1. Introduction
Violence against children is defined as all forms of violence against children below 18 years old, including child maltreatment, physical, emotional or sexual abuse, and neglect by their guardians. Boys and girls are at equal risk of physical and emotional abuse, while girls are at greater risk of sexual abuse [
1]. The United Nations International Children’s Emergency Fund (UNICEF) estimated that 15 million adolescents aged 15 to 19 years have experienced sexual abuse in their lifetime [
2]. The sexual abuse of a child is defined as any sexual activity conducted with a child who is below the age of legal consent for sexual gratification of an adult or a substantially older child. These activities include oral–genital, genital–genital, genital–rectal, hand–genital, hand–rectal, or hand–breast contact, exposure of sexual anatomy, forced viewing of sexual anatomy or pornography, or using a child in the production of pornography [
3]. The World Health Organization classifies child sexual abuse as a silent health emergency [
4]. Still, it remains a neglected social issue, especially in cases of incest, even though most reported incest victims are children [
5]. Additionally, data from a meta-analysis study showed that victims of intra-familial sexual abuse were younger than the victims of extra-familial abuse [
6].
There is generally no single factor that results in child sexual abuse. However, research has shown several risk factors to be commonly associated with maltreatment. These include familial dysfunction, divorce, substance abuse by parents, low socioeconomic status, and permissive parenting styles [
7]. Research had shown that the cause of child sexual abuse lies with the perpetrator who has psychological problems, which has led them to an inability to control their sex drive and is compounded by a lack of available partners. Hence, it influences the offender’s decision to engage in the behavior [
8]. Other factors include early exposure to online chatrooms, which can lead to victims falling prey to perpetrators whom they befriended through the internet [
9], and parental mental illness, which approximately doubles a child’s risk of physical or sexual abuse [
10].
The short-term and long-term sequelae of child sexual abuse are complex. Major depressive disorder was the most common psychiatric diagnosis, identified in 44.9% of child sexual abuse victims [
11]. The longer the first abuse event to the first psychiatric evaluation, the more intense the potential sexual abuse-related psychiatric disorders can be [
12]. While the victims may recover, their memories of these experiences may alter their perceptions, thoughts, and emotions, leading to overwhelming feelings of sadness throughout their lives [
13].
Cultural taboos prevent Malaysians from discussing sex or sex-related subjects publicly. Individuals who are not sufficiently exposed to accurate sex information are more likely to misunderstand facts and accept myths [
14,
15], which results in children being unaware or unable to recognize sexual misconduct. Most children suffer in silence because they do not know where to turn for help [
5,
14], and the abuse lasts for years.
In some cases, the perpetrators force the victims to keep silent, meaning that, even if family members know what is taking place, the victim will not take action due to fear of repercussions [
16]. It can have a tremendous psychological impact on children. Accordingly, this study aimed to describe both the risk factors of sexual abuse and its impact on the children who experienced it.
2. Materials and Methods
In this study, we applied the Spaccarelli’s Transaction Model. A qualitative study design was employed to explore the emotions and behavior of children who experienced sexual abuse as recorded by the doctors and social workers who treated them. The unobtrusive qualitative method of data mining did not require the researchers to interact with the respondents of the study; the researchers instead studied the secondary data and extracted relevant information from case records. This was considered appropriate because it allowed researchers to collect data without interfering with the subjects under study, therefore avoiding unnecessary traumatic experiences for these children [
17].
This qualitative study was conducted in Universiti Sains Malaysia Hospital, Kubang Kerian, Kelantan, located in Peninsular Malaysia. Kelantan state has a population of 1.93 million, and 36.7% of them are children under 18 years old. A retrospective study of children who experienced sexual abuse, whose medical case records were accessible from 2019 to 2021 until current hospital follow-up in Psychiatric Clinic, Universiti Sains Malaysia Hospital (USM), were retrieved. This research obtained approval from the Human Research Ethics Committee of the USM (USM/JEPeM/20110554).
Children aged 10 to 18 years old who were able to provide information to their doctors were eligible for this study based on inclusion criteria. These criteria were derived based on the children’s age range and their ability to provide information to the treating doctors. Children with vision, hearing, speech impairments, and those with known psychiatric disorders before the abuse, were excluded because these cases were under-reported. This occurred due to the inability of these victims to report their abuse and difficulties in recognizing and understanding the signs on the part of the healthcare services. Purposive sampling was applied, such that hospital case records were deliberately chosen because they could provide the information to the researcher.
