Child Sexual Abuse: A Hidden Epidemic

Child Sexual Abuse: A Hidden Epidemic
David AN, Wapmuk AE, Ezechi OC

Maternal, Reproductive and Child Health Research Group, Nigerian Institute of Medical Research, 6 Edmund Crescent, Off Muritala Muhammed Way, Yaba Lagos

Correspondence: Dr. David AN; email: nkiru_d@yahoo.com

Summary

The United Nations Children’s Fund defines child sexual abuse 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 social taboos of society. It is estimated that at least 150 million girls and 73 million boys under the age of 18 years had experienced forced sexual intercourse or other forms of sexual violence involving physical contact. Although child sexual abuse has serious consequences for many of the victims, the extent and nature of the impact vary considerably, and no symptom or disorder is found universally in every victim. One of the risk factors for CSA is broken or dysfunctional homes. Strategies targeted at stabilizing and making homes more conducive for child nurturing such as providing parenting skills education to parents, and available and accessible counseling services for troubled families can be employed to reduce the occurrence of CSA.

Keywords: Children, Sexual abuse, HIV, genito-anal injuries, sexual behaviourial effects

Introduction

Child sexual abuse (CSA) is a subtype of child maltreatment, otherwise known as child abuse and neglect. It is a complex life experience, not a diagnosis or a disorder but it has far reaching implications, with potentials to adversely affect both the current and future life of affected individuals. It occurs worldwide across all ethnic/racial, socioeconomic, and religious groups. There are gender differences with regard to sexual abuse incidents; girls are at twice  the  risk  than  boys  for  sexual

victimization throughout childhood and at eight times the risk during adolescence.¹ Though there have been sporadic reports in the scientific literature on child sexual abuse for more than 150 years, it was not until the late 1970s and 80s that the issue began to receive any significant attention.² From an initial belief that child sexual abuse was a uniquely American problem, the land mark study by Finkelhor on the international epidemiology of CSA has now shown that the phenomenon is worldwide.³

The magnitude of the sexual abuse against children remains difficult to determine because of differing legal definitions of abuse in many countries as well as the under- reporting associated with it. This under reporting results from failure of disclosure from the abused especially the very young occasioned by fear, feelings of shame and cultural inhibitions.^3,4 Though there are reports of increasing prevalence of childhood sexual exploitation all over the world, this apparent increase may be as a result of increased levels of disclosure among the victims. Because significant physical, emotional, social, cognitive and behavioral problems are related to childhood trauma, it is becoming increasingly important to more effectively address the issue.

CSA has been receiving considerable attention since the 1980s with various reports in the media and scientific literature. The recent disclosures of happenings in the catholic church involving priests and minors spanning decades buttress the fact that child sexual abuse is a hidden menace that may lie undetected for years.⁶

Definition of Child Sexual Abuse

A consensus definition of CSA is difficult to arrive at because of the wide array of sexual activities that can be covered by the term child sexual abuse (CSA). The upper age cut off for child sexual abuse also differs from study to study ranging between below 14 years and below 19 years.^2,5,7 Nevertheless some authorities have given some broad definitions for CSA.

The United Nations Children’s Fund (UNICEF) defines child sexual abuse 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 social taboos of society. Child sexual abuse is evidenced by this activity between a child and an adult or another child who by age or development is in a relationship of responsibility, trust or power, the activity being intended to gratify or satisfy the needs of the other person.⁴ Dominquex and colleagues in their dissertation define CSA as ‘any sexual activity involving a child where consent is not or cannot be given’. They go further to say that sexual contact between an adult and a minor child, as well as an older teen and a younger child, are both examples of sexual abuse.¹⁹ The Child Maltreatment Report of the United States Department of Health and Human Services defines child sexual abuse as “maltreatment that involves the child in sexual activity to provide sexual gratification or financial benefit to the perpetrator”.⁸

The above definitions highlight the victimization of a child by an adult or older child for the sole purpose of the gratification of the abuser. However other forms of child sexual abuse include situations and circumstances where a child may be forced into child prostitution by the parents or relatives for the purpose of financial gains to the victim’s family. This form of CSA is seen in settings of poverty and low socioeconomic status.⁹

