An overview of violence and sexual abuse in children: global data, policy responses, and multidisciplinary approaches in health care
Nuno Coelho 1,2,3, Anabela Neves 4, and João Gregório 1*
1CBIOS – Universidade Lusófona’s Research Center for Biosciences & Health Technologies, Campo Grande 376, 1749-024 Lisboa, Portugal; 2Health Sciences PhD Program -U Alcalá , Madrid, Spain; 3Polícia Judiciária, Lisboa, Portugal; 4Instituto Nacional de Medicina Legal e Ciências Forenses (INMLCF),I.P., Portugal
News of sexual abuse against children is increasingly common. This paper aims to describe the historical and social progress of sexual violence against children through a narrative review of the literature, with the goal of understanding how health systems deal with sexual violence against children, as well as to identify the costs to society and to children's personal lives. The history and latest global and national data on sexual abuse against children are presented, revealing that violence against children is emerging as an endemic threat worldwide, resulting in serious social and health problems, with higher prevalence in low- and middle-income countries than in high-income countries. In these higher-resource countries, understanding and detecting what is abuse and what is not abuse in a given situation is supported by a multidisciplinary team, involving professionals from different sectors. Thus, it is important that all actors be enabled to articulate their actions, working with the goal of safeguarding well-being and development of children.
Keywords: Child; Sexual abuse; Violence; Health professionals
Received : 27/03/2021; Accepted: 20/12/2021
According to the World Health Organization (WHO), child abuse or maltreatment constitutes “all forms of physical and/or emotional maltreatment, sexual abuse, neglect or negligent treatment or commercial or other exploitation, resulting in actual or potential harm to the Child’s health, survival, development or dignity in the context of a relationship of responsibility, trust or power”(1).
To Carder (2), the sexually abused child develops unique physical, mental and behavioral health weaknesses, with implications for their life course, often resulting in post-traumatic stress disorder. Several studies show that traumatic experiences that occur in the early years of life are directly related to future behaviors, correlating childhood violence and leading causes of mortality in adulthood (3). Thus, childhood sexual abuse is possibly the most severe form of abuse or neglect, due to the identity-destroying nature of the child (4).
There are numerous definitions of what constitutes child abuse, with various terminologies used, such as child sexual abuse, child sexual assault, child sexual victimization, child sexual exploitation, adverse sexual experiences, and unwanted sexual experiences (5). Sexual abuse against children is a common form of violence which has endured throughout the ages. Only very recently this form of abuse has been considered a crime. For most of our human existence, these behaviors were not considered criminal, and often were even allowed. While this is not a new phenomenon, its visibility as a social problem is recent. This visibility has helped reveal the sexual abuse of children that occurs in child support institutions such as schools, youth sports institutions, religious institutions, and other youth support organizations (6).
Most victims of child sexual abuse never disclose the abuse, and as a result do not receive the treatment they need (7). Often they may take many years to seek help due to a lack of trust and emotional safety.When reporting does occur, victims disclose to informal sources of support, such as health care professionals and other support services (8,9). Others carry the trauma of their abuse “to the grave”, although reporting of sexual abuse in childhood has been reported in palliative care, weeks to months before death (10).
Sexual abuse crimes adapt and evolve following the development of social norms and standards, finding a place in the present, in new technologies (e.g., the internet) and in the new forms of criminality that may result from them (11), resulting in high mental and social health consequences, and high economic costs to society (12). The reality of the numbers can be visualized as an iceberg, as they remain shrouded in a culture of silence, hidden by shame, guilt, and social stigma. Moreover, the statistical reality is either under-represented in official figures, or these vary depending on the definitions used and how the information is collected.
Health care providers frequently encounter child victims of sexual abuse. Health care systems play a crucial role in the prevention and care of these victims. Some countries have guidelines or protocols that aim to articulate the roles of different health care and other professionals (e.g., police investigation), but, generally, the development and implementation of these protocols have been slow (13). In addition, the role that individual health care providers can play in curbing violence against children is often not recognized or adequately highlighted.
Thus, this article aims to present the problem of child sexual abuse, starting with a historical contextualization to the latest known data on the subject, and to present the solutions that health systems have developed to mitigate this problem.
Child sexual abuse has been a problem of all nations and generations. Research of historical sources reveals the existence of child sexual abuse since ancient times and that State efforts to fight it have always been intense and systematic.
Roman law had defined the age of marriage as 12 for girls and 14 for boys. This law was assimilated by the Byzantine state with the premise that the husband should wait until the underage girl was 12 to have sex. Efforts to control child sexual abuse were based on the annulment of the marriage whenever the law was not followed. Rape, pederasty, and incest took the form of early marriages and state alliances as a way to circumvent the established laws (14).