This study was conducted over six months, from January 2021 to June 2021. The case records were skimmed, read, and synthesized until no new information could be obtained [
18]. The main source of retrospective data was the case records, which included demographic data, the experience of the abuse, and its emotional, behavioral, education, and social impact on the victims. The list of sexual abuse victims attended to by the Suspected Child Abuse and Neglect (SCAN) team came from the pediatric clinic; this team consists of a pediatrician, psychiatrist, psychologist, social worker, religious officer, and obstetrician and gynecologist. The case records were traced and skimmed to determine their eligibility; relevant information was transcribed using Microsoft Word. The case record extraction guide was used in this study and was described in
Table 1, and the focus was on demographic data, abuse history, challenges, and the post-abuse effects on the victims.
The raw data were managed using computer-aided qualitative data analysis software, NVIVO version 12 (QSR International Pty Ltd., Burlington, MA, USA, 2012), and thematic analysis was used to code the information in six phases [
19]. All documents were manually read and re-read to get a sense of the victims’ entire story. The researcher coded these transcripts independently and created an initial list of codes, re-evaluated and finalized in consultation with the other researchers. New codes were continuously added throughout this process, and data were constantly compared to the codes to ensure that none of their meanings changed. Similar codes in the victims’ words and the researchers’ interpretations were clustered to develop subthemes; these were then combined into main themes.
Descriptive analyses were performed using IBM SPSS Statistics version 26.0 (SPSS Inc., Chicago, IL, USA, 2019) for the sociodemographic characteristics of sexual abuse victims. The residential area was determined based on the patients’ addresses as given in the case records; the Kota Bharu district was considered an urban area.
To ensure the rigor of the study, the main themes were agreed upon by all researchers. The saturation of themes occurred when no new themes could be observed in the data. Several validation strategies were also applied as follows. First, any discrepancies in the information were cross-checked with the case records. In the investigator’s triangulation, the co-researchers read selected case reports. Secondly, the thick description specifies the theme by providing many different perspectives to become realistic and richer. Thirdly, negative or discrepant information with contrary information was presented to add credibility to the account.
4. Discussion
The findings highlight some key risk factors for child sexual abuse, including disruption of the family dynamic, low socioeconomic status, and poor peer influences. More than 80% of the victims were of a low socioeconomic class. Most of the victims came from rural areas. Only 15% of their guardians were government servants and had a consistent monthly income. The Fourth National Incidence Study of Child Abuse and Neglect found that low socioeconomic status had a strong relationship with all forms of child abuse, including sexual abuse [
20]. One study also reported that most sexual abuse victims came from lower socioeconomic classes [
21].
One cross-sectional study done in Korea reported that family problems and dysfunctional family dynamics could be associated with child sexual abuse [
22]. We found that a pathological and dysfunctional family dynamic contributed to family conflicts, parental violence, less emotional bonding, and the presence of other forms of child abuse like physical abuse and domestic violence. Cases of incest also happened in impaired family dynamics, such as children being adopted by foster families, children who lived alone with their fathers, and children who lived with family members involved in substance abuse. In our study, all of the events of incest were found to be committed by relatives who lived together without consanguinity, primarily fathers, brothers, brothers-in-law, and uncles. More than half of the incest events in our study involved vaginal penetration, while only one case involved the fondling of private parts.
We found that most victims experienced severe sexual abuse, such as fondling private parts and vaginal penetration, for some time before they disclosed the abuse. This indicated that the victims found it difficult to talk about their abuse due to distress and shame. Sexual abuse is rarely addressed in everyday conversation among family members, even if parents discuss the importance of personal hygiene, developmental issues, or emotional issues with their children. Studies have shown that parents and children rarely talk about sexuality, and when they do, they feel embarrassed [
23].
One study reported that most of the sexual victimization of adolescents aged between 12 to 21 years within heterosexual romantic relationships occurred within 18 months of the start of the relationship [
24]. This finding was similar to our study. We found that the leading causes of child sexual abuse were dating and visitation, where either the perpetrator visited the victims or vice-versa. Smartphones and the Internet acted as the primary communication mediums for the victims and the perpetrators; one study regarding the relationship between internet usage and sexual victimization in college students reported that more than three-quarters of them spent a lot of time with their smartphones and the internet. This is a risk factor for victimization because it can expose potential and can help perpetrators get close to victims [
25].