Forms of CSA include the inducement or coercion of a child to engage in any unlawful sexual activity; the exploitative use of a child in prostitution or other unlawful sexual practices; the exploitative use of children in pornographic performance and materials.⁴ These activities include, but are not limited to rape, sexual intercourse with a child, and incest. It also consists of non- physical contact and non-penetrative activities, such as involving children in watching sexual activities, encouraging children to behave in sexually explicit ways and exposing them to inappropriate sexual material.⁴

Epidemiology

The prevalence of child sexual abuse (CSA) varies across countries and regions and even within countries. A United Nations Children’s Fund (UNICEF) fact sheet stated that in 2002, the World Health Organization (WHO) estimated that globally at least 150 million girls and 73 million boys under the age of 18 years had experienced forced sexual intercourse or other forms of sexual violence involving physical contact.² The multi-country review by Finkelhor in 1994 and a follow up study by Pereda et al in 2009 found prevalences of 7 - 36% and 3 - 29%; and 19.7% and 7.9% in females and males respectively. ^3,11

Each year, the United States of America (USA) reports 63,000 to 135,000 cases of child sexual abuse, while adult retrospective studies show that 1 in 4 women and 1 in 6 men were sexually abused before the age of 18. This means there are more than 42 million adult survivors of child sexual abuse in the U.S.²⁴ Self-report studies in the United States of America also show that 20% of adult females and 5-10% of adult males recall a childhood sexual assault or sexual abuse incident.¹³ Other workers found a prevalence of 34% in American women¹⁴; showing that CSA remains a highly prevalent phenomenon.

Findings from the Caribbean indicate that the first sexual experience of young girls is often forced, this being the case in 42.8% of girls before age 12 years.⁴ In the Indian subcontinent of Asia, a 2007 study revealed that 53% of children were victims of sexual abuse.¹⁵

In the United Kingdom the National Society for the Prevention of Cruelty to Children (NSPCC) maltreatment survey found 16% of young people reported experiences of childhood sexual abuse. However a more recent study by the same organization, of child abuse and neglect in the UK in 2011 found that 16.5% of 11–17 year olds reported sexual abuse by an adult or a peer. There were also 18,915 sexual crimes against children less than 16 years of age were recorded in 2012/13 in the United Kingdom.^15,16 The situation is not different in sub-Saharan Africa. While CSA was previously thought to be rare in the region, recent literature shows that the region has not been spared. A review of the English language literature on child sexual abuse revealed a prevalence of 5% of penetrative forced sexual activity before 18 years of age.⁹ This review found that most studies were clinical or university based with paucity of data from the general population and so the reported prevalence may be a gross under estimate of the true picture. In South Africa more than 67,000 cases of rape and sexual assault against children were reported in 2000 while in Zimbabwe there were 65-81 cases of rape reported against children per week in 2012.¹⁵ Other workers found the prevalence to range between 15%-38% across various countries from the sub region.^17,18

While the true burden of child sexual abuse in Nigeria is unknown; studies indicate that it varies between 5% and 38% across different parts of the country. Our newspapers and other media are filled almost on a daily basis with reports of parents assaulting children, proprietors of schools assaulting pupils, dubious religious leaders sexually abusing under-aged members of the congregation and grandfathers raping grandchildren. Virtually everything is vividly portrayed through these media about the vicious sexual assaults meted on especially Nigeria girls.⁵

A high prevalence of 69.9% was found in Enugu, Southeastern Nigeria among female street hawkers (a particularly vulnerable group). It also appears to be commoner among female than male children.^19-22 A situation analysis of child abuse and neglect in Nigeria found that child abandonment, sexual abuse, child neglect, vagrancy, kidnapping and hawking were the most reported forms of child abuse and neglect.²³

Dynamics of Child Sexual Abuse

The sexual abuse of children is a unique phenomenon; the dynamics are often very different from that of adult sexual abuse. Some of the unique features that characterize child sexual abuse include the fact that physical force or violence is very rarely used. The abuser, who is often known to and trusted by the child, tries to manipulate the child’s trust and hide the abuse. The abuse often occurs over a period of time which can run into years. Often the abuse starts gradually through a process called grooming till the full extent of the sexual abuse desired by the abuser is reached. Incest and intra-familial abuse accounts for about one third of all child sexual abuse cases.¹⁰

