A study on child sexual abuse reported by urban indian college students

Abstract

Background and Objectives:

The prevalence of child sexual abuse (CSA) in India is 18–50% depending on the population studied. To devise strategies for prevention of CSA at the primary care level, we studied the prevalence of CSA amongst college students aged 17–25 years.

Methods:

A group of medical students and their friends were sent, an anonymous questionnaire validated by experts via WhatsApp. The questionnaire assessed demography, occurrence of prior CSA and details of the sexual abuse.

Results:

About 574 students participated in the study. The majority of respondents were female (380, 66.2%). About 467 (81.2%) of participants were from South India. Of the 380 women and 194 men who consented to participate in the study, 218 (57.3%) and 65 (33.5%), respectively, said that they had been sexually abused in the past (p < 0.00001). The event commonly occurred at 12–14 years (22.6%), but about 53% of victims were <12 years of age. The perpetrator was usually male (93.2%), less than 30 years of age (54%) and a stranger (42.7%). The most common form of CSA from 348 instances in 283 respondents was some form of “bad touch or caresses” (56.6%). About 25.8% of those abused did not speak to anyone about the event. Only 249 respondents (43%) were counselled regarding CSA by their parents.

Conclusions:

The prevalence of CSA amongst South Indian college students is 49.3%. The victims were mainly girls <12 years of age and the perpetrators were mainly male (93.2%). Primary Care Physicians can play a greater role in the early detection and prevention of CSA.

Introduction

Child sexual abuse (CSA) is a sinister problem that plagues our society, and effecting change must begin in the household aided by Family Physicians working at the grassroot level. Indian society has generally instilled conservative ideals in its youth regarding sexuality and sexual abuse and is an uncomfortable topic for parents to bring up in conversation with their children. Most households avoid such discussions altogether leading to an underestimation of the risk of danger especially when cases of sexual abuse are remote and underreported. However, Indian children are arguably just as much at risk of sexual abuse as more liberal societies, with many cases of abuse occurring at home. Compounding the problem is the lack of understanding or awareness of what constitutes sexual abuse. Indeed, it is estimated that one-third to one-half of India’s youth have been sexually abused at some point in their life.[1] This problem needs to be tackled directly as there is evidence that abuse during childhood may lead to lifelong adverse psychosocial and economic consequences for survivors.[2] One solution to this lack of awareness is to periodically publish the results of surveys in communities to heighten social consciousness of this ever-present issue, as occurred with the worldwide movement “Me Too” that began in the United States in 2018 to embolden victims of sexual abuse. This paper aims to estimate the prevalence of CSA in our urban community to provide a convincing rationale for primary care physicians to be alert in the detection of CSA in their everyday clinic settings.

Methods

This was a study conducted in Vellore, Tamil Nadu amongst a group of medical students and their friends. We used Google Forms to create a questionnaire that was based on a WHO study performed amongst adolescents in Geneva.[3] The questionnaire was validated by a panel of expert epidemiologists and clinical psychologists using their expert opinions to avoid making questions abrasive or embarrassing. The study was approved by our Institution Review Board (IRB No 13825). Table 1 shows the questionnaire that we used. It had three sections: in the first section respondents had the option to consent to participate and proceed with the questionnaire or exit the form. The next section was a preliminary set of non-identifying questions to assess demography and a yes-or-no question asking if they had ever been sexually abused in the past. At the end of the second section was the option to exit the form or proceed with the last section. The final section had detailed questions of the sexual abuse event. The investigators shared a link to a questionnaire via WhatsApp to their contacts who in turn were requested to pass on the questionnaire to their phone contacts. The form was kept online for a period of 10 days, from 19^th May to 29^th May, 2018 after which access to the link was withdrawn. To reduce recall bias, we included only those respondents <26 years old. We analysed the data with the help of SPSS v23. Data was entered into a 2 × 2 table and prevalence was calculated with the formula [a/(a + b)]/[c/(c + d)].

Table 1.

Questionnaire

Questions	Options
Do you agree to participate in this questionnaire?	Yes/No
Age
Gender
Education
State of origin
Have you ever been sexually abused at any point in your life?.	Yes/No
Sexual abuse consists of any of the following:
a) look at his/her private parts?
b) undress and show him/her your private parts?
c) watch someone arouse sexual pleasure on their own ?
d) undress with another child and fondle each other in front of him/her ?
e) be a victim of bad touch (caresses, rubs, kisses) on the whole body and/or your private parts?
f) look at pornographic pictures, drawings, films, videotapes or magazines ?
g) be naked and to expose your private parts for picture taking or filming ?
h) submit to sexual intercourse ?
What was your age at the first instance of sexual abuse?	Yes/No
Have your parents spoken to you about good touch and bad touch?	Yes/No
Do you consent to answer the following questions?
Which situation affected you more than others?
What was your age at the last instance of sexual abuse?
What was the age of the perpetrator?
Were you advised to inform an adult in case of such an event?	Yes or no
Who did you talk to about these events?
How was the person who got you into this situation related to you?	Family member friend stranger
How old were you when you were abused for the first time?
What was the gender of the person (or people) who got you in this (or these) situation/s (multiple answers possible)?	Male
	Female
Which situation affected you more than the others?
If you were subjected to one or more situations described, how many times did it happen to you?
If not, how old were you the last time it happened to you?
How old would you say he/she was (the abuser)? *multiple answers possible	<30
	>30
Did you ever talk to anyone about this (or these) event/s?	Yes/No

