Biomedical Research

Abstract

Objectives: In this study, it is aimed to evaluate the data of the cases subjected to the sexual abuse/ assault and to compare various characteristics according to the age.

Method: Information of the sexual abuse cases examined by the Psychiatry Department between September 2010-2011 was obtained retrospectively. Descriptive analysis was done and independent group’s rates were compared with chi-square test.

Results: Fifty (62.5%) of the cases were under 18 and 30 (37.5%) of them were over 18 years old. The youngest case was 15 years old. In the group aged below 18 years the female: male ratio was 96%:4% and in the group aged over 18 years, it was 89.3%:10.7%. Under 18 years, 4 (8%) cases were married by religious ceremony only, 1 (2%) case had separated from the spouse of a religious marriage and 45 (90%) cases were single. Over 18 years, 9 cases (30%) were married, 15 (50%) were single and 4 (13.3%) were divorced. In both groups, the proportions of women were significantly higher than men. In both groups it was determined that the majority of the abusers were familiar persons. There was not any difference between the groups by means of the familiarity of the abuser, place where the incident occurred, type of the abuse and the diagnosis determined by the psychiatric examination after sexual abuse.

Conclusion: It is important to determine that the women composed of the majority of the cases in both groups, abusers were generally familiar persons, boyfriend abuses were more prevalent in the adolescent group and there were several cases that had religious marriages in the adolescent group. More studies are needed in this field in order to maintain a standard evaluation of the sexual abuse cases and minimize the understanding and language differences between law enforcement and health care providers.

Keywords

Sexual abuse, Sexual assault, Adolescent, Adult.

Background

Child sexual abuse is a form of child abuse in which an adult or older adolescent uses a child for their sexual stimulation [1,2]. Forms of child sexual abuse include engaging in sexual activities with a child (whether by asking or pressuring, or by other means), indecent exposure (of the genitals, female nipples, etc.), child grooming, or using a child to produce child pornography [1,3].

According to WHO “Child sexual abuse is the involvement of a child in sexual activity that he or she does not fully comprehend, is unable to give informed consent to, 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” [4].

The concept of sexual abuse is defined as ‘a child or adolescent who has not completed sexual development being used to gratify sexual desires or needs by an adult, by means of force, threat or deception [5]. Sexual abuse of a child is defined as an event leading to the sexual gratification of an adult by a child under the age of consent or condoning that situation [6]. When the victim and the abuser are both children, when there is an age difference of 4 years or more, forcing or persuading a younger child or exposing them to activities for sexual gratification is accepted as abuse [6]. The exposure of children to sexual abuse has been reported at 10%-40% [5].

In pediatric, adolescent and adult age groups, the victims of sexual abuse and attacks are generally female [7]. It has been reported in the USA that 1 in 6 women is at risk of sexual violence at some time in their life [8]. In various studies conducted in Turkey, it has been observed that the majority of victims are female [6,9,10].

Exposure to abuse by peers has been reported to occur more in adolescence compared to childhood and young adulthood. Exposure to sexual abuse in childhood increases the risk of being a victim of such an event in adolescence [11]. For similar reasons, children and adolescents are included in the risk groups for sexual abuse [8,11,12].

Previous studies have shown several features which increase the likelihood of being a victim of abuse. These include having experienced abuse in the past, substance and alcohol abuse, having a psychiatric disease, lacking in self-confidence, a low socio-economic level, knowing the abuser, having no knowledge of the risk factors of abuse and engaging in risky sexual behavior in adolescence [8,11,13]. In addition, it must be kept in mind that there is a relationship between these characteristics, the abuser and the societal structure.

Sexual abuse is important in respect of the psychiatric and physical problems to which it will lead both in the short term and at later stages of life. It is not only the victim who is affected but also their family and loved ones [12]. In the legal context of the Turkish Penal Code Law no 102, besides the presentation of objective findings of sexual assault to physicians undertaking a judicial function, that there are some features which increase the severity of the punishment of the attacker creates a responsibility for research [14,15].

It was aimed to compare various characteristics among age groups in this retrospective evaluation of the information of individuals for whom a consultation was requested by the Forensic Medicine Department of a university medical faculty for ‘an evaluation of whether or not the physical and mental integrity of the individual has been impaired because of an alleged act of sexual abuse’.

Materials and Methods

Sexually abused or sexual assault victims who applied to Psychiatry, Forensic Medicine, Departments clinics of Gaziosmanpasa University Faculty of Medicine between September 2010 and September 2011 were investigated retrospectively. The information was recorded on a data form prepared by the researchers. We reached records of 80 cases. Social, demographic and clinical characteristics of victims were analyzed. Age, gender, educational level, marital status, occupation of victim, Assailants familiarity to victim, how they applied (if brought by police; or by consultation of forensic medicine; or self-application) of victims were evaluated.

Approval for the study was granted by the Scientific Research Evaluation Committee of University Medical Faculty.

