Ruhsal Durum Muayenesi İçin Çocuk ve Ergen Psikiyatrisine Yönlendirilen Cinsel İstismara Uğramış Çocuk ve Ergenlerin Demografik ve Klinik Özellikleri Demographic and Clinical Characteristics of Sexually Abused Children and Adolescents Referred to Child and Adolescent Psychiatry for Psychiatric Assessment

Ruhsal Durum Muayenesi İçin Çocuk ve Ergen Psikiyatrisine Yönlendirilen Cinsel İstismara Uğramış Çocuk ve Ergenlerin Demografik ve Klinik Özellikleri Demographic and Clinical Characteristics of Sexually Abused Children and Adolescents Referred to Child and Adolescent Psychiatry for Psychiatric Assessment Sevcan Karakoç Demirkaya1, Mustafa Küçükköse2 Adnan Menderes Üniversitesi Tıp Fakültesi Çocuk ve Ergen Psikiyatrisi, Aydın Aydın Devlet Hastanesi Çocuk ve Ergen Psikiyatrisi, Aydın ARAŞTIRMA / RESEARCH ARTICLE


Introduction
Child sexual abuse has been a serious public health issue worldwide which can lead to serious psychiatric, financial and social problems in the long term, and of which the impact persists for many years. If the child is abused by a caretaker or a relative, this is referred as incest (1,2). As a term, sexual assault includes not only rape but also a wide variety of traumatic situations such as sexual intercourse, attempt to sexual intercourse, oralgenital contact, genital touching, exhibitionism, and using children in pornography (1,3,4). Child sexual abuse is a medical, juridical, social and ethical community mental health problem. Since child abuse is kept hidden in most cases, it has been stated that only 15% of all victims report the crime (5). Therefore, the exact frequency rate is unknown. Sexual abuse is increasingly seen worldwide as well as in Turkey. Increased awareness and mandatory reporting requirements have been suggested to be the causes of this increase (6). A study on women in a general population sample in Turkey reported a rate of 2.5% for childhood sexual abuse (7). The rate of abuse and negligence among high school students in Turkey was found to be 10.7% (8). The epidemiologic data for child abuse including developed countries shows that the frequency is 7-36% for women and 3-29% for men, and the rate is 1.5-3-times higher in women (9). In the United States, 25% of women and 16% of men were reported to have been abused before 18 years of age (10). Perpetrators of sexual violence are men in general while 1-4% of abuses are perpetrated by women (11,12). It is also known that sexual abuse is perpetrated mainly by family members or relatives (13).
Many mental disorders are seen in sexually abused individuals. In Öztop et al.'s study on sexual abuse victims who had been referred to pediatric psychiatry outpatient clinics for forensic evaluation, they reported that psychiatric problems were present in 75% of the cases and the most common diagnoses were posttraumatic stress disorder (PTSD) and acute stress reaction (14). Kose et al. found any active psychiatric disorder in 83.1% of sexually abused children and adolescents, the diagnoses were PTSD, adjustment disorder, acute stress disorder and depressive disorders in descending frequency order (15). Similarly, Aksu et al. found psychopathology in 75.2% of sexually abused individuals, where the most common diagnosis was PTSD (16).
The risk factors of child sexual abuse should be carefully evaluated, and measures should be taken on preventive mental health. While there are many studies on this subject in the literature, all information related to the issue as important as child abuse is valuable. Preventive services can be implemented in this way. Therefore, this study aimed to investigate the sociodemographic characteristics of the children who had been sexually abused and referred for forensic evaluation, together with the identity issues of the abusers.

Sample:
Forensic charts of 41 children who had been sexually abused, referred for forensic psychiatric evaluation in a child psychiatry unit in a state hospital from July 2012 to January 2013 were reviewed.

Evaluation:
The parameters of age, gender, socioeconomic status of the family, the diagnoses received following the assessment if any, and the intelligence tests were evaluated. Socioeconomic levels greater than four times the minimum wage, up to 1-4 times the minimum wage, and equal to or less than one minimum wage were considered high, middle and low, respectively. The incomes were ascertained based on the families' declaration. If known, the gender and age of the abuser, the relationship with the victim, the site of abuse, and the method used by the abuser to approach the victim were evaluated.
Diagnostic evaluation during the forensic psychiatric examination is performed by trained pediatric psychiatrists using the Schedule for Affective Disorders and Schizophrenia for School-age children-Turkish Version (K-SADS), a semi-structured interview based on the DSM-IV diagnostic system (18). Therefore the diagnoses in the files were made based on this interview. All patients were assessed for IQ with age appropriate tests.

Statistics
Descriptive statistical methods (mean, standard deviation, percentage) were used for the statistical evaluation by the SPSS 18.0 software.

