Child Sexual Abuse-Perceptions among Health Professionals in a Tertiary Setting
Simi Mohan Jayamohana Sumam1, Kochuthresiamma Thomas2, Baburaj Stephenson3, Sherlin Victor4
1 Assistant Professor, Department of Nursing, C.S.I. College of Nursing, Dr. S.M.C.S.I. Medical College, Karakonam, Kerala, India.
2 Emeritus Scientist, Government College of Nursing, Thiruvananthapuram, Kerala, India.
3 Professor, Department of Paediatrics, Dr. S.M.C.S.I. Medical College, Karakonam, Kerala, India.
4 Assistant Professor, Department of Nursing, C.S.I. College of Nursing, Dr. S.M.C.S.I. Medical College, Karakonam, Kerala, India.
NAME, ADDRESS, E-MAIL ID OF THE CORRESPONDING AUTHOR: Ms. Simi Mohan Jayamohana Sumam, Assistant Professor, Department of Nursing, C.S.I. College of Nursing, Dr. S.M.C.S.I. Medical College, Karakonam, Kerala, India.
E-mail: simishalomchristian@yahoo.co.in
Introduction
Child Sexual Abuse (CSA) is one of the India’s largest open social divret that leaves enormous physiological and psychological impact on the health and development of children. It is a complex and context-bound phenomenon that exists in every society, but perceptions about it may vary among lay persons, teachers and health professionals.
Aim
This study was aimed at understanding the perceptions of health professionals on child sexual abuse in a tertiary setting in the southern state of India.
Materials and Methods
In a descriptive cross divtional study, 185 health professionals including doctors and nurses in a tertiary setting were enrolled. A self-administered questionnaire which was developed by the researcher (content validity index: 0.8) along with demographic profile sheet to assess the perceptions of health professionals on child sexual abuse was used. Data analysis was done by descriptive and inferential statistics using SPSS 16.0 software and p-value of <0.05 was considered to be significant.
Results
Majority of the participants (82.7%) agreed that girls are at increased risk of being abused, and belong to the teenage group (62.2%). A good proportion of health professionals agreed that the perpetrators are usually male (65.9%) aged between 15-35 years (48.6%). Appearing in the court for legal proceedings (50.8%) and the after effect of child being stigmatized in the society (64.9%) were found to be significant barriers in reporting child sexual abuse. Majority (85.9%) of them perceived that the adult should take responsibility of the protection of children and 86.5% of them agreed that children should be taught about “good touch” and “bad touch” as preventive strategy in child sexual abuse.
Conclusion
The present study has shown that perceptions on child sexual abuse vary among health professionals. Though they are aware about the risk factors, perpetrator characteristics, preventive strategies, still barriers in reporting child sexual abuse exists.
Introduction
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 that violates the laws or social taboos of society [World Health Organization (WHO)]. Though Kempe HC has called it as a “hidden paediatric problem” in the late 1970s; it has turned as a pandemic moral disaster [1]. Despite the efforts to protect children around the world, child sexual abuse remains as a grave global issue. The WHO announced that more than 40 million children worldwide are considered victims of child abuse yearly and the statistics varies among developed and developing countries [2]. In the US more than three million children have been exposed to either abuse and/or neglect. India is the home for the largest number of minors in any country in the world, house for more than forty percent of country’s population. The first ever national study on child abuse was conducted by the Ministry for Women and Child development in April 2007 reported 53% children facing one or more forms of abuse in which 73% of sexual abuse victims belong to the age group of 11-18 years [3]. Abuse is a disquieting everyday reality for as many as half of the country’s children and for an enormous number of cases still under the iceberg.
Child abuse is a complex and context-bound phenomenon that exists in every society, but perceptions about it may vary among lay persons, teachers and health professionals [4]. Though public child healthcare nurses and doctors might observe for both overt and covert signs of child sexual abuse in the child and among family members, they may also have to rely on their knowledge acquisition regarding child sexual abuse [5]. Knowledge is regarded as an important factor for the identification of child abuse which comprises knowledge of, the definition and baseline rates of child abuse, risk factors of child abuse, perpetrator characteristics, and signs of child abuse, preventive strategies and child abuse reporting procedures [6]. A thorough acumen on child sexual abuse among professionals is essential to decrease the magnitude of the problem.