The data obtained in the study were analyzed using SPSS 11.5 program. In addition to descriptive analysis, the ratios of independent groups were compared using the Chi-square test. A value of p<0.05 was accepted as statistically significant.

Results

Between September 2010 and September 2011, evaluation was requested for a total of 80 cases in respect of whether or not mental health had been impaired following sexual abuse. The cases comprised 50 (62.5%) below the age of 18 years with a mean age of 15.50 ± 1.85 years and 30 (37.5%) over the age of 18 years with a mean age of 26.57 ± 6.52 years. The youngest case was 15 years old. In both groups, the ratio of females to males was found to be statistically significantly high (p<0.001). In the group aged below 18 years the female: male ratio was 96%:4% and in the group aged over 18 years, it was 89.3%:10.7%. The educational level of those aged below 18 years was having finished primary school in 7 cases(14%), middle school in 21 (42%), high school in 20 (40%) and 1 was illiterate (2%). The education level of 1 case was unknown. In the group aged over 18 years, the educational level was having finished primary school in 10 cases (33.3%), middle school in 3 (10%), high school in 7 (23.3%), university in 5 (16.6%) and 2 were illiterate (6.6%). No information was available about the educational level of 3 cases.

In the group aged below 18 years, 4 (8%) cases were married by religious ceremony only, 1 (2%) case had separated from the spouse of a religious marriage and 45 (90%) cases were single. In the group aged over 18 years, 9 cases (30%) were married, 15 (50%) were single and 4 (13.3%) were divorced. The marital status of 2 cases was not known. In the group aged below 18 years, 30 cases (60%) were students, 6 (12%) were not students, 12 (24%) were housewives (married officially or by religious ceremony) and 1 (2%) was self-employed. No information was available for 1 case. In the group aged over 18 years, 5 cases (16.6%) were unemployed, 7 (23.3%) were students, 11 (36.6%) were housewives and 5 (16.6%) were self-employed. Employment information was not available for 2 cases. As expected, no statistically significant difference was determined between the two groups in respect of education level, marital status and employment (p<0.001, p=0.011, p=0.014, respectively).

Information related to the relationship between abuser and victim is shown in Table 1, the scene of the incident in Table 2, the type of assault in Table 3. No statistically significant difference was determined between the groups in respect of these variables.

Table 1: Assailants familiarity.

Table 2: Crime scene.

Table 3: Abuse type.

Discussion

Sexual violence is a generally widespread problem throughout the world, with 1 in 5 females exposed to an incident of sexual violence at some time in their life and approximately 1 in 10 females is thought to be a victim of rape [16]. Although sexual violence is a form of violence experienced by both genders, females are at much greater risk [7,12,16]. In the current study, the ratio of females to males was found to be significantly higher in both the group aged below 18 years and those aged over 18 years (96% and 89.3%, respectively). These rates are similar to those of previous studies in Turkey [6,9,10].

In the current study, 62.5% of the individuals who underwent psychiatric evaluation because of sexual abuse were aged below 18 years. Some groups are thought to be at greater risk of sexual abuse. These groups include victims of physical or sexual abuse in childhood or adolescence, disabled individuals, those with substance abuse, sex workers, the extremely poor or homeless, prison inmates or those living in areas of military conflict [8,12]. Adolescence is a turbulent time of life with the effect of rapid physical and psychological changes. In a study by Creighton et al which examined the psychological profiles of the victims of sexual violence, it was reported that females aged 16-19 years were at greater risk of sexual abuse than those of an older age [13]. According to the results of the National Study on Violence towards Women, 32% of the women raped in the USA are aged 12-17 years old [17].

In a study conducted in Denmark, it was suggested that a period of 6 months following the 15th birthday was a high risk period [11]. However much statistical significance was shown in the difference of the ratios between the two groups of the current study, that there were greater numbers of children and adolescents than adults is consistent with previous data that this age group is at greater risk.

In the current study, 74% of the abusers of the group aged below 18 years were known to the victim and 66.5% in the group aged over 18 years (relative, neighbor, acquaintance). The vast majority of sexual assaults are perpetrated by an individual known to the victim [8,16]. In a study by Janisch et al., it was reported that assaults were perpetrated by a current or ex-partner of the victim or by a family member in 24.3% of cases, by an individual known to the victim in 24.3% and by a stranger in 12.6%. In various studies previously conducted in Turkey, the perpetrator has been seen to be a relative, neighbor or close family member of the victim at rates of 70-80% [6,9,10]. Although the results in both groups of the current study were consistent with literature, the closest statistically significant difference between the children/adolescents group and the adult group was seen to be in this area. In both groups, the majority of the perpetrators were known to the victim but not related by blood. In addition, in the children/adolescent group, the perpetrator was a boyfriend in 24% of cases, which was a much higher rate than in the adult group (3.3%). This may be due to children and adolescents making themselves vulnerable to people they do not know well enough for reasons such as feeling the need to prove or confirm a relationship in the belief that they can trust their peers when they are more cautious in their approach to adults.