Results
The average age of the sexually abused children in the sample (n=41; 9 boys, 32 girls) was 11.54±3.31. The youngest and the oldest victims were 4 and 17 years old, respectively. When the socioeconomic levels of the families of victims were distributed to three sub-groups, most of them were found to belong to be in the low socioeconomic level. With respect to the maternal and paternal education levels, the majority of the parents were educated at the level of primary school or lower ( Table 1).
The clinical and/or psychometric evaluation revealed moderate mental retardation (MR) (n=1), mild MR (n=5), severe MR (n=1). Among all cases, those with mental retardation constituted 19.5% of all cases. The notable characteristics of this disabled group were as follows: A boy with moderate MR had been abused while residing in an orphanage managed by the Society for the Protection of Children, and a 15-year-old boy with severe MR had been abused in a specialized education/training center when he was 13 years old. Also, a 14-year-old girl with mild MR had got pregnant as a result of repeated abuse by her paternal aunt's son, which had come to light when she gave birth to a child.
No mental disorders were found in 2 abused cases. One of the cases was the adolescent boy with severe MR.
No abnormal behaviors or behavioral-emotional changes were observed and reported. Other case was a 10 year old girl with a history of abuse of a nonfamiliar abuser 2 months ago, however she was on follow-up to detect further psychopathologies. The diagnoses received by the other cases were as follows (when the disorder that had led to the greatest function loss, based on the severity of symptoms, was considered as the primary disorder): posttraumatic stress disorder (46.3%); other anxiety disorders (17.1%) (acute stress reaction, adjustment disorder with anxiety), and major depression (24.4%).1 case had enuresis, and 1 had encopresis related to the trauma (Table 1). In addition to these diagnoses and not associated with trauma, 3 cases were diagnosed with attention deficit hyperactivity disorder (ADHD), 2 cases with conduct disorder. The evaluations revealed that at the end of the forensic evaluation processes and based on the severity of the symptoms, psychotherapy was recommended for all victims and additional pharmacotherapy was recommended for 70.7% of them. It was found out that the preferred drug group in all victims receiving treatment was selective serotonin reuptake inhibitors (n=29) while additional betablockers (n=2), hydroxyzine (n=1), benzodiazepine (n=2) and risperidone (n=3) were recommended in some cases.
All perpetrators were male with a mean age of 23 years (min 14; max 67). When the relationship between the victim and the abuser was divided into two groups as familiar and unfamiliar, it was seen that 70.7% of the perpetrators were people that were already known by and familiar to the children. 12.2% of the events were domestic (incest; fathers or brothers), 19.5% had been perpetrated by close relatives (such as paternal uncles and cousins), 22.0% had been committed by distant family members, and 14.6% by other nonrelative familiar (such as neighbours, grocers, barbers, boyfriend and school bus drivers) people for the victims. (Table 2).
The site that the event took place was predominantly outside the house, however 19.5% of the places were the victims' houses. Regarding the methods used by the abusers, 19 of them (46.3%) had been threatened. Notably, 3 cases were still very scared, never describing the abuser in any way. When the cases for whom convincing was used as the method were examined, it was found out that the abuse had been initiated through relationships established as boy-girl friends. Playing (19.5%) had been used more commonly than rewarding (12.2%), and it was discovered that this method had been the preferred method in domestic events ( Table 2).

