Child sexual abuse: Report of 311 cases with review of literature

Abstract

Child sexual abuse (CSA) is a global problem that has significant consequences for public health; it has been a prominent topic of public concern for more than a decade, but many basic facts about the problem remain unclear or in dispute. We conducted a study of 311 cases of CSA in order to highlight the epidemiological features and negative impact on victims' well-being and to emphasize the need for a multidisciplinary approach to the primary prevention and management of CSA. We noted an increase in cases number with male predominance. Most of our patients came from lower socioeconomic classes. The perpetrators were male in 100% of cases; acquaintances in 70% of cases and family members in 22 cases. Physical examination were normal in 61% of cases, however, a range of psychological and physical effects were identified with dramatic health consequences: three cases of attempted suicide, five pregnancies and one case of HIV virus infection.

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Child sexual abuse: report of 311 cases with review of literature
Laila Essabar
1
, Abdenbi Khalqallah
2
, Badr Sououd Benjelloun Dakhama
1,&
1
Department of Paediatric Medical Emergencies of Rabat children’s Hospital, Morocco,
2
Laboratory of Clinical and Pathological Psychology,
Mohammed V University, Rabat, Morocco
&
Corresponding author: Badr Sououd Benjelloun Dakhama, Laboratory of Clinical and Pathological Psychology, Mohammed V University, Rabat,
Morocco
Key words: Child, rape, incest, reporting, suicide, depression
Received: 10/05/2014 - Accepted: 22/09/2014 - Published: 19/01/2015
Abstract
Child sexual abuse (CSA) is a global problem that has significant consequences for public health; it has been a prominent topic of public concern
for more than a decade, but many basic facts about the problem remain unclear or in dispute. We conducted a study of 311 cases of CSA in order
to highlight the epidemiological features and negative impact on victims' well-being and to emphasize the need for a multidisciplinary approach to
the primary prevention and management of CSA. We noted an increase in cases number with male predominance. Most of our patients came from
lower socioeconomic classes. The perpetrators were male in 100% of cases; acquaintances in 70% of cases and family members in 22 cases.
Physical examination were normal in 61% of cases, however, a range of psychological and physical effects were identified with dramatic health
consequences: three cases of attempted suicide, five pregnancies and one case of HIV virus infection.
Pan African Medical Journal. 2015; 20:47 doi:10.11604/pamj.2015.20.47.4569
This article is available online at: http://www.panafrican-med-journal.com/content/article/20/47/full/
© Laila Essabar et al. The Pan African Medical Journal - ISSN 1937-8688. This is an Open Access article distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original
work is properly cited.
Pan African Medical Journal – ISSN: 1937- 8688 (www.panafrican-med-journal.com)
Published in partnership with the African Field Epidemiology Network (AFENET). (www.afenet.net)
Case series
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Introduction
Childhood sexual abuse (CSA) is a complex life experience that has
become the subject of great community concern and the focus of
many legislative and professional initiatives. This is evidenced by the
expanding body of literature on sexual abuse, public declarations by
adult survivors and increased media coverage of sexual abuse
issues. However, in Morocco, because sexual abuse is usually a
hidden offense, there are no statistics on how many cases actually
occur each year. Statistics cover only the cases that are disclosed to
child protection associations, to children´s hospitals or to law
enforcement. The purpose of our study is to highlight the
epidemiological features and negative physical and mental health
effects on CSA victims; and emphasize the need for a
multidisciplinary approach to the primary prevention and
management of CSA.
Methods
We conducted a 20 years (January 1993- March 2014) retrospective
study of CSA victims consulting at the department of paediatric
medical emergencies of Rabat children's Hospital. The clinical
records of 311 patients were reviewed; we identified demographic
data, CSA characteristics, clinical and psychological features and
therapeutic and follow-up data.
Results
Frequency
Before the late 1999s, CSA cases were sporadic. In the following
decades, the number of cases reported annually increased with a
peak in 2007, since that year a little decline was recorded (Figure
1).
