Introduction

Child sexual abuse (CSA) is a global problem with intense life‑long outcomes. The physical or mental violation of a child with sexual intent usually by an adult, an older, mentally advanced child, or even a child of the same age is called child sexual abuse.1 According to the Centre for Disease Control and Prevention 2021, one in four girls and one in thirteen boys worldwide are part of Childhood sexual abuse (CSA).2

In India, it is estimated that 40% of children are susceptible to threats like being homeless, forced labor, trafficking, drug abuse and crime. And every second child is being exposed to one or the other form of sexual abuse and every fifth child faces critical forms of it.3 Recently in India, Child Sexual Abuse (CSA) has been publicly acknowledged as a grave problem and a special law called Protection of Children against Sexual Offences (POCSO) was developed in 2012. POSCO act includes child rape, child harassment, and exploitation of children for pornography.4

The child who has undergone sexual abuse might react in various forms like change in behaviors, and physical responses which may appear, disappear, and reappear. Physical effects like body pains, difficulty walking, bleeding, bruising, sexually transmitted diseases, pregnancy, and even death of a child can occur. The abused child might become emotionally weak and show various psychological effects like disorientation, anger, low self-esteem, poor academic performance, cognitive impairment, suicidal thoughts or attempts, speech impairment, nightmares, flashbacks, phobia, severe anxiety, racing thoughts, depression, post-traumatic stress disorder (PTSD). These psychological effects can be short-term and long-term and usually persist into adult life.5

It may also result in withdrawing from social activities, parenting in adulthood, and sometimes engaging in antisocial behaviors. One can become hypersexual or have a phobia of sexual experiences.6 With emotional support and health care treatment by maintaining confidentiality of their identity, many survivors of sexual abuse can overcome adverse health conditions. Sexually abused victims require immediate medical care, psychological support, and legal action, which is possible only by increasing awareness among the general population. Healthcare professionals play a vital role in early access to services and care for child and adolescent victims of sexual abuse.7 Specially obstetricians have an important role in detecting Child Sexual Abuse, and providing immediate and long-term care, counseling, and support to the victims and their families.8 The present study was conducted to draw up an epidemiological, socio-demographic profile of the victims and to study the mental status and the relationship between different parameters to the psychological behavior of the victims.

Materials and Methods

This is a 5 -year descriptive retrospective study from January 1, 2017 to December 31, 2021 conducted at a tertiary care center. All the patients who were the victims of female child sexual abuse and admitted during our investigation period were included in the study.

For each case, the following parameters were studied: the epidemiological and socio-demographic characteristics (age, socio-economic status, family structure, occupation and place of residence) of the victims, the circumstances of the abuse (time, place and context), the characteristics of the aggressor (age, link with the victim, number of aggressor) the frequency of the abuse, the type of sexual contact, the possible lesions found during the physical examination (genital and extra-genital), the mode of admission, the informant during the admission, the delay of the consultation, the reason for the delay in reporting, the attitude after the sexual abuse, the gynecological and obstetrical status of the victim, the repercussions and psychology of the victim, the paraclinical assessment, the treatments administered. The data was entered in MS excel master sheet and statistical analysis was performed using SPSS software version 22 (IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY, USA: IBM Corp.). Categorical data have been presented as numbers and percentages (%) and quantitative data in terms of mean and standard deviation. Categorical variables have been analyzed using Pearson’s chi-square test and Fisher exact tests (when the expected count of 20% of cells is less than 5). A p-value of <0.05 has been considered statistically significant.

Results

During the study period, 158 victims of female child sexual abuse were received at our hospital. The age of the victims ranged from 1 to 17 years with mean average of 15.5 years. The 15 – 17 years was the most represented age group (67.3%). Minimum age of victim was 1 year and Maximum age of victim of the female child was 17 years, as shown in Table 1. The most severe forms of abuse were also found in age group 15 to 17 years.

Around 82.2% of the cases reported had a low socio-economic status. Around 12.6% of the victims were from middle socio-economic class. And 5% cases reported was from a higher socio- economic status. In 3.1% of patients, family impairment was noted. History of absence of one/both parents was noted in 10.1% of cases, and 1.2% of the patients had the presence of a stepfather. Around 88.6% of the victim’s parents were living together. The victims were grouped as pre-school (4%), primary school (12.02%), intermediate to high school (64.38%), and not attending any educational institutions like child workers (19.6%). Infants were also targeted at a rate of 2.5%.

