Childhood sexual abuse: Its complexities and long-term consequences

Childhood sexual abuse (CSA) is a complex calamity plaguing the entire world. It looms in all societies, rich or poor, privileged or not, and remains refractory to most corrective and preventive measures. The world has yet to reach a consensus on its conceptual definition because of the diverse nature of its presentation. Is it solely an unwanted sexual encounter? Can it only be inflicted by an adult? Does it necessitate sexual contact? Does child marriage fall under its purview? Does it also include being unwittingly exposed to pornography? Is there a decisive age cut-off? Such and many more questions continue to evade a conceptual and universal definition of CSA. The World Health Organization (WHO) defined it as “the involvement of a child in sexual activity that he or she does not fully comprehend and is unable to give informed consent to, or for which the child is not developmentally prepared, or else that violates the laws or social taboos of society” and made it applicable across a wide range of activities such as intercourse, attempted intercourse, oral-genital contact, fondling of body parts or genitals directly or through clothing, exhibitionism, exposing child to adult sexual activity or pornography, and the use of child for prostitution or pornography.[1]

CSA also proves to be challenging to study. The topic in itself is extremely sensitive, and the unfortunate stigmatization that comes from being the victim compounds it. Additionally, there are social, cultural, regional, and conceptual barriers to overcome. The child and his/her family fear retaliation and ostracization and are more likely to keep the situation under wraps. The numbers are, hence, underrepresented mainly from what is the accurate picture. Despite that, studies have tried to estimate the prevalence and correlates. Various meta-analyses have concluded that the figures range from 12% to 45%.[2] Globally, the lifetime burden of CSA is estimated to be 41% for females and 29.5% for males.[3] India is home to over 43 crore children and adolescents, comprising 31% of its total population, and is the largest of its kind worldwide.[3] A meta-analysis conducted over various states in India concluded that the prevalence of CSA among Indian children is 53%.[4] In another study conducted by the Ministry of Women and Child Development, over 1,25,000 children reported similarly high numbers of CSA victims (50%), of which 21% were extreme forms of sexual abuse. Until the POCSO Act came into effect on November 14, 2012, there were barely any legislations and laws in place to hold the perpetrators of CSA accountable. Various sections of IPC, ITPA, and JJ act were invoked to cover such cases, which were often specific to a particular gender with regards to both the victim and the offender, had ambiguity over age limitations, and did not cover the vast spectrum of activities that CSA can comprise, including aggravated assaults. The POCSO Act allowed provisions for this and had clear definitions for what comprised punishable offenses: penetrative and non-penetrative sexual assaults, aggravated penetrative and non-penetrative sexual assaults, sexual harassment, and use of children for pornographic purposes. Its amendment in 2019 made punishments more stringent for the perpetrators.[5] The numbers reported for legal action are meager, at just 3%.[4]

Adverse effects

Studies have established a strong association between a plethora of long-term adverse consequences and survivors of CSA, which range across the various domains of psychosocial functioning and health.[3,6] It would be fair to say that the child is changed for life and has to suffer from the consequences and after-effects of somebody else’s vice. The young and impressionable age of the victim at which he/she undergoes abuse results in permanent neurobiological changes, which prove challenging to reverse. However, these long-term effects cannot be fit into brackets, as some may transcend through the abuse and become vocal activists and advocates for the cause. In contrast, others cope by adopting risky ways of life, such as promiscuity, sex trade, substance abuse, and the like.[7,8] The range of adult outcomes is thus extensive but by no means absent. The adult manifestations are also dependent upon the characteristics of the abuse, such as the age of the victim, frequency, duration, severity, proximity with the perpetrator, support system of the victim, and accompanying physical and emotional abuse. The long-term sequelae of sexual type of child abuse have often been overlooked due to the delicacy of the subject at hand, the reluctance of victims to disclose it or to seek help, and most importantly, the fact that because sexual abuse and other forms of abuse occur concurrently, the other forms being more straightforward to deal with are delved into while ignoring CSA.[9,10] Hence, the findings for CSA are more often than not studied as an over-generalization or extrapolation of what has been inferred from the evaluation of emotional or physical forms of abuse.[11,12]