Demographic characteristics
Age:
we noted that approximately 15% of victims were between
ages 0 and 5 years. Between ages 6 and 10 years, the percentage
almost tripled (48%). Ages 11 to 15 years accounted for a quarter
(26%) of cases, with children 16 years and older accounting for the
remaining 11 % of cases (Figure 2).
Gender:
before the age of 16 years boys were at about two times
higher risk than girls, with a percentage of 68 %. Victims 16 years
and older were female in 82% of cases (Figure 2).
Disabilities
: we identified 3 cases of CSA with mental retardation
Socioeconomic status:
reported cases came from all
socioeconomic classes; however, almost 72% of cases had a low
socioeconomic status, the majority was living in sub-rural areas.
Family structure:
we observed some cases of familial
impairments, in fact parental substance abuse was noted in 11% of
cases, the absence of one/both parents was identified in 17% of
cases, as well as the presence of a stepfather in the home (8%) and
parental conflicts (45%).
Abuse characteristics
Offender:
100% of child sexual abuse perpetrators were men.
Offender's relationship to victim: 81% of victims were sexually
abused by a non-relative; offenders outside the family were casual
acquaintances of the victim in 70% of cases and strangers in 30%
of cases. Employers were the offenders in just 3% of victims. We
identified 16% cases of incest; of these, two thirds were abused by
their biological fathers. 7% of victims were abused by multiple
offenders.
Type of abuse:
we noted a spectrum of sexual abuse types
ranging from non-contact forms to contact forms of abuse, through
to intercourse. In fact, 64% of victims were sodomized, 18% were
subjected to fondling and 10% of cases had oral-genital intercourse.
We also noted defloration in 8% and exposure to pornography in
two cases. Furthermore, the sexual abuse was associated with
physical violence in 21% of cases.
Frequency of abuse:
CSA occurred as repeated episodes in 67%
of cases: of these, victims were reabused by the same perpetrator
in 78% of cases.
Disclosure:
reporting delay ranges from a few hours to 24 months.

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Physical findings: clinical examination was normal in 61% of
cases; it showed in the remaining cases non specific findings such
as vulvovaginitis, erythema, anal fissures and perianal scars, as well
as anal dilatation with stool soiling. We noted anal warts in one
case. Signs of additional physical violence were noted in 11%.
Psychological and behavioral symptoms
We observed through our study an array of behavioral disorders
with different degrees including fear, anxiety, irritability, regression
in school performance, sleep disturbances, eating disorders, social
problems as well as poor self-esteem. We also noted inappropriate
sexualized in some cases. However, approximately 22% of our
patients had no symptom. Incest victims had particularly severe
problems such as depression and attempted suicide that was noted
in three cases.
Consequences
The main consequences included three cases of suicide attempts;
five cases of pregnancies, three of whom were subjected to incest.
Two cases of sexually transmitted infections (STIs) were noted, HIV
infection in one case (revealed by the systematic screening for STIs)
and HPV anal warts in the second case.
Management
Management was based on a multidisciplinary approach with on
numerous components ranging from medical and psychological
treatment to reporting through social support.
Discussion
Definition
Having a clear operational definition of child maltreatment - and
CSA as a specific aspect of child maltreatment- is increasingly
recognized as fundamental to effective preventative strategies [1].
The World Health Organization has defined child sexual abuse as
being: "The involvement of a child in sexual activity that he or she
does not fully comprehend, is unable to give informed consent to, or
for which the child is not developmentally prepared and cannot give
consent, or that violates the laws or social taboos of society. Child
sexual abuse is evidenced by this activity between a child and an
adult or another child who by age or development is in a
relationship of responsibility, trust or power, the activity being
intended to gratify or satisfy the needs of the other person. This
may include but is not limited to: the inducement or coercion of a
child to engage in any unlawful sexual activity; the exploitative use
of a child in prostitution or other unlawful sexual practices; the
exploitative use of children in pornographic performance and
materials" [2].