Discussion
Although the number of studies conducted on sexual abuse has been increasing recently, data to understand the nature to set up protective services is still insufficient. In various studies carried out in our country, the mean age of sexual abuse victims who were admitted to pediatric psychiatry outpatient clinics for forensic evaluation was found as 10.9, 11.3±3.2; 11.4±4 and 12.7±3 years respectively (14,(18)(19)(20). In our study, the mean age of the victims was found to be 11.54±3.31 years, consistent with the literature. Studies conducted to evaluate sexual abuse victims who were referred to forensic medicine units in our country have reported that the highest number of cases were within the age group of 12-15 years (rate: 45.8%) and that 56.3% were abused before 14 years of age (21,22). Studies conducted abroad have reported that the abuse age for boys and girls were 9.1 and 9.0, respectively, 53% of the victims were aged less than 14 years, and the sexual abuse risk was increased during the late childhood and early adolescence periods (23)(24)(25).
Many studies have reported that the rate of abuse was higher in girls when compared to boys (26)(27)(28). Similarly, the studies conducted in our country have found the ratio of girls to boys as about 4:1 (14,15,(19)(20)(21)(22). On the other hand, the rates in boys and girls were found to be similar in our study. The lower rates in boys in this study and the other studies might have resulted from the fact that female gender is an important risk for abuse as well as the fact that sexual abuse may be reported and disclosed less in boys for cultural reasons.
Although sexual abuse can be seen in all socioeconomic levels, it is reported more commonly in children of families with low socioeconomic levels (21,29,30). Consistent with the existing data, many (51.2%) of the sexually abused children in our study were children of families of low socioeconomic levels. This may be caused by the facts that the families do not take care of their children because the children are raised in a crowded environment with the risk of presence of more abusers, or that the families do not provide necessary information to their children to protect them from abuse because of their low educational levels. Further studies may clarify this causality relationship. However, one limitation of this study is that the real status might have been underestimated since the socioeconomic status evaluation was made based on self-reported information.
The majority of abusers are male. The identified perpetrators in our study were all male. The low level of reporting abuses perpetrated by females may be due to the fact that these acts are carried out more unclearly during daily activities (e.g. bathing or care), the nature of the relationship between the abuser and the victim, or the fact that such abuses are perceived as desirable especially by adolescents (31).
While the mean age of abusers was found as 30 years in one study, Oztop and Ozcan, in another study, determined it as 28.2±12 years (range: 11-60 years) (13,32). The mean ages of the perpetrators of these sexual abuse cases were similar. It was demonstrated that the majority of the abusers in sexual abuses against children and adolescents were male and single with low educational levels and high rates of history of substance and/or alcohol use problems (20).
Regarding incest, the perpetrator is often the father and the most common relationship type is that seen between father and daughter while the most unusual type is that seen between mother and son (33)(34)(35). In our country, the most commonly reported incest is the father-daughter type (35). The ratio of intra-familial sexual abuse in our country was found to be in the range of 4.2% to 13.8% (14,15,20,31,36). The ratio of incest in our study was 12.2% which was similar to the previous studies. The child victims often already know the perpetrators and many studies have demonstrated that more than half of the reported perpetrators were familiar people (15,18,20,21). A current study reported the percentage of familiar people to be 77.2%, and also our study showed a very similar ratio (75.6%) (36).
Children who are mentally retarded or physically handicapped, neglected and socially isolated are at higher risk for abuse (36)(37)(38). Mental retardation has been reported in 35-40% of sexually abused children (15,16). The reported underlying cause is the weakness of communication skills and more dependent characteristics of mentally retarded individuals (38). In our study, the clinical and test evaluations revealed that 19.5% of the sexually abused children had mental retardation in various levels.
Abuse and negligence during childhood have been demonstrated to be associated with increased mental disorders and suicide, and these conditions proceed to adulthood. In a study that evaluated a sample of adult victims retrospectively, there were more depression diagnoses in those who had been sexually abused before the age of 12 when compared to those abused after the age of 13 (39). Therefore, identification of sexual abuse during early childhood and provision of the necessary therapy will reduce the incidence of adulthood psychopathology. It was reported that sexually abused Canadian girls, aged between 7 and 12 years, had shown more severe PTSD symptoms than the non-sexually abused control girls, and that social support had reduced PTSD symptoms (39,40). Bulimia nervosa, substance use, and alcohol dependence are more frequently seen in individuals who were sexually abused during childhood (40)(41)(42)(43). A study reported that 63.9% of sexually abused individuals had psychiatric diagnoses (36). The rates of mental disorders (95.1%) and PTSD (51.2%) were higher in our study than those previously reported; this is caused by the fact that the majority of the data in our sample had been obtained from detailed structured interview. The facts that the number of cases being unrepresentative of the entire sample and that the participants including only the children and adolescent age groups who had been referred for forensic evaluation make it impossible to extrapolate the results to cover all cases of sexual abuse. Since the data were obtained from the patients' files, some important risk factors that might have had an impact on abuse such as immigration, pathology of the parents and other characteristics of the perpetrators could not be evaluated. These constitute the limitations of our study. However, differently from the previous publications, our study provides valuable data regarding the relationship of the perpetrator with the child, the site of the abuse and the methods used. In order to prevent child abuse, nationwide protection programme must be implemented. Sexual awareness lessons about "special or secret organs", "good or bad touch", and self-defense might be taught. Parents should keep eyes more on their handicapped children. Standardised child abuse protection courses developed by experts in the field must be taken by all parents, especially by mothers.
In summary, the risk factors that we identified for sexual abuse are as follows: being in the late childhood period, having a mental retardation, low socioeconomic status and low educational levels of the mother and father. Most of the abusers were young adult males already known by the child. 1/5 of the abuses occurred in the child's house. Threatening was the most commonly used method of abuse. For implementing appropriate treatment of cases who had undergone sexual abuse causing persistent mental health problems in the future, the abuse should be discovered during the early period, and most importantly, should be prevented before being perpetrated. Besides mental health problems other consequences of sexual trauma such as early-aged child birth, venereal diseases, and academic failure are important public health issues. Therefore, recognition of the risk factors identified from the study data and the general characteristics of the events, together with those of the perpetrators will be helpful in the development of preventive and informative educational programs.