Our findings also support a study that has shown that abuse also depends on other factors related to children’s character, family dynamics, community environments, and cultural and social attitudes [
26]. The average age of the victims was around 15 years old. Most were in primary and lower secondary school; the younger the child at the time of the abuse, the more complex the disclosure of the event, which can be underdeveloped cognitive, verbal, and recall abilities. We also found that most victims attempted to alert adults to their problems through angry outbursts, serious substance abuse, social withdrawal, school abstinence, or by running away from home. Having a physical disability, especially blindness, deafness, and mental retardation, increased children’s risk of sexual abuse [
27].
In our study, 33% of the victims experienced teen pregnancy. Premarital sex and adolescent pregnancy are socially unacceptable in Malaysia and are always kept hidden. In this study, all victims reported premarital sex as rape because the events initially happened against their will. It is considered statutory rape if the victim is less than 16 years old at the time of the event. A review of research on child abuse in Malaysia reported that the mean age of premarital sexual activity was around 15 years old [
28]. An increase in premarital sexual activities in younger age groups will significantly increase the risk of teen pregnancies and, later, of abandoned babies [
29].
Younger mothers were more likely to have a low socioeconomic status, be single parents, abuse substances, and drop out of school [
30]. We noted that most victims confessed that they had no idea what to do; children who experience sexual abuse tend to hide from telling anyone about it because they feel guilty. They are also afraid of the perpetrator’s anger and are sometimes even threatened by the perpetrator. A review of 45 studies on the impact of sexual victimization among children reported that sexually abused children had more symptoms of fear, post-traumatic stress disorder, sexualized behaviors, and poor self-esteem than non-abused children [
31]. Another study reported that children are more traumatized when the perpetrators are their parents [
32].
We also found that child sexual abuse can significantly affect the family environment due to societal and cultural embarrassment. Families feared being labeled “bad” because they failed to protect their children. In addition, many Asian communities are embarrassed to discuss sexual abuse because of a fear of public exposure and a fear of culturally insensitive responses from professionals [
33]. Culture, therefore, plays a significant role in evaluating the victim’s symptoms and potential outcomes. When a case of child sexual abuse is reported, a psychiatrist must explore the child’s family dynamics, particularly their religious understandings and belief systems, in addition to clinical assessments. This necessary information includes the child’s knowledge of the sexual activity, the reasons for the abuse, the victim’s relationship with the perpetrator, the process of disclosure, the support system, and coping strategies.
When summing up all the risk factors from our findings and their effects on child sexual abuse, we applied Spaccarelli’s Transactional Model [
34] to understand why children react differently to different stressors. In this model, sexual abuse is the stressor that creates a risk of maladaptive adjustment; the level of risk depends on the level of abuse-related stress. It can be mediated by other factors, such as support systems, coping mechanisms, and a child’s cognitive appraisal. This model also offers a comprehensive approach for developing intervention methods for the victims experiencing post-traumatic stress disorder.
Limitations
This qualitative study explored data from case records, limiting the exploration of the victims’ emotions, and hence, there was the possibility of recall bias. In-depth interviews with victims could lead to important information for the clinicians, and the clinicians could explore this with more specifications. This study also excluded children with disabilities, who will have more intrusive abuse experiences. We cannot explore their experience of sexual abuse because children with disabilities may have limitations in speech and language and require specific tools such as photos or drawings. Children with disabilities may only answer yes or no when answering the question during the consultation and may limit the researchers in an exploration of their history.
5. Conclusions
All victims in this study complained of sexual abuse, but it can present non-specific behavioral and physical symptoms, including school refusal, sleep disturbances, or chronic symptoms like headache or stomach ache. It is necessary to take a history from the children to diagnose and determine the appropriate tests, treatments, and potential need to report suspected child sexual abuse to child protection and law enforcement services. If they have not disclosed the abuse, these children should be questioned carefully and in a non-leading manner about the possibility of sexual abuse. Child sexual abuse dramatically affects the victim and society; it cannot be ignored, and prevention and intervention programs must be implemented. School-based awareness and educational programs should be promoted in Malaysia to keep children informed of the potential risks.
Studies on the long-term effects of sexual abuse on survivors are required. They need to consider the implications of child sexual abuse on their eventual parenting styles; many survivors may not realize that some traumas may interfere with their parenting practices. There is a need to evaluate further the effects of child sexual abuse on survivors’ conversations with their children about sex to determine whether these mothers could benefit from a parenting intervention to help them engage in healthy discussions with their children.