Statistics
Designing effective child protection measures requires a reliable
understanding of the extent of the problem and its context.
Globally, the number of studies on the prevalence of CSA has been
growing. Based on a summary of existing studies, WHO estimates
that between approximately 20 percent of girls and 5 to 10 percent
of boys are victims of sexual abuse all over the world [3]. In
Morocco, like many developing countries, there is a huge lack in
data and the existing findings don't reflect the accurate magnitude
of the problem, the main challenge is the sociocultural context and
the huge culture of silence that surround sexual issues. A further
challenge is that current estimates vary widely as a function of the
definitions used, the quality of data collection methods as well as
the age of study participants and the age at which childhood is
defined. As a global phenomenon, CSA was regarded as rare before
the late 1970s. In the following decades, we noted through our
study and many other series that the incidence increased
dramatically (Figure 1) [4]. Although much of this apparent
increase probably reflected a growing awareness among the public
and professionals, some studies suggest that the overall incidence
of child abuse and neglect increased [5]. The increase in our study
may also be due to the creation in 1999 of the children's listening
and protection center of the child rights observatory, a structure
that provides support and encourages victims to disclose their
victimization; reported cases of CSA, however, declined since 2007.
This decline could be due to the creation of new medical centers
where new cases were referred instead of our department.
Risk factors
While it is impossible to create a profile of children who will be
sexually abused, it is possible to describe characteristics that are
more common among victims and are identified as risk factors for
CSA.

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Age:
there is some discrepancy in the available data about whether
teenagers are at higher risk or whether the risk is more uniformly
distributed. Some data [6] show a relatively uniform risk for children
after age 3. Other studies found that over half of the children who
were sexually victimized were between 15-17 years old [7]. In our
study, nearly half of cases were between 6 and 11years while
children aged 16 years and older counted 11% because most of
them were referred to the gynecological department (for girls) and
the adult emergency department (for boys). Moreover, some studies
[8] believe that, as a risk factor, age operates differentially for girls
and boys, with high risk starting earlier and lasting longer for girls.
Disabilities:
physical disabilities are associated with increased risk
[9]. Three factors seem to contribute to this increased vulnerability:
dependency, institutional care, and communication difficulties. In a
study of 150 interviewed deaf youth at a residential school, 75
children reported being sexually abused, 19 reported being victims
of incest, and 3 reported both physical and sexual abuse [8]. We
identified, in our study, 3 cases of CSA with mental retardation.
Gender:
all reliable studies conclude that girls experience more
sexual abuse than do boys in 78% to 89% of cases [10]. Male
children in our studies constitute a large proportion of victims before
the age of 16 years.
Socioeconomic status:
although low socioeconomic status is a
powerful risk factor for physical abuse and neglect, it has much less
impact on CSA. However, a disproportionate number of CSA cases
reported to Child Protective Services come from lower
socioeconomic classes [11]. In our study, victims coming from
economically disadvantaged backgrounds accounted about three
quarters of cases.
Family structure:
parental inadequacy, unavailability, conflict, and
a poor parent-child relationship show up most consistently in
epidemiological studies [12-14] as risk factors for CSA. In many
studies children with alcoholic, drug abusing, or emotionally
unstable parents are also at risk, as are those with parents who are
punitive or distant [15, 16]. However many victims of sexual abuse
display none of these markers.
Other types of victimization:
children who experience other
forms of victimization are more likely to be the target of sexual
victimization [7, 17].
Abuse characteristics
Type of abuse:
At the extreme end of the
spectrum, sexual abuse includes sexual intercourse or its deviations.
