Analyzing the concept of sexual self-care in preschool children: A qualitative study

Abstract

BACKGROUND:

Child sexual abuse is a global concern for families and societies. Therefore, child protection from sexual harassment is of particular importance. The present study aimed to investigate the concept of sexual self-care in children.

MATERIALS AND METHODS:

The present research is a qualitative study conducted with a content analysis approach. The study participants include 39 child sex education specialists, parents of children aged 4–7 years, adolescents who were sexually abused in childhood, and those with no experience of sexual abuse in childhood. The participants were selected through purposive sampling method. Different people's interpretations of the concept of sexual self-care in children were explored using semi-structured and face-to-face interviews, which continued until the saturation of concepts. Data were analyzed using the Graneheim and Lundman method. Guba and Lincoln's criteria were used to strengthen the validity and transferability of the data.

RESULTS:

Sexual self-care in children was identified from participants’ viewpoints in the study. This self-care includes three main components and six subcomponents of (1) knowledge about privacy, risk situation, and trustworthy people, (2) attitude and perception of risk, and (3) behavioral skills in self-protection (i.e., post-injury reaction).

CONCLUSION:

Further injuries can be prevented by improving the level of awareness, forming the right attitude, and strengthening children's behavioral skills toward sexual self-care. Such issues, which are representatives of privacy, risk situations, and self-protection ability, can improve children's sexual self-care skills.

Introduction

Childhood is one of the critical stages of human development,[1] during which most of one's personality develops. Childhood experiences and relationships and others’ behavior with the child shape their way of understanding.[1] As a highly devastating childhood event, child sexual abuse (CSA) causes long-term and significant consequences, with severe and long-term physical, emotional, and psychological damage to the child. It results in various mental disorders in adulthood, including severe depression, personality disorders, and self-harm.[2,3] CSA is more harmful than any other form of child abuse and has long-term consequences.[4,5]

CSA is an adult's coerced and deceptive sexual relationship with a child. Other types of sexual harassment include activities such as caressing, inviting the child to touch or make sexual contact, penetration, rape, nudity, child pornography, or trapping a child through cyber predators.[6] The figures for CSA in developing countries are higher than those in developed countries. Since more than 80% of sexual harassment cases are not reported, accurate figures are not available on the number of child abuse victims. The prevalence of sexual harassment is reportedly 11%–62% in various studies.[7] In the UK, more than 36,000 sexual offenses against children were recorded in 2018.[8] In Iran, the rate of CSA is reported to be 8%–15%.[9]

Evidence from a meta-analysis of 55 studies conducted in 24 countries indicates that the prevalence rates of CSA are 8%–31% and 3%–17% among girls and boys, respectively.[10] The most common CSA-associated injuries are observed during childhood and adolescence; for example, these ages are 7–12 years in the United States,[11]5–12 years in Ireland,[12] and 4–15 years in China.[13] This period usually coincides with elementary school. Studies show that 20% of children experience sexual abuse before the age of 8 years.[14]

This issue's high statistics and prevalence further necessitate proper prevention and education in children. CSA prevention programs are very popular regarding their low management costs, easy implementation, and the availability of many children without labeling a particular group. These primary prevention methods are more popular than other methods, such as treating people.[15]

Based on the concepts of empowerment, a major preventive effort is self-care, which was used in the anti-rape movement. It recommends teaching self-care to children against adults’ sexual desires[16] because adults cannot always fully supervise and care for children.[17] Self-care involves acquired, conscious, and targeted actions of a person to stay healthy and protect their mental and physical health.[17]

Preschool years are one of the critical years of children's lives because the child's personality, attitude, awareness, and behaviors evolve and form during this period. Also, in this period, children discover their desires and sexual development characteristics alone or in interaction with others. Sexual behaviors, such as touching their genitals, asking about the differences between girls and boys, and doctor role-playing, are very common among children.[18] Existing evidence also suggests that preschool is the best time to teach sexual self-care.[19] Self-care has recently been possible in preschool children, who can recognize improper contacts and learn self-care skills from the age of 3 years.[20]

In Iran, limited studies have been conducted on sexual self-care of preschool children. Therefore, this study was designed and conducted to analyze the concept of sexual self-care in children from different people's perspectives.