In a study which investigated the risk of peer sexual abuse, factors which increased the risk were shown to be having a depressive friend who had been exposed to violence on a date, a high number of sexual partners, displaying high risk sexual behavior (going to the house of a man not well known or inviting him to your house) and being over-sensitive to rejection by peers [11]. It must be noted that there is a reciprocal, self-sustaining relationship between the risk factors and exposure to abuse. Adolescents who try to maintain a secret friendship with a friend of the opposite sex of whom the family disapproves may increase the risk as an adult may be aware of dangers that they have not noticed. Informing adolescents about sexual matters and parents dealing with approaches to friends of the opposite sex will make improvements on this subject. As the perpetrator was known to the victim in the majority of cases in both age groups, it should be kept in mind that there will be efforts to keep the abuse secret and this could result in repeated episodes of abuse.

A different situation in Turkish society is that generally underage marriages resulting in pregnancy have been evaluated as judicial cases. Unlike in previous studies in Turkey, in the current research, 4 cases were found with this feature. None of these cases were determined as having any signs of psychiatric illness. In these types of cases, there may be a tendency for the women to show that they are better than they really are as they are likely to be under pressure from both families with the possibility of the wife being left alone and pregnant when the husband is imprisoned after the passing of a certain time since the ‘marriage’. To be able to make progress in the area of child marriages, there is a need for multi-disciplinary studies in sociocultural and economic areas.

Compared with other types of trauma, there is known to be a much higher risk of sexual trauma causing psychological problems [10]. In the current study, problems at varying rates were determined in both groups of acute stress disorder, depression mood disorder, post-traumatic stress disorder, mixed anxiety-depression mood disorder and depression with anxiety mood disorder. Following sexual abuse, 30-65% of victims can be seen to develop depression, anxiety, substance abuse or eating disorders [12]. In students who have experienced sexual abuse, behavioral and social problems have been reported such as reduced academic success, alcohol or substance abuse, eating disorders, aggression and leaving school [18]. Previous studies have reported that mental health disorders develop at a rate of 60% in children who have suffered sexual abuse [18]. Psychiatric problems are experienced such as anxiety, feelings of humiliation, depression, stress, suicidal thoughts and concentration difficulties [12,18,19]. The results of the current study seem to be consistent with these findings.

In the current study, there were 2 individuals with mental retardation, 1 in each group with a diagnosis of bipolar affective disorder. It has been reported that individuals with psychiatric diseases are more vulnerable to sexual abuse than those who do not have a psychiatric disorder [13]. For example, feelings of desperation and worthlessness when in a depressed state make it difficult to make the right decisions in dangerous situations. Therefore, individuals with depression are thought to be more vulnerable to physical harm In a study by Weinhardt et al., it was reported that of females with disease groups including severe depression and psychotic disorders, 76% had been exposed to sexual abuse at least once in their lifetime [20]. It is also known that mentally retarded adolescents are at a greater risk of sexual assault than those without mental retardation [21]. Another situation requiring evaluation by the judicial authorities is ‘whether or not the individual could defend themselves physically and mentally’. In cases when the victim cannot defend themselves, an increased sentence is passed on the perpetrator [22]. Therefore, clarification of the characteristics of the defined psychiatric disease experienced before the event will be helpful in explaining how this would affect the ability of the victim to defend themselves.

The current study differs from previous studies in Turkey in that a comparison is made of the features of sexual abuse in a children/adolescent age group and an adult group. No statistically significant difference was found between the groups, which may be due to the low number of cases. However, that the majority of cases were in the childhood/ adolescent group and that some features of the abuse showed a difference in the adult group are subjects requiring special interest. If the number of cases is thought to be low for a study, when it is considered that these were the cases of a small province in Anatolia, the seriousness of the subject is revealed.

Another point of note in the current study is that some aspects in the evaluated consultations were not mentioned. For example, whether or not any other family member had experienced a similar problem or whether there was a history of violence within the family was not clearly defined. In addition, as the evaluation was focused on the victim, there was little questioning of the relationship of the perpetrator to the victim. Taking these deficiencies into consideration, in the evaluation of incidents of sexual abuse, the creation of standard interview forms with specific headings, without forgetting that each case is different in its own characteristics, would be helpful in respect of not overlooking anything medical in this sensitive area.

Conclusion

It is important to determine that the women composed of the majority of the cases in both groups, abusers were generally familiar persons, boyfriend abuses were more prevalent in the adolescent group and there were several cases that had religious marriages in the adolescent group. More studies are needed in this field in order to maintain a standard evaluation of the sexual abuse cases and minimize the understanding and language differences between law enforcement and health care providers.

Limitations

The retrospective nature of our paper is limitation of its scientific design.

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