Finkelhor D and Korbin J presented a view assessing the interplay of three variables: (i) the behaviour of the parent; (ii) the effect on the child; and (iii) the perception of the observer [7-9]. Parents have maltreated their children since time immemorial, leaving innumerable physical and emotional scars. These two variables may not have altered significantly over the centuries or across nations and cultures, which is evident from extensive literature review, but what has changed has been the ‘perception of the observer,’ including not only recognition by the society, that certain caregiver deeds are inappropriate and harmful to the child. The issues that may have been kept a secret (such as sexual abuse) must be aired and addressed. It is only when observers (or third parties) are outraged by particular actions perpetrated on children that they will identify them as abusive. Treatment of child abuse requires the services of multidisciplinary teams, and unless there is agreement on what is abusive, intervention may be compromised. Despite the importance of consensus, and the apparent variances among perceptions of different professional groups, perceptions diverged across groups [9]. However, loopholes in the law and lack of an adequate social support system have meant that there is limited information on this problem. It is extremely important for people who deal with children or work in a child’s environment to be able to identify indicators of CSA. If CSA cannot be detected, it can also not be reported and tackled. Majority of the studies regarding perceptions were done in the African and American countries in the last decade and the generalizability is questionable. As health professionals play a pivotal role in the identification and prevention of child abuse among children and study was aimed at understanding the perceptions of health professionals on child sexual abuse in a tertiary setting in the southern state of India.
Materials and Methods
A descriptive cross sectional study was adopted for the study. The current study was conducted in a tertiary hospital in the outskirts of Thiruvananthapuram, Kerala, India, from January 2017 to March 2017. Convenient sampling technique was adopted. The sample included health professionals (doctors and nurses) in the paediatrics and emergency department with a diverse background which aid the generalizability of the study and the sample size was 190 based on previous perception of 67% with allowable error of 10% [10]. Ethical clearance was obtained from the Institutional Review Board. After explaining the study purpose to the participants, an informed consent was obtained. Data was kept confidential and no information was leaked out to the public.
A self-administered questionnaire was developed by the researcher which consisted of a demographic profile sheet containing data such as age, sex, and educational qualification, level of education, years of experience and history of child abuse being noted along with participants’ response to the question about their perception on risk factors, perpetrator characteristics, barriers in reporting and preventive strategies regarding child sexual abuse. Coding was done based on a three point rating scale as follows: Agree (3) Disagree (2) Not sure (1). For negative statements reverse coding was given. Tool validation was done by subject experts and the content validity index was 0.8. Pilot study was done on 18 samples and the study was found to be feasible. These samples were also included in the main study.
Results
Health professionals were asked to fill a self-administered questionnaire and the response rate was 97%; 3% of the questionnaires which were incomplete were excluded from the study.
Distribution Based on Socio Demographic Variables (N:185)
About 81% of the participants were women and 24.3% of them had a history of child abuse being noted. Around 45.4% are registered doctors who have completed their medical education and 54.6% are registered nurses who have completed their basic nursing education program. Majority of the health professionals had completed their undergraduate education [Table/Fig-1].
Distribution based on socio demographic variables (N:185).
| Variables | Frequency | Percentage |
|---|
| Age in years |
| 20-25 years | 62 | 33.5 |
| 26-35 years | 94 | 50.8 |
| 36-50 years | 29 | 15.7 |
| Sex |
| Male | 34 | 18.4 |
| Female | 151 | 81.6 |
| Profession |
| Medicine | 84 | 45.4 |
| Nursing | 101 | 54.6 |
| Level of education |
| Medicine: | | |
| Undergraduate | 62 | 73.8 |
| Postgraduate | 22 | 26.2 |
| Nursing: | | |
| Undergraduate | 76 | 75.2 |
| Postgraduate | 25 | 24.8 |
| Years of experience |
| Less than one year | 49 | 26.5 |
| 1-5 years | 58 | 31.4 |
| 6-10 years | 44 | 23.8 |
| 11-15 years | 26 | 14.1 |
| More than 15 years | 8 | 4.3 |
| History of child abuse noted |
| Yes | 45 | 24.3 |
| No | 140 | 75.7 |
Distribution Based on Perceptions of Health Professionals on Risk Factors of Child Sexual Abuse (N: 185)
Overall, 153 (82.7%) participants agreed that girls are at increased risk of being abused with majority of the victims belonging to the teenage group 115 (62.2%). One hundred 69 (91.4%) respondents accepted that child sexual abuse do happen in high class families, and of these 37.3% disagreed that children living in joint families are at increased risk of being abused, as in [Table/Fig-2].