The primary reason that the public is not sufficiently aware of child sexual abuse as a problem is because there seems to be a culture of silence around the issue. This silence is as a result of several factors, one of the most important of which is that 73% of child victims do not tell anyone about the abuse for at least a year. 45% of victims do not tell anyone for at least 5 years and some never disclose. They are either too ashamed or too afraid to report the incident. The reluctance to disclose abuse stems from a fear of the perpetrator who may have made threats, such as “If you tell anyone I will kill you/ kill your mother”.¹⁰ The “child sexual abuse accommodation syndrome”, proposed by Summit²⁴ has been invoked by a number of researchers to explain why children’s disclosures are often delayed following abuse and why disclosure is sometimes problematic or retracted.¹⁰ The typical pattern of events after an incident of CSA is as follows: the child is forced to keep the sexual abuse a secret and initially feels trapped and helpless. These feelings of helplessness and fear that no one will believe the disclosure of abuse lead to accommodative behaviour. If the child does disclose, failure of family and professionals to protect and support the child adequately, augment the child’s distress and may lead to retraction of the disclosure.²⁴

Another reason for the silence is that most abusers are often known and trusted adults. In a World Health Organization study, 47.6% of young women and 31.9% of young men claimed that their first intercourse was forced or somewhat coerced by family members or persons known to their family.²⁵ In many cases, the non-abusive parent remains silent and is reluctant to file charges against the perpetrator, because it brings shame to the family household. Surveys covering several countries in the Caribbean have shown a high percentage of the non-abusive partners who turn a “blind eye” when children are sexually abused in their family.⁴ Often there is a social tolerance and acceptance of child sexual abuse because of stigma, fear and sometimes lack of trust in authorities. Disclosure of sexual abuse in children can be purposeful or accidental (i.e. either intended or not intended by the child or perpetrator). Disclosure is often initiated after an enquiry about a physical

complaint, for example, pain when washing the genital area or a bloodstain in the panties. Child sexual abuse disclosures are usually a process rather than a single event. When children do disclose it is usually to their mother; however, the mother may also be the victim of abusive behaviour by the same perpetrator. Alternatively, disclosure may be to a close friend, peer or teacher.

Factors associated with Child Sexual Abuse

Situations and circumstances that place children in vulnerable positions make them particularly vulnerable to all forms of maltreatment including child sexual abuse. The children who are most at risk of being sexually abused, especially outside the home, are those who do not believe or know that they can say ‘No’ to adults, those who are afraid of being punished, those who are denied affection from and ties with adults, those who are physically or mentally provocative or receive little supervision from their parents or those who are naturally shy.²⁶ Some of the factors that make individual children vulnerable to sexual abuse have been identified and are discussed in details.

• Gender: Girls are far more at risk of being sexually abused than boys. The World Health Organization reports an approximate 2: 1 ratio of girls to boys abused.¹⁰ Also Finkelhor and Pereda report ratios of about 2.5: 1 of females to male children suffering CSA.^3,11 The lower reported prevalence among male children may however be due to lower levels of disclosure from males, the fact that majority of CSA perpetrators are males (who are more likely to target female children for abuse) and that many males who present at a health or correctional facility were unlikely to be asked about a child sexual abuse history.^6,30 However in some developing countries male children constitute a large proportion of child victims. Male victims of child sexual abuse are more likely to be abused outside the home, by strangers, and by female perpetrators.³⁰
   
