Review
The public health crisis of child sexual abuse in low and middle income countries: An integrative review of the literature

https://doi.org/10.1016/j.ijnurstu.2014.10.017Get rights and content

Abstract

Purpose

Theoretical and empirical studies conducted to ascertain the incidence and characteristics of child sexual abuse (CSA) in developing countries around the world are inconsistent and poorly synthesized. In order to prevent and respond to these heinous acts, clinicians and policymakers require a substantive body of evidence on which to base interventions and treatment programs. The purpose of this study is to conduct an integrative review of the literature concerning CSA in non-industrialized nations. Ultimately, this evidence could be used to drive research and policy implementation in this area.

Methods

An integrative literature review of publications identified through a comprehensive search of five relevant databases (PubMed, CINAHL, EMBase, PsycINFO, and Web of Science) regarding the incidence and characteristics of all forms of child sexual assault in low and middle-income countries (LMICs) since 1980. Independent and collective thematic assessment and analysis was utilized to identify major concepts of the phenomenon.

Findings

Forty-four articles were identified. These represented 32 separate low or middle-income countries. More studies were identified in low-income countries, and there was a disproportional distribution of studies conducted on regions of the world. CSA has been identified at all levels of society in nearly every region and continent of the world. It is being falsely perceived as a new phenomenon in some developing countries, most likely as a result of increases in CSA reporting. Researching and discussing CSA is difficult because of the sensitive and taboo nature of the topic. Four major themes emerged including difficulty of accurate measurement, barriers to reporting, barriers to justice, and the false perception of CSA as a new phenomenon. Themes of early marriage, human trafficking, sexual coercion and forced first sex, and males as victims have been identified as characteristics and topics placing individuals at risk for CSA. Poverty and its resultant social or family strain are exacerbating factors to CSA.

Conclusions

There is inadequate representation of CSA research in LMICs, and an increasing awareness that sexual abuse of children is an endemic threat to the health and safety of children worldwide. This review lays the foundation for an array of further areas of analysis to explore the expanse of unanswered questions that remain regarding the phenomena of CSA in low and middle-income countries.

Clinical relevance

Healthcare workers hold a unique position and responsibility for identifying and responding to CSA.

Introduction

Child sexual abuse (CSA) is a global phenomenon that spans countries, continents, and socioeconomic classes. The World Health Organization (2006) has estimated that 150 million girls and boys under the age of 18 have experienced sexual violence. However, the true incidence of CSA cannot be readily or reliably determined (Forjuoh and Zwi, 1998). This knowledge gap is particularly acute in low and middle income countries (LMICs) where theoretical and empirical studies related to the problem of child sexual abuse (CSA) are inconsistent and underrepresented.

There are a multitude of interconnected factors that may contribute to a lack of information regarding CSA. The problem may be due to funding constraints or may be reflective of how seriously a country regards the issue. Whether or not CSA is considered a crime and whether there are statutory child protection services in place may also impact the availability of evidence. Discussing violence itself is considered taboo in many cultures, especially sexual violence. Ethical and regulatory constraints regarding the conduct of research involving children add additional layers of complexity to the exploration of this issue.

In addition to being a violation of an individual's basic human rights child sexual abuse produces severe and adverse health outcomes in the realm of physical, mental, and sexual wellbeing. The health-related consequences of CSA are relatively similar despite geographic and cultural differences and include depression, physical injuries, out-casting, shaming, and psychiatric disorders (Meursing et al., 1995). Sexual abuse in children is also associated with an increased risk for suicidal ideation, suicide attempts, substance abuse, multiple sex partners, and sexually transmitted infections (Brown et al., 2009). The effects of exposure to CSA are cumulative in nature meaning that more sexual abuse leads to an increase in negative health behaviors, decreased health outcomes (Brown et al., 2009), and a decreased overall perception of the child's own health (Bassani et al., 2009). The only geographically-based difference in health sequelae identified in the literature relates to increased HIV transmission in regions where HIV is endemic (Forjuoh and Zwi, 1998). Sexually transmitted infection rates are higher in children who have been victims of sexual abuse (Haffejee, 1991).

Pediatric healthcare providers function as advocates for child health and fill a vital role in identifying children who are victims of sexual abuse. There are often very few physical signs of sexual maltreatment and less than 5% of victims show physical signs of abuse (Hornor, 2011). Victims are identified during the history component of examinations (Adams, 2011) or are not identified at all. Because of the taboo nature of CSA, it is imperative that clinicians understand risk factors for CSA and the importance of extensively assessing children for victimization.

Child sexual abuse is an atrocious act that directly affects the child's quality of life and creates a lifelong mental health burden. Greater understanding of the phenomena of CSA is proposed as an important step in order to prevent and respond to these heinous acts. The purpose of this study is to conduct an integrative review of the literature concerning CSA in LMICs in order to identify reporting issues, trends in the phenomena, attributes/risk factors for perpetrators and victims, and the role health care providers play. The information provided in this review is intended to give the reader an overview of CSA and to guide further research and policy in halting these acts.

Section snippets

Methods

An integrative review of the literature was conducted using the framework provided by Whittemore and Knafl (2005) which allows for the inclusion of diverse methodologies (i.e. experimental and non-experimental research). An integrative review is a specific review method that summarizes past empirical or theoretical literature to provide a more comprehensive understanding of a phenomenon (Broome, 1993). Integrative reviews differ from systematic review and meta-analysis approaches that may

Results

The original search strategy identified 264 published works. 32 articles were identified after duplicates were removed. Eleven publications were added to the review from Latin American countries and the Caribbean and one was identified and added from former USSR states. Fig. 2 outlines the selection strategy used to identify and include articles in this review.

Table 2 outlines the distribution of studies identified based on the income level of countries and to what extent the economic classes

Difficulty of systematic ascertainment

Despite the fact that multinational aid organizations have rigorously defined CSA there is still no international consensus as to what specific acts constitute abuse. Khalid (2001) interviewed 24 Tanzanian CSA responders and found that researchers have defined it in other studies in a multitude of ways depending on type of physical contact, willingness of the child, degree of penetration, presence of threats and intimidation, or developmental state of the child. This diversity, along with

Discussion

Despite the challenging nature of measuring and combatting a taboo subject such as child sexual abuse, ample evidence exists to inform new, more effective policy, public health, and primary care interventions aimed at enumerating and eventually curtailing this shameful act.

Conclusion

Globally, there is currently an inadequate representation of CSA research in LMICs. CSA research has disproportionately been performed in selected regions and countries for largely unknown reasons. Our integrative review of the available research indicates that sexual abuse of children has been identified as an endemic problem that exists in LIMCs and affects female and male children from all social classes. This review lays the foundation for a wide array of further areas of analysis to

CSA clinical resources

International Rescue Committee (IRC) and UNICEF Caring for Child Survivors of Sexual Abuse: Guidelines for health and psychosocial service providers in humanitarian settings (2012) http://www.unicef.org/pacificislands/IRC_CCSGuide_FullGuide_lowres.pdf.

USAID (2013): The Clinical Management of Children and Adolescents who have experienced Sexual Violence, Technical considerations for PEPFAR Programs. http://www.aidstarone.com/sites/default/files/AIDSTAR-One_Report_PEPFAR_PRC_TechConsiderations.pdf

Conflict of interest

None declared.

Funding

None.

Ethical approval

N/A.

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    1

    Dr. Veenema and Clifton Thornton are both Sigma Theta Tau International Members in the Beta Nu Chapter.

    2

    The 2013 Florence Nightingale Medal of Honor and 2004 Robert Wood Johnson Executive Nurse Fellow titles belong to Dr. Veenema.

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