To begin with, mental health disorders have been purported to be twice as likely in the survivors of CSA. The likelihood of an adult to develop psychiatric illnesses after exposure to CSA is at least 30%.[13] Symptoms of anxiety, depression, post-traumatic stress disorder, personality disorders, insomnia, self-harm, somatization, pre-menstrual dysphoric disorders, aggression and hostility, truancy, low self-esteem, substance abuse, and sexual maladjustment are often encountered by them. Poor self-esteem, frigidity, eating disorders, borderline personality disorder, and depression are more commonly seen in women. In contrast, substance abuse, anger, hostility, aggression, and increased sexual drive may be seen more in men as compared to women. Common to both, however, is an increased likelihood to attempt suicide, with studies suggesting a nearly 30 times higher probability to do so.[11,14] Studies done to assess the academic success of survivors show high rates of dropouts and poor academic performance compared to the rest. Their performance at work and other social areas of life also suffers a setback, and they are more likely to fall back upon poor methods of coping when faced with inevitable stressors. Depression and post-traumatic stress disorder have received particular attention in the context of CSA. An earlier onset of abuse, more severe form of abuse, closer proximity to the perpetrator, greater severity of abuse, and lack of a support figure for the victim are predictive of more severe symptoms of depression and PTSD. Because the diagnosis of PTSD was overshadowed due to the varying nature of the presentation of symptoms, mimicking other psychiatric illnesses, the concept of complex PTSD (cPTSD) was brought to the fore. Due to its relatively new recognition as a psychiatric illness by the WHO, formal studies establishing the relation between CSA and cPTSD are meager. However, the relation is ineludible and has the potential for further studies to infer a positive correlation is robust, as it not only encompasses the symptomatic presentation predictive of PTSD but also addresses the portentous symptoms of emotional dysregulation, negative self-concepts, and disturbed interpersonal relations that are commonly encountered in adult survivors of CSA.[13] This could explain why these victims are eight times more likely to be victims of interpersonal partner violence in their adult life.[9] Adult survivors of CSA are also more likely to report somatic symptoms and complaints, such as non-remitting headaches, migraines, generalized or localized aches and pains that cannot be explained by inflammatory or neurological causes, abdominal pain, indigestion, acidity, respiratory distress, backaches, shin pain, and even cough or fever. They frequent various non-psychiatric doctors and health personnel for the same but are usually unable to find long-lasting respite from their symptoms.[11]

Survivors of CSA also have to endure adverse consequences in the aspect of physical health. They are prone to develop chronic illnesses such as asthma, cardiovascular diseases, chronic fatigue, fibromyalgia, chronic pelvic pain, inflammatory bowel syndrome, urinary incontinence, recurrent urinary tract infection, dyspareunia, dysmenorrhea, and insulin resistance, among various other conditions. They also become unsuspecting victims of HIV/AIDS and other sexually transmitted diseases, which put their own lives, as well as those of others, at risk. A neurobiological explanation for these symptoms is as follows. The chronic state of hyperarousal and vigilance in these children, when they are subject to abuse, drives their hypothalamic-pituitary-adrenocortical (HPA) axis into a state of overactivity. This overactive HPA axis suppresses immune reactivity and predisposes to metabolic and cardiovascular diseases in the long term, leading to the health consequences that have been delineated above.[11,12]

According to a recent study, exposure to elder abuse through intimate partner violence victimization was predicted by certain forms of childhood victimization, specifically those involving interpersonal violence committed by a carer (e.g. a parent engaging in physical or sexual abuse).[15] This outcome is in line with the findings of another study that found that interpersonal traumas such as physical and sexual abuse and assault were the main cause of revictimization risks among a sample of young people (average age: 39.5 years).[16] These consistent results highlight the detrimental, traumatic repercussions of betrayal, broken trust, and shattered safety and imply that victimization clustering/persistency may be more pronounced when impacted by interpersonal violence.[17]

Over and above all the adverse consequences of CSA, it is also a financial burden and is accountable for 33–35 disability-adjusted life years. Behavioral, mental, and physical health conditions can lower the levels of achievement of individuals and can hamper their contributions to society. CSA is a public health concern of gigantic proportions and needs strict redressal. Public health policies should be set forth, and the general public needs to be educated on properly utilizing these to their benefit. Children must be gently but firmly explained about CSA and its various forms through plays and skits, television shows, and awareness programs at school and home. Parents should also be made aware of the consequences of CSA and how to report it. Sex education should be made a compulsory part of the Indian academic curriculum.[4,18]

Health practitioners are often the first professionals to whom such children are brought. We must ensure the child is safe and protected at that time and that the child adequately feels so. The provocation to reveal the incidence is unnecessary until then and may even be detrimental. No physical examination should be undertaken in this interim, either. Recommended guidelines should be followed, and a close follow-up is necessary to ensure that the child can flourish despite the heinous encumbrances.[1,19]

CONCLUSION

Addressing CSA requires a concerted global effort that combines prevention, education, and support for survivors. While the complexities of CSA remain challenging, increasing awareness, strengthening legal frameworks such as the POCSO Act, and enhancing mental health support can pave the way for more effective interventions. By fostering open conversations, equipping children and parents with knowledge, and ensuring accessible services, we can mitigate the long-term consequences of abuse. As societies become more proactive in safeguarding children, there is hope for a future where every child is protected from the horrors of abuse and those affected can heal and thrive.

Authors’ contributions

Concept and design of paper: SC, TA. Drafting the article and revising it critically for important intellectual content: TA, SC. Final editing and approval of the version to be published: JP, KS. Manuscript has been read and approved by all authors.