• Age: Though sexual abuse occurs across all ages, it is more prevalent among pre pubertal children. These children are just developing secondary sexual characteristics but are vulnerable and relatively unable to defend themselves. Different studies have found that the average age at initiation of abuse varies between 8 and 12 years.⁶ The US state Department for Health and Human services however reveal a fairly constant rate through the years. The writers point out that the lower rates observed in the youngest children in earlier reports were probably as a result of under coverage in the age groups 1-2 years and 3-7 years.³¹ However if the abuser is a father figure, the abuse tends to start earlier. The abuse is also more likely to start later in boys ³² Disability: Physical and mental handicaps as well as psychological or cognitive vulnerabilities place a child at an increased risk of sexual abuse according to the WHO Guideline on child abuse and neglect.⁴ However the US State Department of Health and Human services report on child abuse and neglect shows a lower rate of sexual abuse among children with disability.³¹ This apparent disparity may reflect that fact that the US is a technologically advanced high income country with well-established and functional social welfare systems to take care of children with disabilities so that they are protected from situations that are likely to predispose to abuse.
   
• Race/Ethnicity: In multiracial, multiethnic societies like in the US, sexual abuse prevalence is higher for black children than for white and Hispanic children. However Putnam reports that Hispanic girls have worse emotional and behavioral problems than African-American or white girls.³² In contrast, in South Africa, a multiracial country in sub-Saharan Africa, contact sexual abuse was more prevalent among the coloured people followed by whites and then blacks.⁹
   
• Low Socioeconomic Status: Studies from developed countries show that low socioeconomic status, while a significant factor for physical abuse and neglect has much less impact on CSA. Community survey studies find almost no socioeconomic effects, but a disproportionate number of CSA cases reported to Child Protective Services come from lower socioeconomic.⁶ Child prostitution, a unique form of child sexual abuse especially in developing countries is significantly associated with low socio economic status.^3,9,33
   
• Vulnerable Children: Children in foster care, adopted children, stepchildren; those from broken homes or unaccompanied children are also vulnerable to sexual abuse. Children in war or armed conflicts, in refugee camps and the homeless or those socially isolated and lacking an emotional support network are at particular risk.^10,23 Not surprisingly children with a history of past abuse are also at an increased risk. The circumstances that predisposed them to the initial abuse are now compounded with feelings of guilt, fear shame, inadequacies resulting from the abuse and making them more vulnerable to further abuse.¹⁰

Consequences of Child Sexual Abuse Short term effect

Children do not typically disclose sexual abuse voluntarily and disclosure may be inadvertent through the finding of some physical and behavioural indicators which may signal sexual abuse in the child. Often these signs are discovered by the mother or immediate caregiver especially in very young non-verbal children. This then prompts the mother to take the child for medical evaluation. Alternatively a vigilant health care worker with a high index of suspicion will probe for history of sexual abuse in children presenting with the some symptoms and signs (table 1) ¹⁰.

It is pertinent to point out that while the finding of one or more of the signs in the table may suggest sexual abuse, it does not prove that the child has been abused. However the presence of the sperm or pregnancy in a child below the age of consent is diagnostic of abuse.¹⁰

Table 1: Physical and Behavioural Indicators of Child Sexual Abuse¹⁰

Although child sexual abuse has serious consequences for many of the victims, the extent and nature of the impact vary considerably, and no symptom or disorder is found universally in every victim.

