CHARACTERISTICS OF CHILDREN WHO HAVE BEEN SEXUALLY ABUSED , INCIDENTS OF ABUSE AND PERPETRATORS ; A STUDY FROM OF A TERTIARY CARE CLINIC SAMPLE IN CENTRAL SRI LANKA

Background: Child sexual abuse (CSA) has been a neglected topic in Sri Lanka (SL) despite its devastating effects on the victims and families. Though there is some growing concern, ignorance and stigma continue to prevail. While a few local studies have looked at CSA in selected groups, our understanding of CSA in SL still remains obscure. Objectives: To describe the characteristics of a clinic sample of sexually abused children, the perpetrators and incidents of abuse. Method: All children who had been victims of sexual abuse, presenting to the child and adolescent psychiatry clinic of a tertiary care centre in the Central Province of SL, from its inception in 1984 to 2016, were included in the study. Data were extracted from clinic records. Results: No CSA was reported before 2001 and 84 cases were identified since then, of whom 81% were females and 19% were males. The alleged perpetrator was known to the child in 94% of the incidents. Only 12.5% had presented within one week of abuse. About one third (30.4%) were abused more than once. The victims were unsupervised in 71.4% of cases while the family structure was disturbed in 22.6%. About a quarter (26.2%) were adolescent females having sexual contact with their boyfriends. Conclusions: Records of CSA were available only after 2001, though the clinic has been functioning for 32 years. This raises concerns about possible non reporting of CSA to authorities and possible deficiencies in record keeping. The findings from this study were comparable with those from other parts of the country as well as international findings. This work is licensed under a Creative Commons Attribution 4.0 International License (CC BY) Sri Lanka Journal of Medicine Vol. 27 No.2, 2018


Introduction
Child sexual abuse (CSA) has been defined as 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 norms of society 1 .While sociocultural and legal definitions of CSA show a wide variation, it has been identified as a universal problem across the globe 2 .It is a silent and violent epidemic, silent because the victims and guardians are often reluctant to come out in public and seek justice 3 , and violent because of the serious damaging effects on the victim 4,5,6 .According to international data, 7-36% of women and 3-29% of men have reported being victims of sexual abuse during childhood 2 .These findings highlight the ubiquitous nature of this grave problem.
In Sri Lanka (SL), ignorance and stigmatization of CSA have been present for many years, despite some growing concern over this issue, in recent times 7,8 .A few decades back, in the coastal areas of the island, use of the male child for commercial sex work in tourism was a flourishing business 9 .Sexual abuse of a male child by an adult was not only not acknowledged but was termed as homosexuality, and the victim was considered an offender 7 .Such children and their parents are often hesitant to take action against the alleged perpetrators due to fear of negative consequences such as stigma, and the risk of harassment by the perpetrator, particularly if the perpetrator is perceived as powerful.In relation to the female child, cultural concepts about virginity and the tendency to blame the female may prevent disclosure of sexual abuse 8 .
Fortunately, in recent decades, there has been an increasing trend of acknowledging the harmful effects of child abuse both for the male as well as the female child, with the formation of state bodies such as the National Child Protection Authority (NCPA) and introduction of new legislation 10 .A few studies are available in the literature on CSA in SL.Most of these studies have been conducted among selected groups 7,11 with the notable exceptions of a community survey in the Colombo district 12 and a study on late adolescent school children in Southern SL 13 .More recently, two studies, describing victim and perpetrator characteristics of CSA referred to hospitals in Chilaw and Jaffna, have been published 14,15 .No published work is found on CSA in the central part of SL.In order to educate the general public about the prevention of CSA and to aid the formulation of policies on the prevention and management of this rather ignored yet grave health issue, it is important to gain further insight into the nature of CSA in SL in relation to victims, perpetrators and the abusive incidents.

Objectives
To describe the demographic and clinical characteristics of sexually abused children referred to a child psychiatry clinic, and the characteristics of the perpetrators and incidents of abuse.