Materials and Methods

Study design and setting

Regarding the research question, the present qualitative study was conducted through an interpretive philosophical approach, and the collected data were analyzed using inductive content analysis. The research environment is the city of Tehran, where a combination of cultures and beliefs can be obtained due to the extensiveness and different socioeconomic levels in this city

Study participants and sampling

The statistical population consisted of sexual health professionals, parents of preschool children, adolescents who experienced sexual abuse in childhood, and those who were not sexually abused in childhood and lived in Tehran. The participants were selected based on the purposive sampling method. The inclusion criteria varied depending on the target group, including expertise and experience in teaching children about sexual health for professionals, having a healthy child of 4–7 years old, and the parents’ ability to speak Persian. Adolescents aged 12–17 years, who grew up without sexual abuse in preschool age and who were willing to cooperate in the research were included in the study. Inclusion criteria for injured adolescents were sexual harassment in preschool age and willingness to cooperate in research.

Participants were selected according to the inclusion criteria. The interview time was fixed in coordination with the participants. The study purpose was first explained to eligible participants, written informed consent was received from them and their parents, and they were assured about the confidentiality of their information. At this stage, maximum diversity was considered as far as possible in selecting participants. In this way, participants were selected from different ages, gender, and job groups to achieve maximum diversity. Parents were allowed to interview the teens. Samples were obtained for parents and adolescents by visiting city parks and for specialists by searching scientific websites and sending emails. The interviews were conducted by a researcher who was a PhD student in health education. Only adolescents who had been sexually harassed as children used the adolescent trust psychologist, and the researcher indirectly supervised. Face-to-face interviews were conducted at a location approved by the participants. It was performed for parents and adolescents in the park, for professionals at work, and for adolescents who experienced child sexual abuse at counseling centers.

Data collection tool and technique

In this study, data were collected using semi-structured interviews. Samples were recruited from May 2019 to July 2020. An agreement was made with the participants at the time of the interviews. The interviews were performed in person (28 interviews) or by video (4 interviews) or telephone contact (6 interviews), based on the participants’ wishes while maintaining their confidentiality and convenience. All interviews were done according to the relevant thematic guide, starting with general questions to gain the participants’ trust, and followed by specific questions to achieve the research objectives. At the beginning of the interviews, general questions were asked to build trust and create a sense of security and easier responses. For example, the interview began with “Tell me what self-care means,” followed by questions such as “How can a child take care of oneself?” For a better understanding of the issues raised, the interviewers asked seeking phrases, such as “Can you explain more if possible?” In this way, the participant could clearly express the concepts. Finally, the interviews finished with an open question: “Is there anything else you want to add?” Each interview lasted between 45 and 60 minutes. The interview site differed for various research groups and, depending on the convenience of the subjects, it was often at the workplace for professionals, in city parks for adolescents, and in counseling centers for injured adolescents. The interviews were held by a trusted interviewer who was a counselor and adolescent psychologist. The interview was done by telephone if some subjects were not interested in face-to-face dialogues. All interviews were recorded after obtaining the participants’ permission. Each interview was written verbatim immediately after the interview or in the shortest possible time and then analyzed using MAXQDA 2020 software. The interviews continued until information saturation.

After 37 interviews, the researcher identified no new data in response to the research question, indicating the conceptual saturation stage. Two more interviews were conducted to ensure data saturation. Finally, sampling ended with data saturation by 39 interviews, which were done without repetitions.

Data were analyzed using the content analysis method (Lundman and Granheim). In the first stage, the interviews recorded by the researcher were typed in Microsoft Office Word. In the second stage, the texts of the interviews were studied several times for a deep understanding of the interviews. In the third stage, the texts of the interviews were entered into MAXQUDA 2020 software and studied verbatim and accurately. Afterward, the initial codes were extracted based on the interview text. In the fourth stage, the codes were classified based on conceptual similarities. In the last stage, the classes were continuously compared through a rotation process, and more abstract categories were extracted from the analysis and interpretation of these data.

Validation

The acceptability, reliability, and verifiability criteria were used to ensure the accuracy and reliability of data. The research acceptability was confirmed by the researchers’ involvement with the research topic and data and by observing the extracted codes and the text of the interviews by several participants. The data reliability was considered by transcription as soon as possible, accurate records of all research stages, and providing similar situations for the participants by the researcher. Finally, validity was observed by returning the data obtained from the participants to them to review the accuracy of the findings. The research was verified using the review method by colleagues and the researchers. The triangulation method was also useful for more reliability of the results by receiving different people's views, including parents, professionals, and children.

Ethical considerations

This research was approved by the Iran University of Medical Sciences with the ethics code of IR.SBMU.PHARMACY.REC.1399.193. The researchers first introduced themselves and explained the objectives of the research. Before starting the interviews, permission was obtained from participants for audio recording and taking notes. They were assured of the confidentiality of their personal information and were informed of the right to discontinue the study at any time. Informed, written consent was obtained from the participants. For injured adolescent participants, people interested in the research topic were invited via advertisements in counseling centers. Written consent was also received from the parents of people who were simply interested, met the inclusion criteria, and participated voluntarily in the study.