Distribution based on perceptions of health professionals on risk factors of child sexual abuse (N: 185).
| Risk factors of CSA | Agree n (%) | Disagree n (%) | Not sure n (%) |
|---|
| Child sexual abuse cannot happen in high class families | 5 (2.7) | 169 (91.4) | 11 (5.9) |
| Children living in joint families are at risk of being abused | 65 (35.1) | 69 (37.3) | 51 (27.6) |
| Mentally challenged children are more likely to suffer abuse | 138 (74.6) | 27 (14.6) | 20 (10.8) |
| Abuse does not happen in families where father is an alcoholic | 158 (85.4) | 13 (7.0) | 14 (7.6) |
| Abuse is more likely in families where mother has mental illness | 110 (59.5) | 35 (18.9) | 40 (21.6) |
| Presence of step father does not increase the risk of child being abused | 13 (7.0) | 127 (68.6) | 45 (24.3) |
| Poverty is not a predisposing factor for the child being abused | 34 (18.4) | 98 (53.0) | 53 (28.6) |
| Child being left alone at home without adequate supervision has a high chance of being abused | 165 (89.2) | 11 (5.9) | 9 (4.9) |
| Most victims of abuse are teenagers | 115 (62.2) | 34 (18.4) | 36 (19.5) |
| Girls are at increased risk of being abused | 153 (82.7) | 20 (10.8) | 12 (6.5) |
Distribution Based on Perceptions of Health Professionals on Perpetrator Characteristics of CSA (N=185).
A good proportion of health professionals agreed that the perpetrators are usually male (65.9%) aged between 15-35 years (48.6%). About 22.2% perceived that that the abusers are usually strangers who usually approach the child with valuable gifts (71.9%), making the child feel special (69.2%) as in [Table/Fig-3].
Distribution based on perceptions of health professionals on perpetrator characteristics of CSA (N=185).
| Perpetrators of CSA | Agree n (%) | Disagree n (%) | Not sure n (%) |
|---|
| The perpetrators of child sexual abuse are usually male | 122 (65.9) | 31 (16.8) | 32 (17.3) |
| Most abusers are aged between 15 and 35 years of age | 90 (48.6) | 51 (27.6) | 44 (23.8) |
| Children are never sexually abused by women | 44 (23.8) | 86 (46.5) | 55 (29.7) |
| Most offenders were sexually abused when they were children | 79 (42.7) | 38 (20.5) | 68 (36.8) |
| The abusers are usually strangers | 41 (22.2) | 97 (52.5) | 47 (25.4) |
| The abusers usually approach the child with valuable gifts “grooming” | 133 (71.9) | 25 (13.5) | 27 (14.6) |
| The offenders usually ask the child to keep it as secret | 160 (86.5) | 10 (5.4) | 15 (8.1) |
| The abuser will make the child feel special | 128 (69.2) | 24 (13.0) | 33 (17.8) |
| Men sexually abuse in most cases | 135 (72.9) | 26 (14.1) | 24 (34.6) |
| Perpetrators usually approach the child on views of religious beliefs | 54 (29.2) | 52 (28.1) | 79 (42.7) |
Distribution Based on Perceptions of Health Professionals on Barriers in Reporting CSA (N=185)
Health professionals’ perception plays a pivotal role in reporting CSA. Though a whole lot of act was enacted still the factual cases lies under the iceberg. Appearing in the court for legal proceedings (50.8%), the after effect of child being stigmatised in the society (64.9%), health professionals not having enough information about the suspected case to make a formal report (41.6%), were found to be some of the common barriers for not reporting CSA as in [Table/Fig-4].
Distribution based on perceptions of health professionals on barriers in reporting CSA (N=185).
| Barriers in reporting CSA | Agree n (%) | Disagree n (%) | Not Sure n (%) |
|---|
| I feel uncomfortable in talking to a child being abused | 56 (30.3) | 101 (54.6) | 28 (15.1) |
| Reporting a case of child sexual abuse to the social services usually does more harm than good | 60 (32.4) | 85 (45.9) | 40 (21.6) |
| I am afraid since abusers are always dangerous | 70 (37.8) | 91 (49.2) | 24 (13) |
| Persons in authority cannot be trusted | 81 (43.8) | 62 (33.5) | 42 (22.7) |
| If I report, the situation at child’s home is causing more harm to the child | 46 (24.9) | 80 (43.2) | 59 (31.9) |
| Did not have enough information to make a formal report | 77 (41.6) | 42 (22.7) | 66 (35.7) |
| I was confused at being the witness of the incident | 95 (51.4) | 53 (28.6) | 37 (20) |
| Fear of child being taken away from parents by child welfare agencies | 66 (35.7) | 56 (30.3) | 63 (34.1) |
| I may have to appear in the court for legal proceedings | 94 (50.8) | 50 (27) | 41 (22.2) |
| The child will be stigmatised in the society | 120 (64.9) | 41 (22.2) | 24 (13.0) |
Distribution Based on Perceptions of Health Professionals on Preventive Strategies of CSA (N=185)
Around (85.9%) of them agreed that adult should take responsibility of the protection of children and 86.5% of them responded positively that children should be taught about “good touch” and “bad touch”. Universal education program at the primary level (48.6%), severe punishment to perpetrators (42.7%) and children being taught about assertiveness (51.4%) were found to be effective strategies in prevention of CSA as in [Table/Fig-5].