Yet all offences that involve sexually touching a child, as well as
non-touching offenses and sexual exploitation, are just as harmful
and devastating to a child's well-being. Touching sexual offenses
include fondling; making a child touch an adult's sexual organs; and
penetrating a child's vagina or anus no matter how slight with a
penis or any object that doesn't have a valid medical purpose. Non-
touching sexual offenses include: engaging in indecent exposure or
exhibitionism; exposing children to pornographic material;
deliberately exposing a child to the act of sexual intercourse; and
masturbating in front of a child. Sexual exploitation can include
engaging a child or soliciting a child for the purposes of prostitution;
and using a child to film, photograph or model pornography.
Physical violence is very rarely used; rather the perpetrator tries to
manipulate the child's trust and hide the abuse [7, 17]. However in
our study CSA was associated with physical violence in 21% of
cases.
Perpetrators:
the perpetrators of sexual abuse are overwhelmingly
male. Male constituted 100% of the offenders in our study and
more than 90% in many studies [10, 18, 19]. Although female
perpetrators constitute a small percentage; abuse by female has
been mushrooming recently [20]. According to studies, the third of
convicted sex offenders were sexually abused as children [21]. Our
study and several studies agree that approximately half of offenders
are acquaintances [6, 22]. The studies differ more about the
percentage who are family members, the range is going from 14%
to 47% [17, 18, 23] with 16% in our work. Strangers make up the
smallest group of perpetrators ranging from 7% to 25% [5, 10, 24,
25] with 24% in our study. The apparent percentage of extrafamilial
perpetrators should not obscure the accurate proportion of
intrafamilial abuse which tends to be underrepresented among
reported cases given the sociocultural restraints surrounding sexual
issues especially in developing countries like Morocco.
Frequency of abuse:
CSA frequently occurs as repeated episodes
that become more invasive with time. Perpetrators usually engage
the child in a gradual process of sexualizing the relationship over
time [2]. In our study CSA was repeated in 67% of cases: of these,
victims were reabused by the same perpetrator in 78% of cases.
Dynamics of disclosure: children rarely disclose sexual abuse
immediately after the event [26, 27]. Disclosure tends to be a

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process rather than a single episode and is often initiated following
a physical complaint or a change in behavior. Disclosure was
delayed in the majority of cases in our study reaching 24 months in
a 12 years old incest case.
Physical findings: the evaluation of children requires special skills
and techniques in history taking, forensic interviewing and
examination; the examiner may also need to address specific issues
related to consent and reporting of child sexual abuse [28, 29]. In
practice, clear physical findings of sexual abuse are seldom seen in
children, as physical force is rarely involved. Many studies have
found that normal and non-specific findings are common in sexually
abused prepubertal girls [30, 31]; clinical examination in our study
was normal in 61% of cases. Moreover, in the vast majority of cases
the medical examination will neither confirm nor refute an allegation
of sexual assault. Clinical examination may reveal physical health
consequences [26, 32], that include gastrointestinal disorders (e.g.
irritable bowel syndrome, non-ulcer dyspepsia, chronic abdominal
pain); gynaecological disorders (e.g. chronic pelvic pain,
dysmenorrhea, menstrual irregularities) and somatization (attributed
to a preoccupation with bodily processes). Other serious
consequences include pregnancy and sexually transmitted infections
(STIs), pregnancy was noted in 5 cases in our study, three of whom
were incest victims. A study of factors associated with teenage
pregnancy [33], found that forced sexual initiation was the third
most strongly related factor, after frequency of intercourse and use
of modern contraceptives. An organization for teenage mothers in
Costa Rica reported that 95% of its clients under the age of 15 had
been victims of incest [34]. The prevalence of STIs in pediatric
victims of sexual abuse depends on the type of abusive exposure,
genital symptoms, prior consensual sexual activity in adolescents,
and the regional prevalence of STIs in the adults [35]. Gellert et al
[36] evaluated the risk for HIV seroconversion among children with
a history of sexual abuse and found that 28 0.4% were HIV
seropositive. Systematic screening for STIs in our study revealed
HIV in one case. Sexual abuse is the most worrisome form of HPV
transmission. One of our patients contracted HPV anal warts.