Results

The research population consisted of 39 participants, including 9 parents and 18 adolescents with no sexual harassment, 6 adolescents who experienced sexual harassment, and 6 professionals for sexual education of children. The participants’ demographic variables are listed in Table 1.

Table 1.

Demographic variables of participants

Target group	Variable	n
	Gender
Parents	Female	9
	Male	0
	Education
	Illiterate	1
	Primary school	0
	Diploma	1
	Bachelor	3
	Master	2
	PhD	2
	Socioeconomic status
	Low	3
	Medium	4
	High	2
	Gender
Adolescents	Girl	10
	Boy	8
	Education
	Illiterate	6
	Secondary school I	6
	Secondary school II	6
	Socioeconomic status
	Low	10
	Medium	3
	High	5
	Gender
Sexually abused adolescents	Girl	5
	Boy	1
	Education
	Secondary school I	3
	Secondary school II	3
	Socioeconomic status
	Low	3
	Medium	3
	High	0
	Gender
Professionals	Female	2
	Male	4
	Education
	Master	1
	PhD	5

According to the results, the concept of sexual self-care in children consists of three main components, namely awareness, attitude, and skills. Also, this concept comprises of six subcomponents, namely recognition of privacy, identifying risk situations, identifying trustworthy people, perception of danger, self-protection skills, and post-injury function [Table 2].

Table 2.

The main components and subcomponents of the concept of sexual self-care in children

	Main component	Subcomponent	Code
Sexual self-care (298)	Awareness (149)	Recognition of privacy (53)	Ownership, familiarity with the body, identification of private organs
		Identifying dangerous situations (46)	Stranger’s proximity to private organs, unsafe place, being alone with strangers
		Identifying trustworthy people (49)	Circle of trustworthy people, identifying specific tasks with the help of trustable people
	Attitude (37)	Perception of danger (37)	Definition of danger, signs of danger
	Skills (113)	Self-protection skills (55)	Leaving the situation, the protection mode
		Post-injury function (58)	Ability to express the problem, leaving the situation, shouting

Awareness

This component includes three subcomponents: recognition of privacy, identifying the dangerous situation, and identifying trustworthy people.

Recognition of privacy

Ownership, familiarity with the body, and identification of private organs are among the codes of this subcomponent.

Remind the child that their body belongs only to themselves and no one should perform actions that will embarrass or upset them; no one should touch or even look at their body. For example, regarding the importance of educating the child about the ownership of their body, a 38-year-old mother of two children, aged 7 and 4 years, stated, “We have to teach the child that the body is their own and no one has the right to touch it without permission.” Awareness is also important concerning the limits and boundaries of proximity to a person. For example, a social trauma specialist stated, “I think it is very important for a child to know how close people can get to their body.” An important issue raised by a teenager who experienced sexual harassment in childhood was adult jokes about children's genitals in childhood, which negatively affects a child's perception of how close others can be to their genitals. A teenager participant of this study expressed, “A child must know their privacy. In my childhood and now, I see that adults joke about the child's private body in front of others. Although it is like playing with and laughing a child, it makes the child think that everyone gets close to them and touches their body for playing.” Therefore, child parents and care providers should teach children the necessary information and awareness about privacy and its limits.

Identifying risk situations

The proximity of strangers to private organs, insecure place, and being alone with strangers are some of the subcomponents of this component.

Children should be adequately informed about dangerous situations and the possibility of sexual harassment. According to the mother of a 6-year-old child, “I think the child should somewhat know and feel the danger to be able to protect themselves against touching their private organs; for example, someone wants to take their pants down.” Accordingly, a child should be taught the necessary information about distrust toward strangers. For example, the mother of a 7-year-old child said, “A child should know not to be alone with a stranger and not to go anywhere. I remember when we were children, we were always afraid of being kidnapped. Now, I too tell my kid not to leave me or not to stay with someone else but familiar people.”

”Loneliness is horrible; as of that day, I’m so scared of being alone,” said a teenage girl who had been harassed by a neighbor. She added, “I was playing with my friend; suddenly, all were hidden, and I saw that I was alone once I opened my eyes; the neighbor's son was getting close to me. I felt the danger with every bit of me, loneliness. I was in a situation where I could not defend myself. He was getting closer to me, and I could not do anything but fear.” The presence of a child alone in a place and the warning of staying alone with a stranger in a place are dangerous situations that must be understood by a child. The proximity of people and any kind of touch are also considered risk factors.