The concern with education, and living a good childhood, emerged with Ariès (15) in his iconographic work on children, profiling their characteristics since the 12th century. With his work, it was possible to verify the role of children in society at that time, as well as the family and social relationships they maintained, revealing their fragility in the social network and their devaluation, and showing a social discourse that accepted situations of abuse against children. Part of this acceptance was related to the moment when children become physically independent, taking their place in the adult environment, being seen as miniature adults for the delight of adults. Until the 17th century, children were associated with adult sex games, and this practice was part of the customs of the time. In front of them, the adults allowed themselves to do everything: crude words, actions and scabrous situations; the children heard and saw everything (15). However, research on the subject has revealed that this medieval religious society, whose State, with its strict legislation, and the Church, with the spiritual pressures at its disposal, developed efforts to restrict child sexual abuse but failed to eradicate the behavior.
Looking at a child as a child was only possible when various movements, including the social movement for citizenship during the French Revolution of 1789, saw their demands recognized, including the acceptance of citizenship in childhood (16). The ideal of Democracy, at the basis of the French and American Revolution, eventually played a determining role in the construction of the standards of acceptable behavior that led to the conceptualization of childhood and adolescence as developmental periods essential for the maturation of personality. In the early 19th century, a group of church workers in New York, USA, resorted to laws written by the Society for the Prevention of Cruelty to Animals (SPCA) to protect a child (named Mary Ellen) from abuse by her foster parents, claiming that the child was a member of the animal kingdom and should be protected under animal protection laws (17). However, with the evolution of thought and the creation of norms and conduct in modern society from the 19th century onward, sexual activity with children became a highly condemnable crime punishable by imprisonment.
Current Knowledge & Policies
Currently, the WHO defines violence as “the intentional use of physical force or power, actual or threatened, against oneself, another person, or against a group or community, that results in or is likely to result in injury, death, psychological harm, developmental disability or deprivation” (1).
Depending on their age, a child may experience one or more types of violence (Figure 1). It is estimated that one in two children aged 2-17 experience some form of violence each year, and approximately 300 million children aged 2-4 experience regular violence at the hands of their caregivers (12). In addition, it is estimated that by early 2020, one-third of 11- to 15-year-olds worldwide will have been bullied by their peers and that 120 million girls will have experienced some form of forced sexual contact before the age of 20 (12).
Violence against children is emerging as an endemic threat worldwide (18), resulting in severe health and social problems (Figure 2) (19–23). The existence of violence against children can cause traumatic events called Adverse Childhood Experiences, and impact of these events will be reflected in future perpetration of violence and victimization, as well as in health status (24). Some meta-analyses have shown that approximately 23% of children have experienced physical abuse, 36.3% have experienced emotional abuse, and 13% of children worldwide have experienced sexual abuse (25–27). Worldwide, rates of violence against children are highest in Africa, Asia, and North America. In 2015, approximately 50% of children in these continents experienced violence (3). The prevalence of violence tends to be higher in low- and middle-income countries than in high-income countries (28,29). The highest prevalence of child sexual abuse is found in the African continent (34.4%), while in Europe, the prevalence is much lower (9.2%) (30). More than 80% of children in the world live in low- and middle-income countries (31), with a marked difference in demographic profiles. According to the WHO (32), over 94% of DALYs* due to interpersonal violence against children aged 0-15 years occurred in low- and middle-income countries in 2016. The investment made by these countries in social protection policies for children (0-14 years) is lower than in high-income countries (33). Sociodemographic factors associated with sexual and emotional violence include lower socioeconomic status of the household, being female, and the primary education of mothers and adults in the household (34).
The Convention on the Rights of the Child defines in particular that "the child, because of his physical and intellectual immaturity, needs special protection and care, including appropriate legal protection, both before and after birth" and therefore a safe and happy family environment must be ensured for the proper development of their personality (35). It has also been defined in the Convention that a Child is every human below the age of 18 years unless, under the law applicable to them, they reach adulthood earlier. With the publication of the 2002 World Report on Violence and Health, the worldwide visibility of sexual violence crimes against children has increased. It is now recognized that it is the responsibility of the State to protect the child from all forms of maltreatment by parents or others responsible for the child, and to establish social programs for the prevention of abuse and for the treatment of victims (36). Because of its importance, it was recently as (UN) Sustainable Development Goal 16.2, which aims to end all forms of violence against children by 2030 (37).