Results

We received 596 responses of whom 574 consented to participate in the study. There were 380 (66.2%) women and 194 (33.8%) men with a median age of 22.88 years, ranging from 17 to 25 years. Most participants 467 (81.2%) were from South India, of which 385 were from Kerala and Tamil Nadu. About 283 (49.3%) respondents reported a history of sexual abuse, which occurred most commonly when they were 12–14 years old as reported by 64 (22.6%). The next most common age was 8–10 years (44, 15.5%), 6–8 years (40,14.1%), 10–12 years (39, 13.7%), more than 14 years (36, 12.7%), and less than 6 years (28, 9.9%). Of the 380 women and 194 men who consented to participate in the study, 218 (57.3%) and 65 (33.5%), respectively, said that they had been sexually abused in the past (p < 0.00001).

A total of 283 victims reported sexual abuse by 330 perpetrators, in which 141 (42.7%) were strangers, 121 (36.6%) were friends or acquaintances and 68 (20.6%) were family members. The approximate age of the perpetrator was mentioned in 303 of these events and 164 (54%) were less than 30 years, whereas 139 (46%) were above the age of 30. About 253 respondents provided the gender of the perpetrator, whereas 39 did not answer the question. About 236 (93.2%) perpetrators were male and 17 (6.8%) were female.

The act of sexual abuse is tabulated in Table 2.

Table 2.

Forms of sexual abuse reported

Questions	Options
Look at his/her private parts?	36 (10.3%)
Undress and show him/her your private parts?	40 (11.5%)
Watch someone arouse sexual pleasure on their own?	17 (4.9%)
Undress with another child and fondle each other in front of him/her?	9 (2.6%)
Be a victim of bad touch (caresses, rubs, kisses) on the whole body and/or your private parts ?	197 (56.6%)
Look at pornographic pictures, drawings, films,	30 (8.6%)
videotapes or magazines ?	5 (1.4%)
Be naked and to expose your private parts for picture taking or filming?	14 (4.0%)
Submit to sexual intercourse ?	348

Reporting the crime

About 221 respondents answered the question regarding who they reported the crime to, and of these, 57 (25.8%) did not tell anyone of the CSA event. About 164 reported the crime to 248 people, which included a friend in 202, a parent in 106, a sibling in 68 cases, and medical professionals in 2 cases. Of the entire cohort of 574 respondents, irrespective of being subjected to CSA, 270 (47%) were not spoken to by their parents regarding CSA, whereas 249 (43%) said that their parents counselled them about sexual abuse and “bad touch”. The remaining 34 did not answer the question. Seventeen of those counselled by their parents were not specifically instructed to inform an adult in such an event.

Discussion

The key findings of our study clearly show that about 49% of respondents experienced some form of sexual abuse, mainly inappropriate touching. The victims were commonly 12–14-year-old girls preyed on by strangers (42.7%), but friends (36.6%) and family members (20.6%) were implicated as well. Significantly, one-third of victims did not confide with anyone about the sexual abuse and almost one-half of all respondents had not been counselled by their parents about sexual abuse.

Prevalence of child sexual abuse

CSA is a complex phenomenon that poses a dangerous threat to the mental, physical and social well-being of an individual. According to the WHO, CSA “is the involvement of a child in sexual activity that he or she does not fully comprehend, is unable to give informed consent to, or for which the child is not developmentally prepared and cannot give consent, or that violates the laws or social taboos of society.”[4] According to the recent national census, India is a relatively young nation with 44.4% under the age of 18.[5] Numerous prevalence studies pertaining to CSA have been performed in India revealing that between 18 and 50% of the population experiences some form of sexual abuse.[5] The wide variation in prevalence can be explained by the methodology used in obtaining the data; a large study using face-to-face interviews in adolescent girls found an incidence of sexual violence in only 0.7% of 4038 girls indicating that they were reluctant to provide the factual information to strangers.[6] Retrospective studies in adulthood are also affected by a recall-bias, however these confounding factors probably played a smaller role in our study from an urban, educated college population, with 49% self-reporting an incidence of sexual abuse in childhood.