Identifying trustworthy people

Identifying the duty of trustworthy people, the circle of trustworthy people, and recognizing specific tasks with the help of trustworthy people are some codes of this subcomponent.

A 25-year-old mother with a 6-year-old son said the following: “I tell him that only me, dad, and grandma can see you, and you can change clothes in front of us, but others have no right to see you.”

According to a child sex education specialist, “Who can actually talk to you about this, or in what conditions can they see these, and who has no right to look at and touch these? All this should be clear to the child.”

A teenager who was sexually harassed by their cousin stared while crying: “My mother always scared me of strangers and would not let me out. She didn’t know that I was being harassed at my house, and I could not say anything. I could not tell what was going on, who was trustworthy, and who was not? Now that I am in the community, I ask myself if even the father or brother is trustworthy; a child should know that even people close to them can sometimes be a threat. So, the child should be enabled to talk about the problem without fear with a close trustworthy person like a mother.” Parents should be aware that a sign of suspicious sexual abuse behavior is refusing to stand in a special place or being alone with an adult and showing resistance for unknown reasons, which should alarm parents to identify trustworthy and untrustworthy people around the child.

Attitude

Understanding the existence of danger is a subcomponent of attitude.

Perception of danger

Definition of danger and signs of danger are the codes of this subclass.

An abused teenager said, “I should have known what danger meant; my mom always scared me by saying that thieves would cut off your head, but the reality of danger is something else. They should have explained to me as much asI [sic] could understand what danger means”.

A boy's parent said, “It does not matter where the kindergarten is, in the house of an acquaintance, or a relative, or a stranger. The child must know that it is dangerous if someone gets close to their private organs. They should know that it can be dangerous if someone invites them alone without their parents’ permission.”

An abused teenager recalled, “I was so abused that I did not understand what it meant. My cousin, who was much older than me, used to tell me we were playing, and I really thought it was a play. Until 2 years ago, I did not know what he did to me. I would never have thought it was a play if I had been taught and told about the dangerous situation.”

Practices of child abuse are often complex. Understanding the danger that a child can perceive and sensitize to danger based on circumstances is an important factor in self-care. The child should believe that danger can exist at any time and place and consider self-protection as a value.

Function

The self-protection skill and post-injury function are the subcomponents of this component.

Self-protection skill

Leaving the situation and protection skills are the codes of this subcomponent.

According to a child sex education specialist, “In fact, sexual self-care in a child is shaped if the child learns effective behaviors to prevent sexual misconduct toward them and can consciously use them in situations prone to these injuries or sexual abuse.”

A 15-year-old teenager stated, “Children must be able to take care of themselves. We did not grow up to be able to take care of and protect ourselves. Our parents always cared for us, and that is why we do not know how to take care of ourselves.”

A 14-year-old teenager said, “I remember when I was a kid, I went with my dad to a bank. When my dad went to the counter and left me alone, a man got close to me while blinking and making ugly gestures that scared me a lot, but I could get up quickly to stand up next to my dad before happening anything” [sic].

Post-injury function

The ability to express the problem, leave the situation, and shout are the codes of this subcomponent.

The child should talk to someone about improper behaviors when seeing those who make them agitated. Children should report anything that may be suspicious of sexual harassment. The abuse will not stop if the child does not express the issue. In this regard, a 16-year-old teenager stated, “If something happens and someone did wrongdoing, let the family know. In general, we should try to talk about the event instead of being embarrassed until the problem is solved.”

A sex education expert stated, “A child should know the one who is the first to inform. The child must know whether the family is available first, or the social police and social emergency workers can help.”

The parent of a 4-year-old child stated, “I think the first defense of a child, particularly at a young age, is to shout and ask for help. If they are in danger, they can shout quickly and ask for help; otherwise, they could do nothing in such a stressful condition, so they should learn this.”

It is better to give examples to the child and ask them what they would do if they were in such a situation. The child has been involved with the subject in such cases and make them think that they need to learn self-care skills. The ability to talk about an event to trustworthy people and to leave the environment can somewhat protect the child and prevent the harmful effects of the injury.