Psychological and behavioural symptoms
A variety of adult psychiatric conditions have been clinically
associated with CSA. These include the disorders of major
depression, borderline personality disorder, somatization disorder,
substance abuse disorders, posttraumatic stress disorder (PTSD),
dissociative identity disorder, and bulimia nervosa [5]. This apparent
diversity can be explained in part by the heterogeneity of CSA
experiences, the complexity of the confounds among abuse severity
variables, and a host of moderating and mediating constitutional
and environmental variables together with important individual
differences in coping strategies that may come into play at different
points in development in any given case [37]. Some studies suggest
that penetration, the duration and frequency of the abuse, force,
the relationship of the perpetrator to the child, and maternal
support affected the degree of symptomatology [38]. For instance,
survivors of incest may have particularly severe problems, especially
if the offender was a father or stepfather. 53% of adult survivors of
incest said the abuse caused "some" or "great" long-term
psychological effects [21]; in our study, incest resulted in three
cases of attempted suicide. Numerous studies have found that
sexually abused children exhibited more sexualized behaviors than
various comparison groups, including non abused psychiatric
patients [38-40]. These include such activities as kissing with one's
tongue thrust into the other person's mouth, fondling one's own or
another person's breasts or genitals, masturbation, and rythmic
pelvic thrusting. Furthermore, a history of CSA, but not a history of
physical abuse or neglect, is associated with a significantly increased
arrest rate for sex crimes and prostitution irrespective of gender
[41]. Despite the variety of behavioral disorders that was found in
our study, initial psychological evaluation showed no symptoms in
approximately 22% of our patients, this result was consistent with
those of other studies [38]. The limited longitudinal data available,
however, suggest that 10% to 20% of asymptomatic children will
deteriorate over the next 12 to 18 months, this phenomenon is
termed sleeper effects [5]. Thus, further studies will be needed to
find out the long-term effects on our patients.
Management
medical care:
includes STIs screening and
treatment; decisions about STI testing in children should be made
on a case-by-case basis. If testing is warranted, age-appropriate
diagnostic tests should be used. Presumptive treatment of children
for STIs is not generally recommended [2]. STIs screening in our
study was systematic, it was repeated when the abuse occurred
recently because STI cultures were likely to be negative.
Psychological treatment:
an array of treatment protocols have
been offered in the literature providing care for the victims, their
families and also the perpetrators. Many studies showed that
sexually abused children improved significantly over time [5]. A
number of symptoms, especially aggression and sexualized
behavior, remain largely resistant to these approaches, however.

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Reporting:
every community has its own set of laws governing
how, and to whom, a report regarding suspicion of child sexual
abuse should be made. Typically the reporting law leaves the final
determination as to whether or not abuse occurred to the
investigators, not the reporters [42]. Morocco like most communities
also has a mandatory reporting structure for professionals working
with children.
Counselling and social support:
provide support to the victim
and to those caring him. This may be required even if the child itself
is not assessed as needing therapy.
Follow-up consultation:
is strongly recommended to ensure that
the appropriate counselling referrals have been made and that there
is adequate support for the child and family.
Conclusion
Child sexual abuse has substantial consequences not only for the
affected persons, but also for society as a whole, and these can no
longer be ignored. This Urgent situation has now been recognized in
Morocco which is responding with a diverse range of prevention and
intervention programs. However the serious shortcomings in data
tend to impede the effectiveness of such measures. Thus, improved
studies are required in order to provide data on the accurate
magnitude of the CSA, on its distribution and factors that point to
vulnerability.
Competing interests
The authors declare no competing interest.
Authors’ contributions
All authors have read and approved the final version of the
manuscript.
Figures
Figure 1: reported cases by year in our study
Figure 2: age and gender of victims in our study
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Figure 1: reported cases by year in our study
Figure 2: age and gender of victims in our study