According to the United Nations Children's Emergency Fund (UNICEF), child protection is done through philosophies, policies, standards, guidelines, and procedures to protect children from intentional and unintentional harm. In that sense, the responses to build the national child protection system are broad and include legislative reforms, strategy development and planning, coordination, mapping of needs and gaps in services, capacity building and development of service structures, acting to change attitudes and behaviors (36).
Another policy to curb violence against children was presented by the WHO in 2016, with the publication of seven strategies with the acronym INSPIRE: Implementation and enforcement of laws; Norms and values; Safe environments; Parent and caregiver support; Income and economic strengthening; Response and support services; and Education and life skills (38).
In 2007, the Council of Europe indicated the importance of the topic with the organization of a convention with special standards to prevent and protect children from sexual exploitation and sexual abuse: the "Council of Europe Convention on the Protection of Children against Sexual Exploitation and Sexual Abuse", which became known as the Lanzarote convention (39).
The Comparing Sexual Assault Interventions (COSAI) project was also created in Europe with funding from the European Union (EU) through the DAPHNE III program, with the aim of improving services for victims of sexual abuse (40). This project has mapped national strategies in 34 European countries, presenting evidence that of the 34 countries, 11 (33%) have protocols and strategies that address sexual violence, while 7 (20.5%) have no protocols or strategies implemented that address sexual violence against women over 16 (40). This finding is not surprising, since in the Global Report on Preventing Violence Against Children 2020 (12), is reported that although most countries present some kind of law to protect children against violence, about half of these countries declare that those laws are not heavily enforced.
In Portugal, sexual crimes were viewed as crimes against freedom and against the sexual self-determination of the person only after 1995 (41). Currently child protection policies in Portugal are assisted via the Comissão Nacional de Promoção dos Direitos e Proteção das Crianças e Jovens (42) and the health programs of Direção Geral de Saúde (43,44) with the goals of early detection and intervention of children at risk of violence and sexual abuse.
A culture of acceptance of interpersonal violence against family members and other close acquaintances still prevails in some social circles, keeping the rates of this type of crime high (45).
In the first six months of 2018, five children were victims of sexual crimes and more than one rape was reported per 24 hours (46). According to investigative police sources cited by Moreira (46), of the 1,518 cases related to sexual abuse and coercion, pimping, pornography, prostitution, or rape, 885 involved children and adolescents and that most were perpetrated by family members or someone close. After child sexual abuse (665 cases), rape (231 cases) and sexual harassment (97 cases) top the list of the most committed (reported) sexual crimes, followed by sexual acts with teenagers (83 cases). According to data from the Portuguese Association for Victim Support (APAV) (47), in 2018, a total of 46,371 attendances were recorded, a 31% increase compared to 2016. These attendances reflect 11,795 new cases and cases in follow-up, where it was possible to identify 9,344 victims and 20,589 crimes and other forms of violence. These results are not different from the figures on a global scale (48), referring that women, children and the elderly suffer the most physical, psychological and sexual abuse.
Health systems and the role of professionals in dealing with victims of child abuse
Health professionals, as frontline health care providers for children, play an extremely important role in the detection of these crimes, and therefore should value the main warning signs for the detection of child maltreatment (Table 1) (44).
The approach, treatment, and care of child victims of sexual abuse begin with the medical intervention for the treatment of injuries, prevention of unwanted pregnancy, diagnosis and treatment of sexually transmitted infections (49) maltreatment and sexual crimes. The victim should be subsequently referred to psychosocial support to help cope with the traumatic episode, ensuring the safety and protection of the victim and with the support of the criminal system in the investigation of the crime, collection of evidence, trial, and punishment of the perpetrator. Collecting trace evidence and recording injuries that may exist is done by forensic medicine experts (50).
Understanding and detecting what is and is not abuse in a given situation then requires multidisciplinary work. Thus, coordinated action between different family doctors, pediatricians, childhood and adolescent psychiatry doctors, psychologists, family nurses, forensic nurses, the investigative police, and the courts is essential. For this reason, it is important that all actors are able to articulate actions so that the well-being of the child or young person is guaranteed, avoiding interventions that lead to secondary victimization (51). It should also be noted that other professionals can intervene, such as educators and teachers, due to their direct contact with children (52–55).
Historically, the reality of the response of the legal, medical, mental health, and social support teams to victims of sexual assault has been uncoordinated. These systems respond in isolation to survivors of sexual assault, with role confusion and/or conflict between the different actors about who should do what and when to respond to the assault. In order to find solutions to this problem, North American communities have developed Sexual Assault Response Teams (SARTs), a model which was quickly spread around the world, for example, in the United Kingdom, with the creation of the so-called SARCs (Sexual Assault Referral Centres). These teams and centers intervene in the community and aim to build positive professional relationships and increase collaboration between stakeholders in response to sexual violence, improving the procedural effectiveness of sexual assault cases in the courts.