• Behaviourial effects of child sexual abuse. Sexualized behaviour include acting out in an inappropriate sexual way with toys or objects as well as such activities as kissing with one’s tongue thrust into the other person’s mouth, fondling one’s own or another person’s breasts or genitals, masturbation, and rhythmic pelvic thrusting.^10,30,31 Although the majority of sexually abused children do not engage in sexualized behaviour, the presence of inappropriate sexual behaviour may be an indicator of sexual abuse. The sexualized behavior must be interpreted with the child’s developmental stage in mind and should only be worrisome when it is not in keeping with the child’s developmental stage e.g. a 10 year-old boy versus a 2 year- old boy playing with his penis in public, or a 6 year-old girl masturbating repeatedly in school.¹⁰
• Genito-anal effect of child sexual abuse. Many sexually abused pre-pubertal children actually have no abnormal genito-anal findings. This is because child sexual abuse rarely involves the use of force or physical harm. Normal findings on genital examination do not, therefore, rule out the possibility of sexual abuse. Also certain sexual actions such as oro-genital contact are unlikely to produce physical injuries while others such as penetration of the anus or penetration of the labia but not the hymen may only produce injuries depending on the amount of force is used.¹⁰ Abnormal genito-anal findings that may be seen in cases of CSA include vaginal or urethral discharge, hymenal bruising/.laceration, vulvovaginitis, labial agglutination, sperm or seminal fluid in, or on, the child’s body, and intentional, blunt penetrating injury to the vaginal or anal orifice. In addition child sexual abuse may coexist with other forms of child maltreatment and neglect and so it is difficult to attribute any subsequent adverse outcome solely to CSA.³² Apart from the symptomatology of CSA noted above, there are other effects of sexual abuse or assault on children and they can also be both physical and psychological. The effects can be debilitating throughout life and should be of considerable concern to the society.
• Sexual transmitted infection. HIV infection is one of the devastating STIs that children could contract especially through penetrative sexual abuse. Although the prevalence of the scourge is on a downward trend globally, the highest rate of new infections is among young people aged 15years to 24 years. At least 5 million young people are living with HIV and in 2009 they made up 40% of all new HIV infections.³¹ In places like southern Africa, an erroneous but strongly held belief that an HIV infected person who sleeps with a virgin would be cured led to a lot of sexual abuse of young girls by HIV infected men thus driving the HIV epidemic in young persons to astronomic proportions.³³ The acquisition of HIV which remains without a cure till date, coupled with the trauma of sexual abuse can be devastating or a young person; and can lead to more profound psychological sequelae.
  Another important way that sexually abused children risk acquiring HIV/AIDS is through subsequent high risk behavior such as multiple sexual partners, unprotected sex and intravenous drug use which they may later engage in as a consequence of the abuse. They may also acquire other STIs from the abuse which place them at increased risk of HIV subsequently.³⁴
  Other sexually transmitted infections (STIs) that can be acquired by a child in the course of child sexual abuse include gonorrhea, syphilis, chlamydia, hepatitis (B and C) and even human papilloma virus (HPV) infection which is predisposes the child to the development of cervical cancer in the future.
   
• Pregnancy. Clearly this is a sequel that can only happen to post menarcheal girls abused by older male children or adult males. However it is pertinent to consider it as literature has shown that about two times more girls than boys are victims of child sexual abuse. ^3,10,11 This consequence of CSA can permanently alter the course of a girl’s life.³⁵ Some of these consequences include abandonment by parents/guardians; cessation of schooling; unsafe abortions; poor fetal and maternal outcomes such as prematurity, low birth weight and development of vesico- vaginal and recto-vaginal fistulae in the under-aged and under developed “child” mother.^36,37 All these contribute to the poor infant and maternal mortality figures of especially developing countries.

Prof Lev-Wiesel and colleagues also conclude from their study of 1830 pregnant women that even when a woman who suffered child sexual abuse willingly and happily commences a pregnancy, the body relates the sexual act that created the pregnancy with the abuse trauma, evoking negative feelings which can be expressed in physical and gynaecological problems. ³⁵

Long Term effect

Significant associations have been found between CSA and subsequent onset of mood, anxiety, and substance use disorders among both women and men. Various studies have demonstrated that the depression, suicidal ideas, substance use problems, poor sexual functioning, poor self-esteem, marital difficulties and posttraumatic stress disorder (PTSD), are significantly associated with CSA. However the use of force and threat of force may be a necessary concomitant and greater long- term harm is associated with abuse involving a father or stepfather and abuse involving penetration. ^28,38-41

Sexual Revictimisation

Various studies have highlighted the relationship between child sexual abuse and later sexual revictimization. Humphrey and White in their longitudinal study of 1569 college students in the United States of America found that the risk of sexual victimization in college was 4.6 times higher for those who had been assaulted in early adolescence than for non-victims. They also found that women had an 11% and 12% higher risk of penetrative and contact non-penetrative sexual violence respectively than men in their study. ⁴²

Classen and colleaguse in their review of the literature on sexual revictimization also found that 2 of every 3 individuals who are sexually victimized will be revictimized. They note that the occurrence of childhood sexual abuse and its severity are the best predictors of revictimization.⁴⁷ While Mandoki and Burkhart found that those sexually victimized as children were not more likely than non-victims to be sexually assaulted as adults, they however note that the number of child and adult victimization was related to the number of adult consensual sexual partners.⁴⁴

