to be raised and for preventive measures to eventually be taken. As it is known that for the child to believe that he/she is safe after the event and to be able to describe his/her experiences will reduce the adverse effects of the trauma in the long term, cases of abuse not remaining hidden but being reported to the appropriate authorities are very important in terms of treatment and rehabilitation. For that reason, medical and social support units
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