Method
In this retrospective study, data were collected using clinic records of all the children who were referred with a complaint of sexual abuse to the child and adolescent psychiatry clinic of Teaching Hospital Peradeniya (THP).The records from the inception of the clinic in 1984 to 2016 were examined for relevant data.No exclusion criteria were used.Ethical approval for the study was obtained from the Ethical Review Committee of the Faculty of Medicine, University of Peradeniya, Sri Lanka.Detailed notes on history, examination, investigations, initial management and follow-up are recorded routinely in the patient's clinic book, which is a confidential document kept under lock and key.Any associated mental disorders such as depression or adjustment disorder, if present, diagnosed according to the International Classification of Diseases 10 th version (ICD -10), and also recorded.Data pertinent to this study were extracted from these records.Confidentiality of any personally identifiable information was strictly maintained.Data entry and analysis were done using SPSS 20 software.

Results
There was no reported CSA among the clinic records from 1984 till 2001; and 84 cases of CSA were identified over the 15 years from 2001 till 2016.As depicted in Figure 1, the number of CSA cases presenting to the clinic has increased with time, reaching a peak in 2013 and showing a decline thereafter.In 82 (97.6%) of cases, the place of residence of the victim was situated within the Central Province of Sri Lanka.
Of the 84 cases, 68 (81%) were females and 16 (19%) were males.In the sample, 73.5% were over 11 years, whereas 16.9% were 6 to 10 years old and 9.6% were aged less than 6 years, at the time of initial referral (Table 1).Adolescent females constituted 58% of the sample population.
Based on available data on the duration of time taken to present from the time of abuse, the delay for presentation ranged from 1 day to 6 years, with a mean duration of 160 days.The wide range of this delay is illustrated in Figure 2.
About one third (30.4%) were abused more than once.Repeated abuse occurred more frequently in males (Table 2) and this difference was statistically significant (Chi-square=4.6,p=0.032).
The alleged perpetrator was a known person to the child in 94% of the cases (Table 3).
All the perpetrators were males.In about a quarter (26.5%), the sexual activity was consensual; all these instances were females having sexual contact with their boyfriends.The family structure was disturbed (single parenthood with no proper mother or father figure, domestic violence, and parental substance abuse) in 22.6% of cases, and 71.4% of the victims were unsupervised.