The core team of the SARTs includes police officers, prosecutors, physicians, social workers and Sexual Assault Nurse Examiners (SANE), and in this context, these SANE are usually the first specialized line of contact with sexual assault victims in the health care system (56). SANE are a specialty of forensic nursing. Forensic nursing originated in the United States, later expanding to countries including England, Canada, Australia, and Northern Europe (57). Forensic nurses are at the front line of contact with the victims of sexual abuse. They also have an important role in educating parents, community members, and other healthcare professionals about sexual abuse (58). The goal of the SANE is to protect the sexual assault victim from secondary victimization; intervene in crisis situations; collect documentation and preserve evidence, evaluate and prophylactically treat sexually transmitted diseases (STDs), assess pregnancy risk and offer prevention, evaluate, document and provide care for injuries, appropriately refer victims for medical and psychological follow-up, and work to increase conviction success in sexual assault cases. A SANE program provides 24 hour emergency services for all victims of sexual assault or abuse.
In Portugal, the SARTs teams are not yet a reality, despite the existence of the necessary resources for a multidisciplinary approach to the victim, because in the (hospital) emergency department, other professionals are involved along with doctors and nurses, such as social workers, criminal police bodies and experts from the National Institute of Forensic Medicine and Sciences (INMLCF) and psychologists. In fact, it is with the nurse at the triage of the Pediatric Emergency Department (UP) that the first contact with the health professional takes place, and the victim is subsequently referred to the pediatrician in charge of the team (59). Some data from the study of Vasconcelos et al. (59) reveals that in 31% of the cases, the first observation of the genitals was performed by the pediatrician at the UP and in 5.5% of cases by Gynecology; 70% of the cases were sent to the INMLCF for observation. Social Services took charge of the child in most of the cases (89%), studying and guiding the child; the Commission for the Protection of Children and Youngsters at Risk received referral in 63.7% of the cases; only 3% received support from Psychology. Finally, only 41% of the situations were reported to the police.
It is important to highlight the need for specific training for multidisciplinary teams working in this area to properly assess and address child sexual abuse. In fact, it is often the lack of professional training which limits the scope of action of nurses in the detection of sexual abuse preventing a timely intervention in these situations. Furthermore, interaction with police inspector teams also needs to be improved, as practices show that little or nothing is done to meet the needs of the investigation and that police inspectors often face contamination or destruction of evidence due to the procedures performed by emergency medical teams in providing assistance to victims (60).
The recognition of Forensic Nursing as a differentiated nursing specialty is a very recent reality in Portugal (61). However, it is a topic that most nurses are aware of, even if there are still few nurses who have training in the area (62). Therefore, for the practice of SARTs teams with SANE-type nurses to be implemented in Portugal, it is necessary to provide nurses with forensic skills or knowledge of forensic sciences so that their application in clinical practice can be effective, in order to ensure an effective response to the victims of sexual abuse. Furthermore, it is also necessary to investigate how to best integrate these professionals into the current health care and victim support system in the Portuguese context.
Given the current reality, we conclude that child sexual abuse is a problem that cuts across societies and spills over borders imposed by different cultures. Although over the last few years, much has been done to help the victims, with the review, creation and implementation of different measures aimed at their protection, there is still a long way to go.
The complexity of this situation entails serious short- and long-term consequences, affecting not only children but also their caregivers, with high costs to economies, judicial systems, and societies. Health care systems and health care professionals can play an important role in both the prevention and detection of child sexual abuse. In this sense, further research in this area becomes a priority to make it possible to know which organizational and/or legislative measures should be implemented to improve the interaction between health professionals, social action professionals, and police investigators, in order to ensure an effective response to victims of sexual abuse.
Authors Contributions Statement
NC and JG, conceptualization and study design; NC, data analysis; NC, JG and AN, drafting, editing and reviewing; NC, figures and graphics; JG, supervision and final writing.
This study funded by national funds through FCT - Foundation for Science and Technology, I.P., under the UIDB/04567/2020 and UIDP/ 04567/2020 projects. João Gregório is funded by Foundation for Science and Technology (FCT) Scientific Employment Stimulus contract with the reference number CEEC/CBIOS/EPH/2018
Conflict of Interests
The authors declare there are no financial and/or personal relationships that could present a potential conflict of interests.
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