Distribution based on perceptions of health professionals on preventive strategies of CSA (N=185).
| Preventive strategies in CSA | Agree | Disagree | Not Sure |
|---|
| Adult should take the responsibility of the protection of children | 159 (85.9) | 13 (7) | 13 (7) |
| Universal education programs in the primary level at school always stands as the gold standard method | 90 (48.6) | 51 (27.6) | 44 (23.8) |
| Publicity on social media decreases its incidence | 44 (23.8) | 86 (46.5) | 55 (29.7) |
| Severe punishment to perpetrators can reduce its occurrence | 79 (42.7) | 38 (20.5) | 68 (36.8) |
| Prevention programs can aid early detection of child sexual abuse | 97 (52.5) | 41 (22.2) | 47 (25.4) |
| Child sexual abuse prevention programs will allow the children to make false allegations of abuse | 133 (71.9) | 25 (13.5) | 27 (14.6) |
| Children can be taught about “Good touch” and “Bad touch” | 160 (86.5) | 10 (5.4) | 15 (8.1) |
| Child sexual abuse prevention programs may induce the child to know too much about sex | 33 (17.8) | 128 (69.2) | 24 (13.0) |
| Children should be taught to be assertive and to tell someone they trust if they are upset, without frightening | 95 (51.4) | 26 (14.1) | 64 (34.6) |
| There is no need to conduct prevention programs since children will acquire knowledge as they grow | 54 (29.2) | 52 (28.1) | 79 (42.7) |
Discussion
The results of the present study demonstrate the complexity and dynamics of the perceptions of health professionals on risk factors of child sexual abuse; perpetrator characteristics, barriers in reporting CSA and preventive strategies in CSA. Important conclusions can be extrapolated from the current study. The generalizability of the study findings was limited only to health professionals including medical doctors and nurses.
There is a highly significant association between perception regarding risk factor that children living in joint families are at risk of being abused with education, perpetrator characteristics like most abusers are aged between 15 and 35 years with years of experience, children are never sexually abused by women with education. Barriers in reporting like the child will be stigmatised in the society with age, I was not the witness of the incident and publicity on social media decreases its incidence with age and if I report the situation at child’s home is changed causing more harm with years of experience were found to be highly significant. The findings of the present study were contradictory to other study findings in which living with a step-parent during childhood (OR 2.59 and 2.01 and p<.05) was associated with sexual abuse [11-13]. Other studies identified females to be at higher risk for child sexual abuse (OR 1.85 and p<0.01, and OR 3.85) [11,12,14-17]. Finkelhor D and Hotling G, based on the retrospective study findings regarding characteristics of perpetrators concluded that 90% of sexual abuse is committed by men and by persons known to child with family members constituting a higher percentage of the perpetrators [19]. The results were similar to the present study findings in which majority of health professionals agreed that the perpetrators are males (65.9%) and are familiar to the child (47.5%), who generally asks the child to keep it as secret (86.5%).
Schols MWA et al., identified many factors that influence the ability to recognise and report Child Abuse and Neglect (CAN) like lack of awareness of legal responsibilities and protections; uncertainties about what constitutes CAN; lack of training in identifying characteristics of children who are victims of CAN, uncertainties regarding the assessment of a patient’s problem, lack of knowledge and skill in reporting procedures, uncertainties regarding the outcome of reporting, reluctance to interfere in the parent-child relationship and fear of legal involvement [20] which were congruent to research findings of the present study in which 50.8% agreed that they may have to appear in the court for legal proceedings with majority (64.9%) agreed that the child being stigmatised in the society. The POSCO act of 2012 has specifically mentioned about mandatory reporting of CSA and being asked to be a witness in the court is indeed acting as a hidden barrier in reporting CSA. Health professionals not having enough information about the suspected case to make a formal report (41.6%), and being confused at the witnesses of the incident (51.4%) were also identified as their perceptions as barriers in reporting CSA.
Limitation
The study was limited to only health professionals including doctors and nurses who were working in the Department in Paediatrics and Emergency setting.
Conclusion
The present study concluded that perceptions of health professionals on child sexual abuse were affected by age, sex, educational qualification and years of experience with children. Though they were aware about the risk factors, perpetrators characters and preventive strategies there still exists loopholes in reporting cases of child sexual abuse.