We identified 3 cases of female CSA with Intellectual disability.

All (100%) of child sexual abuse perpetrators were men. Most of the perpetrators were younger men from 18 years to 25, constituting around 62.02%. Among the abusers, the age group less than 18 years constituted around 14.55%. Nearly, 15.82% of the abusers belonged to the age group 26 to 40 years. Three of the victims were abused by people of all age categories. One of the victim was around 75 years.

In majority of the cases i.e 149 cases of the abuse (94.3%), the number of assailants were single. However, in around 3.7% and 1.8% of cases, there were 2 and 3 abusers respectively. For most victims, the offenders remained their boyfriends (44.6%). Strangers accounted for 16.1% of the offenders. It was a parent (father, brother, cousin, uncle) in 10.7% of cases, others (acquaintance, neighbour, shopkeeper, school bus driver) in 11.93% of cases, an authority figure (teacher) in 1.5% of cases. A close friend constituted around 3.7% of the abuse. Penetration was by far the most frequent type of sexual contact with an estimated 62.3%. Around 2% of the patients did not want to disclose the type of assault. Exhibitionism constituted around 1.5% of the assault. One case of Genital biting of toddler. Other forms of sexual assault included fingering, oral penetration, groping, touching of genital area etc. In around 6% of cases all forms of sexual abuse was noted. Penetration was most commonly seen in age group 13 to 17 years.

Clinical examination was normal in 87.7% of cases as they presented many days after the incident. In remaining cases non-specific findings such as vulvovaginitis, erythema, genital wound, inflammation of genitalia was seen. Around 4.3% of victims were not willing for examination. One case of Laceration of Labia was noted. Minor scratch marks, inflammations were seen in few cases. Signs of additional physical violence were noted in 3.1%. The details of Physical findings are given in the below Table 2.

After the clinical examination, 50% of the victims had received antibiotic prophylaxis; 50% had received analgesic and antiseptic treatment respectively. Anti-tetanus sero vaccination concerned only 9.5% of them.

Majority of the female children were abused multiple times contributing 45.6% of the cases. Two cases (1.3%) did not reveal the number of episodes of sexual abuse (Figure 1).

Figure 1

Distribution of study subjects based on the number of episodes of sexual abuse

Most of the cases were brought to the department after 1 day and a very few majorities were brought just after the assault in around 6.8% of cases. Majority of cases around 39% were brought after many months of sexual assault, the reason being the victims were scared and innocent.

We observed through our study an array of behavioural disorders with different degrees including fear, anxiety, irritability, regression in school performance, sleep disturbances, eating disorders, social problems as well as poor self-esteem. The psychological state of the victims was apparently normal in 36.7% of them. Around 26.5% of the victims were anxious. Few (25.9%) were scared regarding the sexual abuse and the pregnancy coming to light. In 17% of the victims had developed depression. Three victims had suicidal thoughts. Three victims had Intellectual disability which had made them easy target for abuse. Few (5.6%) of the victims could not be assessed as they were not willing to disclose any information. Incest victims had particularly severe problems such as depression and attempted suicide that was noted in three cases.

Psychological care was provided to only 50% of victims.

Discussion

In the present study, the age of the victims ranged from 1 to 17 years with a mean average of 15.5 years. The present study findings concerning age were similar to the study carried out by Oumar GYF et al, where, the average age of the patients was 15 years.9

In our study, victims coming from economically disadvantaged backgrounds accounted for more than three-quarters of cases and 26.5% of cases showed signs of depression. Parental inadequacy, unavailability, conflict, and a poor parent-child relationship show up most consistently in all the epidemiological studies as risk factors for CSA.10

In the current study, most of the victims were high school (64.38%) students, followed by child workers (19.6%). Mamadou Chérif DT et al., in their study, observed that most of the victims belonged to high school (23.2%) and primary school (18.3%) which is comparable to the present study.11

In the present study, most of the perpetrators were younger men aged 18 years to 25 (62.02%) and 26 to 40 years (15.82%). Maha Almuneef, in his study also found that most of the perpetrators were young adults aged 18-30 years (74.8%). 12