Discussion
CSA has, for a long time, been an issue shrouded in ignorance and stigma in SL 7,8 .Although data on CSA in SL is limited, a prevalence rate of 14% has been reported in a survey of adolescents in 2009, indicating the debilitating magnitude of the problem in the island 13 .As sexual abuse during childhood leads to many acute and long-term psychological consequences in the victims, evaluation of a child following CSA should include a referral for a proper assessment of the psychological impact.
The two recent studies performed in the North Western and Northern SL, have reported more CSA cases, despite having examined CSA data over a relatively shorter period 14,15 .Even if allowances are made for the fact that the Central Province, compared to the Northern province was less affected by the war, the total number of CSA victims assessed at one of the oldest and few specialized centres catering to mental health needs of children in the Central Province of SL over three decades being limited to 84, is probably a gross under-representation of the true picture.One major reason for the apparent nonexistence of any CSA cases from 1984 till 2000 could be due to the fact that the concept of CSA was almost non-existent in the Sri Lankan culture in the past 8,9 .Therefore, it is possible that children facing abuse were never brought to the attention of the healthcare system, while others who were brought to the healthcare services were never referred for psychiatric evaluation.Also, such children might have been referred to the bigger and older general hospital in Kandy and other psychiatrists who were increasingly manning the base hospitals around Peradeniya, thereby reducing referrals to this centre.However, it will be of interest to explore in a future comparative study whether rates of CSA in the Central Province are truly lower then elsewhere in SL, and if so, reasons for this difference.
The female to male ratio of 4:1 among the abused is consistent with findings from previous studies where girls were found to be more at risk of abuse than boys 2 .The majority of abused children being girls over 13 years is compatible with the conjecture that the tendency to get sexually abused is raised after menarche 16 .However, girls having sex with their boyfriends willingly constituted a significant proportion of girls in this age range in the sample.After exclusion of females who had consensual sexual activity, the female to male ratio was 2.87:1.
Previous authors have noted that abuse of the male child was widespread in SL, especially in the coastal region a few decades back 7,8 .Such professional attempts at highlighting the abuse against the male child did not garner much recognition and even faced criticism from some media as late as 1998, where some even tried to justify male child abuse, citing Buddhist temples being a venue of abuse as an example of its "normality" in Sri Lankan culture 8,17 .The relatively lower rate of abuse for males in this study may be due to under-reporting because of the shame and the fear of being labelled as homosexual (if the perpetrator was a man), or weak (if the perpetrator was a woman), combined with the fact that they are more often accused of having provoked the abuse 18 .
As demonstrated by the present findings, there is a highly unacceptable delay in bringing a child victim of sexual abuse to the attention of relevant authorities in the Central Province of SL.Only one eighth of the sample had presented within a week of the abusive incident.Delay in disclosure of sexual abuse to the guardians by the child, as well as the delay in reporting to the authorities by the guardians accounted for this delay.Delayed disclosure due to reasons such as stigma and ignorance among the general public and healthcare professionals has been reported in other countries as well 3 .
The Sri Lankan culture does not accept romantic relationships during adolescence.For an adolescent to give consent for sex, he or she should be 16 years or above, as per Section 364(2) of the Penal code 19 .Therefore, when an adolescent girl under 16 years engages in consensual sexual contact with her boyfriend, the case is brought to the legal system as a case of statutory rape.About a quarter of our sample falls into that category, where they had consensual sex with a boyfriend and was reported to the law.The authors raise the need to revise the legal interpretation of such consensual sex, based on present findings, as sexual contact among consenting adolescents is more a cultural taboo than a legal offense when the biological construct of adolescent sexuality is concerned.
The repeated finding in studies around the globe that the alleged perpetrator is most often a known person to the victim is replicated in our study as well 2,14,15,20 .The corresponding percentages from two previous studies done in different provinces of SL were 94% and 70% 14,15 .The finding that almost one third of the sample were abused more than once may reflect poor communication between parents and the child, a fear of being accused as guilty, stigma and a lack of knowledge regarding the abuse.There was also a statistically significant difference between the males and females with regard to the repeated abuse.To our knowledge, no previous published studies, national or international, have compared the repetition of sexual assault in relation to the sex of the victim.Our finding that male children are more likely to be abused repeatedly may be a reflection of the more lenient attitudes towards the abuse of the male child Sri Lanka 8,9,17 .
It is noteworthy that a significant proportion of abused children were under the age of 11 years, while sex education is recommended for children only above 13 years in the Sri Lankan school curriculum.The UNESCO recommends education on sexuality should start from the early years of primary schooling 21 .Comprehensive sex education and preventive programmes for CSA have been proven effective in reducing risky sexual behaviour in children 22,23,24 .Therefore, it is important for authorities to rethink the age of sex education in SL.The authors suggest the school curriculum should incorporate age appropriate awareness raising programmes on the primary prevention of CSA, from the level of primary school onwards.
There is robust evidence that childhood sexual trauma leads to various adverse psychological outcomes in both the acute stage and long term.Our results substantiate findings from previous studies conducted in other countries, where emotional problems such as depression and post-traumatic stress and behavioural problems such as conduct disorders were reported following sexual abuse among children 4,5,6 .This highlights the importance of a proper psychological assessment of the child by an expert in the event of sexual abuse.
As this study is limited to a small sample, our findings may not be entirely generalizable to the rest of SL.Although the results of this study show many parallels with those of other studies done in different parts of the world as well as other locations in Sri Lanka, further research on this subject is recommended, in order to expand our understanding of the patterns and undercurrents of CSA in different parts of the country and trends over time.

Conclusions
This study gives an insight into the CSA patterns in Central SL.The results are comparable with other local and international data and this study further raises concerns regarding certain important aspects, such as delayed presentation, more male children facing repeated abuse and adolescent consensual sex, which in turn warrant a review of preventive methods and a review of the minimum age at sex education in relation to CSA.

Figure 1 :
Figure 1: Trends in presentation of CSA over the years

Figure 2 :
Figure 2: Time taken to present from the time of abuse

Table 2 : Number of times abused cross- tabulated for gender Gender Number of times abused Once n (%)
Out of the 84 victims in the current study, 39.6% were suffering from a mental health disorder that met ICD-10 diagnostic criteria, while 9.6% had subclinical anxiety and depressive features.Moderate depression was the most common disorder,