[1]. Kempe HC, Sexual abuse, another hidden pediatric problem: The 1977 C. Anderson Aldrich Lecture’ Paediatrics 1978 62(3):382-89. [Google Scholar]
[2]. Kacker L, Varadan S, Kumar P, Study on child abuse 2007 IndiaMinistry of women and child development. Government of India [Google Scholar]
[3]. World Health Organization. World Report on Violence and Health, WHO, Geneva, 2002. Available from http://www.who.int/violence_injury_prevention/violence/world_report retrieved on 10.01.2017 [Google Scholar]
[4]. Pearce J, Pezzot-Pearce T, Psychotherapy of abused and neglected children 2013 New YorkGuilford Publications [Google Scholar]
[5]. Paavilainen E, Tarkka MT, Definition and identification of child abuse by Finnish public health nurses Public Health Nursing 2003 20:49-55.10.1046/j.1525-1446.2003.20107.x12492825 [Google Scholar] [CrossRef] [PubMed]
[6]. Darkness to light. Available in https://www.d2l.org/education/5-steps/; retrieved on 14.08.2017 [Google Scholar]
[7]. Finkelhor D, Korbin J, Child abuse as an international issue Child Abuse Neglect 1998 12(1):03-23.10.1016/0145-2134(88)90003-8 [Google Scholar] [CrossRef]
[8]. May Hall PD, Norgard KE, Child abuse and neglect: sharing responsibility 1983 New YorkMacmillan Publishing Company [Google Scholar]
[9]. Gough D, Child abuse in Japan Child Psychology & Psychiatry Review 1996 1(1):12-18.10.1111/j.1475-3588.1996.tb00003.x [Google Scholar] [CrossRef]
[10]. North Dakota State wide Child Abuse and Neglect Study; 2005 [Google Scholar]
[11]. Uma A, Segal YI, Perceptions of child abuse: a comparison of three professional groups in Japan Children & Society 2004 18:16-29.Retrieved from www.interscience.wiley.com10.1002/chi.780 [Google Scholar] [CrossRef]
[12]. Carey P, Walker J, Roussow W, Seedat S, Stein D, Risk indicators and psychopathology in traumatized children and adolescents with a history of sexual abuse European Child & Adolescent Psychiatry 2008 17:93-98.10.1007/s00787-007-0641-017876504 [Google Scholar] [CrossRef] [PubMed]
[13]. King G, Flisher A, Noubardy F, Reece R, Marais A, Lombard C, Substance abuse and behavioural correlates of sexual assault among South African adolescents Child Abuse & Neglect 2004 28:683-96.10.1016/j.chiabu.2003.12.00315193855 [Google Scholar] [CrossRef] [PubMed]
[14]. Madu S, Peltzer K, Risk factors and child sexual abuse among secondary school students in the Northern Province (South Africa) Child Abuse & Neglect 2000 24:259-68.10.1016/S0145-2134(99)00128-3 [Google Scholar] [CrossRef]
[15]. Anderson N, Ho-Foster A, 13,915 reasons for equity in sexual offences legislation: A national school-based survey in South Africa International Journal for Equity in Health 2008 7:2010.1186/1475-9276-7-2018664250 [Google Scholar] [CrossRef] [PubMed]
[16]. Breiding M, Reza A, Gulaid J, Blanton C, Mercy J, Dahlberg L, Risk factors associated with sexual violence towards girls in Swaziland Bulletin of the World Health Organization 2011 89:203-10.10.2471/BLT.10.07960821379416 [Google Scholar] [CrossRef] [PubMed]
[17]. Davis GR, Domoto PK, Levy RL, The dentist’s role in child abuse and neglect, issues, identification, and management ASDC J Dent Child 1979 46:185-92. [Google Scholar]
[18]. Collings S, Physically and sexually abused children: A comparative analysis of 200 reported cases Social Work 1993 29:301-06. [Google Scholar]
[19]. Finkelhor D, Hotaling G, Lewis IA, Smith C, Sexual abuse in a national survey of adult men and women: Prevalence, characteristics, and risk factors Child Abuse & Neglect 1990 14:19-28.10.1016/0145-2134(90)90077-7 [Google Scholar] [CrossRef]
[20]. Schols MWA, How do public child healthcare professionals and primary School teachers identify and handle child abuse cases? A qualitative study BMC Public Health 2013 13:807retrieved from http://www.biomedcentral.com/1471-2458/13/807 on 30.06.201710.1186/1471-2458-13-80724007516 [Google Scholar] [CrossRef] [PubMed]