In the present study clinical examination was normal in 87.7% of cases as they presented many days after the incident and in the remaining cases, non-specific findings such as vulvovaginitis, erythema, genital wound, and inflammation of genitalia were seen. Similar type of findings were seen in a study conducted by Baldé IS et al, where the lesions observed included vulvovaginitis (45.8%), vaginal tears (8.7%), facial bruises (8.7%), anal tears (4.4%), and ocular contusions (4.4%). The gynecological examination was normal in 21.4% of cases. Vaginal penetration was the sexual act practiced most often (88.4%) by aggressors, compared with acts of sodomy (4.3%). We noted 7.2% of fondling.13

The psychological aspects of the victims could not be studied in detail as the victims could not be followed up after discharge and study being retrospective record-based research.

In our study, we observed that abused females were suffering from 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. Much research supports the present study findings and concludes that CSA may lead to anger, anxiety, shame, inappropriate sexual behavior and preoccupations, guilt, depressive disorder, post-traumatic stress disorder, and various emotional and behavioral disorders throughout their life.14, 15

Tyagi S et al16 also observed that psychological state of most of the victims in their study was apparently normal and 6% victims were anxious. Lahav Y et al17 observed that CSA victims with high dissociation from the traumatic event had higher chances of revictimization. Child sexual abuse is a known risk factor for early onset depression in adulthood as indicated in the meta-analysis carried out by Li D et al18 which further emphasizes that even though the present psychological state seems normal but the victims need long term psychological support and care. On further comparison of context of abuse with the time of reporting, it was observed that incidents where the victims were forced into the act reported relatively early compared to those who suffered abused and cited love/ relationship, marriage as reasons. Victims who were forcibly abused, the incident commonly occurred in abandoned buildings and fields whereas those who were in relationship/ love/ marriage were also abused in abuser’s/ relative’s home, victim’s home and also in lodge/ farmhouses.

Limitations of the Study

The present study is the retrospective nature of the study and the examination was carried out by multiple service providers. And it is a single-centre study.

Future Perspective

There is a need to raise awareness and teach children, and their families, how to recognize predators, when they are about to be victimized, and how to protect themselves. Digital campaigns are very good options in this digital era.

Online Psychotherapy can bring significant contributions to our protocol. This will make it possible to offer alternative treatment to victims of childhood sexual abuse within this risky context of social distancing due to the pandemic. Psychotherapies help in reducing the symptomatology presented by this population which hinders their functioning in different areas of adult life.

Conclusion

The study reveals that child sexual abuse (CSA) in India is a prevalent and deeply concerning issue, characterized by underreporting, socioeconomic vulnerabilities, and a significant delay in reporting. A high proportion of female child sexual abuse takes place within the family and is revealed only after multiple episodes. Perpetrators, typically male, are often known to the victims, and abuse frequently occurs in familiar settings. The psychological impact on victims is substantial, with both short-term and long-term consequences. Prevention requires a systematic and lifelong approach to educating children about personal space, good touch and bad touch and privacy. There is an urgent need for comprehensive prevention programs, awareness campaigns, accessible support services, and legal enhancements to address CSA effectively. It is crucial to implement prevention programs in schools and communities that educate children on recognizing and reporting abuse.

Public awareness campaigns should break the culture of silence surrounding CSA, strengthening and enforcing child protection laws is essential, with a focus on reducing reporting delays. Community involvement and parental education are key components of fostering a safer environment for children. Further research is needed for a more in-depth understanding of CSA dynamics in India and to develop evidence-based interventions. Overall, addressing CSA requires a collaborative effort involving government, communities, educators, and families to protect children from its devastating consequences and promote their well-being.

Ethical Statement

The study is conducted after obtaining approval from the Institutional Ethics Committee (NO: KIMS: ETHICS COMM: 23:2023-24).

Authors contributions

Dr. Puneetha V S has contributed to designing the study and methodology. Dr Ashwini Raju has worked in methodology collecting the data and entering the data in an Excel sheet. Dr. Raghavendra H has contributed to extracting the results and software provision. Dr. Saraswati Kreal has contributed to designing and collecting the data. All the authors are equally involved in designing the entire work and contributed to making necessary corrections and revisions of the manuscript.

Sources of Funding

Nil.

Conflicts of Interest

Declared none.