According to the National Crime Records Bureau report in 2019, 45,390 cases were registered under the POCSO Act of 2012, of which nearly one-third were reported from Maharashra (16%), Uttar Pradesh (14%) and Madhya Pradesh (7%), wherteas 8% were collectively from Tamil Nadu and Kerala. Our college students were predominantly from Tamil Nadu and Kerala (67%).[7] Our findings clearly show that sexual abuse is as prevalent in the urban community as in the rural community in Tamil Nadu, a finding that has been reiterated in studies published during the COVID-19 pandemic from other parts of the country.[8,9]

Perpetrators of child abuse

The data from prevalence studies done in India clearly reveal that the perpetrators are usually in positions of trust or authority; however, the degree to which they are known to the victim varies. In roughly 94% of rape cases registered under the POCSO Act, the perpetrator was known to the victim, and in 8% of cases the accused was a family member.[7] Amongst adolescents in Delhi, perpetrators were commonly female friends for boys (60%) and strangers for girls (93%).[7] Our findings show that the perpetrator was either a friend, an acquaintance or a family member (57%), but in a significant number of cases the perpetrator was a stranger (43%).

Population at risk for child sexual abuse

While a majority of children in the adolescent age group were the most vulnerable in terms of rape according to the NCBR statistics in 2019,[7] most Indian studies demonstrate a younger age group at risk for other acts of sexual abuse, including non-contact forms. For example, a 2007 study[10] demonstrated that younger children (5–12 years of age) reported higher levels of abuse. More than a decade later, the data remains unchanged as we found more than half (53.2%) less than 12 years of age. There have been many studies comparing data among boys and girls separately; however, most studies show that they are equally at risk of physical abuse. We found that one-half of the females and one-third of the males were sexually abused. Boys are known to report sexual abuse to a less extent, particularly if the perpetrator was a male for fear of being labelled a homosexual.[11] Possibly due to the relatively better educated and affluent population in our study, more than two-thirds of those who were sexually abused reported the crime to a higher authority, whereas in the rural population, the majority (70%) of abused child respondents never reported the matter to anyone.[10] In a 10-year, cross-sectional study, the potential risk factors for sexual abuse were: Menarche, girls, related to perpetrator, physical disabilities, low socio-economic status, absence of one or both biological parents, marital conflicts, parental substance abuse, child marriages, Devadasi system and child belonging to the LGBT community.[12]

Long-term effects of child sexual sbuse

The effects of childhood sexual abuse on lifelong health, social and economic consequences for the survivors are well-described. The sexually abused girls performed worse than non-abused girls on psychometric measures of depression, self-esteem, anxiety and despair.[13]

We agree with Choudhry et al.[5] that Indian families tend to keep delicate matters involving sexuality a secret from the community in fear of tarnishing their family name. This potentially protects the perpetrator, which cannot be condoned. It is well known that sex education and knowledge of sexual health is limited in our rural population,[6] but it is indeed surprising that even in our well-educated study population, less than 50% were counselled regarding the difference between good and bad touch by their parents.[8]

Prevention of child sexual abuse at the grassroot level

We believe that our study provides relatively recent data on the prevalence of sexual abuse in our country’s population, being more than 10 years after the studies by Kacker et al. and Deb et al.[10,13] It indicates that despite the telling evidence of one in two children being sexually abused, not much has changed by way of national policies, intervention programs and sex education in schools and homes. The findings of our study should alert primary care physicians and healthcare workers to the dark reality of CSA and open avenues of discussion about ways to reduce its incidence. Apart from large-scale policy changes by the local government, small changes in the approach of healthcare practitioners to dealing with families to include a discussion and screening for CSA can certainly help in effecting change. Regular publishing of such surveys serves to alert Family Care Physicians of the persistent need for a third-party to facilitate discussions between parents and children about the dangers of sexual abuse.

Some methods that have been shown to have significant benefit are school-based child education programs where a study in 2000 found that those who had participated in a school-based sexual abuse prevention program were significantly less likely to have been sexually abused.[14] Similar intervention programs need to be implemented in India at the grassroot levels if we can ever dream of reducing the national incidence of such a dangerous social disease. We agree with Tyagi et al.[15] who stress the importance of a “Health and Wellness Curriculum” at school, where teachers may educate children with age-appropriate discussions of good touch and bad touch. Additionally, Tyagi et al.[15] have suggested the utility of parenting manuals or brochures, which may be disseminated by Family Care Physicians in regular out-patient department visits. Another promising intervention could be the utilisation of the Nurse Home Visitation model that focussed on educating parents. Indeed, such a model resulted in nearly 50% reduction in child abuse rates in the home visitation families, with the greatest impact on poor, unmarried participants.[12]

Strengths and limitations

The main strengths of our study was that we gave an anonymous, online questionnaire to college students that should provide more accurate data reducing recall bias and false reporting from embarrassment. However, our sample size was small and the prevalence rates of CSA should be interpreted with caution.

Conclusions

In summary, the prevalence of sexual abuse in a cross-section of an urban Indian population approached the national estimates of 50%, and the perpetrator was nearly always a male (93.2%) and usually a stranger (42.7%), however, one-third were family members. The population at risk appears to be young girls between the ages of 5 and 12, although one-third of boys also reported history of sexual abuse. Only 50% of youngsters were counselled regarding the difference between good and bad touch by their parents. These findings suggest that if primary care physicians and healthcare providers are made aware of the enormity of sexual abuse, they can play a significant role in the early detection and prevention through their involvement with the community at the grassroot levels.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.