Discussion

The results of the current study showed that self-care consists of enhancing awareness, understanding the dangers, and self-protection skills. This finding is consistent with that of previous studies.[17,21]

In agreement with previous studies,[22,23] our results revealed that the knowledge, attitude, and function of children in the context of sexual self-care are of paramount importance. Children's personal knowledge and skills, perception of their body, right to safety, and seeking help from others (if necessary) are among the preventive factors of sexual harm. In this respect, preventive knowledge and skills can be taught to achieve a statistically significant increase in children's knowledge about the concepts of sexual abuse prevention in developing countries.[24]

Recognition of privacy is one of the essential factors mentioned by participants in this study. Privacy means the individual-specific physical, mental, and emotional boundaries that preclude others from profiting and encroaching on one's freedom. For having a better effective child-centered prevention programs, Walsh et al.[3] believe that children need to learn the names of their organs and preventive measures against further harassment in the event of abuse. According to their results, sexual self-care programs include the following points: (1) A child has the right to decide about access to their own body; (2) there is a difference between good touch, bad touch, and confusing touch; (3) the child should practice saying “No” when they may feel threatened or scared; and (4) a child needs to know how to escape.[16] These findings are consistent with those of the present study.

Identifying risk situations and recognizing safe and unsafe environments are some of the main findings of the present study. Children's perception of safety in environments where possible abuse may occur is one of the variables that should be used to prevent sexual harassment. Individual self-care programs implemented in the United States include (a) helping children identify potentially annoying situations or potential abusers, (b) teaching children to resist by saying “no” and to draw off themselves from the potential offender.[25] Identifying the situation helps the children recognize the unsafe and harmful situation and seek solutions or leave the place to take care of themselves.

According to the findings, children can identify trustworthy adults to have communication and respectful interactions to discuss body-related physical and health issues and report incidents to a trustworthy person in the event of sexual harassment. Jin states that a child should identify a support system to talk to someone.[26] Since the abuser is known by about 90% and trusted by the child and their family,[27] it is imperative to introduce trustworthy people and identify those with whom the child can share their secrets.

Self-protection skills are among the items that help children stay safe from sexual victimization. According to Rudolph, increasing sexual self-protection focuses on training children to (1) effectively identify subtle signs of abuse and appropriately delay manipulation and psychological threats of the offender, (2) challenge power, and (3) report abuse.[28] In a study, Mkumbo concludes that children's books contain educational materials on self-protection against sexual abuse. These materials include recognizing proper and improper touch, resistance methods, and reporting sexual abuse to trustworthy adults.[29] These findings are in line with those of the current study.

To prevent sexual abuse, studies have shown that children need to be educated with self-protection skills (e.g., trying to avoid sexual abuse and reporting to someone about it) to evade sexual abuse. In a study by Leclerc et al.,[30] interviews were done with 197 adult men who committed CSA crimes with children aged ≤ 16 years. According to their results, 74.3% of offenders stated that children who used “self-protection measures”, such as expressing unwillingness to participate in sexual acts and shouting “No” were the most effective method to escape from the offender. The results also revealed that such strategies as shouting to be alone, crying, expressing fear, or shouting at someone are also effective. This study showed that self-protective measures, such as telling offenders about their unwillingness to be touched, were 88.9% effective in real-life situations.

Parents cannot monitor their children 24 hours a day to protect them. Harassment may still occur when parents believe that their children have been left with a trustworthy adult. The findings of the present study suggest that children should act well after sexual harassment and be able to control the conditions. According to Rudolph et al.,[28] increasing sexual self-protection focuses on the child's ability to report abuse, which is in line with our findings. In terms of self-protection skills, however, only 13% of the children reported that they would talk to someone about sexual abuse incidents. In addition, 6% of children reported sexual abuse or sexual harassment incident (reporting skills).[17] Murfiah cites some strategies for training post-injury function, including (a) learning to say “no” in response to sexual abuse allurement, (b) leaving the situation, (c) reporting a trustworthy adult (i.e., disclosure), and (D) learning medical terms related to one's genitals.[21]

The present study examined different viewpoints of a wide range of participants about sexual self-care, which is one of our research strengths. On the other hand, this study's limitations include difficulty accessing the participants due to the COVID-19 pandemic. The authors conducted interviews in various methods, including online via WhatsApp or through in-person interviews, by following health protocols. Other limitations were the reluctance of some participants to interview and record audio. The researchers delineated their research objectives and the whole research process to build trust and used a researcher skilled in qualitative research for the interview.

Conclusion

According to the study results, the concept of sexual self-care in children consists of various factors such as the child's knowledge, attitude, and function. Therefore, increasing awareness in children can lead to sensitization and prevent further sexual harassment. To improve function and build self-confidence in children, the child's family should learn the appropriate teaching method in this context and be explained the importance of such teachings and the concept of self-care. Training should be provided at the society level. Thus, educating families, childcare providers, kindergartens, children themselves, and psychologists is important in this regard.

Financial support and sponsorship

The Vice Chancellor for Research, Iran University of Medical Sciences financially supported us.

Conflicts of interest

There are no conflicts of interest.