Prevention

Child sexual abuse, a gross violation of the rights of a child, is a complex problem with many dynamics and risk factors. The perpetrators of CSA gain access to children through caretaking, such as babysitting; using bribes, gifts and games; used force, anger, threats, and bribes to ensure their continuing compliance; and systematically desensitized children through touch, talk about sex, and persuasion.⁴⁵ Efforts at prevention therefore have to be multi- faceted and holistic, taking cognizance of the way children are made vulnerable to abuse. There needs to be cooperation between the educational, health, social welfare, police and judicial systems as well as non-governmental organizations working in the area of child protection.

School-Based Prevention Programmes.
School based intervention programmes to provide children with knowledge on CSA and how to protect themselves from potential abusers have been found to be beneficial by several workers. A meta- analysis of school based CSA prevention programmes found that they are successful in teaching children sexual abuse concepts and self-protection skills. Gibson and Leitenberg went further to demonstrate a significant reduction in the actual occurrence of CSA after school based prevention programmes.^46,47
The provision of sexual health education to children especially adolescents in middle school years will also equip them with the knowledge and skills to enable them take informed decision that will protect them from abuse, and some studies have demonstrated that adolescents are poorly informed on sexual and reproductive health issues. Since one of the tools of the child sexual offender is coercion through misinformation, deception and manipulation, children armed with proper sexual health knowledge are in a better position to counter such measures.

Media Campaigns
Media campaigns that help to create awareness of CSA, the circumstances that may favour the occurrence of abuse and how victims and family members can get help when abuse has occurred have also been found to be effective in reducing the burden of CSA. This awareness creation is important because there is a lot of societal ignorance about the facts of CSA as discovered by Chen and his colleagues.⁴⁸ Media campaigns will also help in the reduction of the shame and stigma associated with CSA which is driving the culture of silence around the issue, and encourage disclosure.
Non-Governmental Organizations (NGOs) and international organizations like the United Nations Children’s Fund (UNICEF) are active in this regard. In the Caribbean, the Break the Silence initiative by UNICEF helped to strengthen child protection systems– including laws, legal processes, policies, regulations, and reporting mechanisms and the provision of comprehensive services to child victims. They also developed advocacy and communication initiatives for awareness creation on child sexual abuse and the implications of HIV for community mobilization to change behaviours, attitudes, norms and practices that are harmful to children.⁴

Other Prevention Strategies
One of the risk factors for CSA is broken or dysfunctional homes. Strategies targeted at stabilizing and making homes more conducive for child nurturing such as providing parenting skills education to parents, and available and accessible counselling services for troubled families can be employed to reduce the occurrence of CSA. Another strategy which is receiving some attention in the literature is the provision of cognitive behavioural therapy (CBT) as a secondary method of prevention targeted at identified abusers.⁴⁹

Conclusion
Although child sexual abuse has serious consequences for many of the victims, the extent and nature of the impact vary considerably, and no symptom or disorder is found universally in every victim. One of the risk factors for CSA is broken or dysfunctional homes. Strategies targeted at stabilizing and making homes more conducive for child nurturing such as providing parenting skills education to parents, and available and accessible counselling services for troubled families can be employed to reduce the occurrence of CSA.

References

1. UNICEF Demographic trends for adolescents: ten key facts. www.unicef.org/sowc2011/pdfs/De mographic-Trends.pdf accessed 07/01/2015
2. WHO Adolescent pregnancy World Health Organization. www.who.int/mediacentre/factshee ts/fs364/en/ accessed 07/01/2015
3. Finkelhor D. The international epidemiology of child sexual abuse. Child abuse & neglect 1994; 8(5): 409-417.
4. UNICEF. Fact Sheet: Child sexual Abuse. www.unicef.org/lac/break_the_Sile nce_Initiative- Fact_sheet(1).pdf accessed 24/07/2014

1. Odu B, Falana BA, Olotu OA. Prevalence of violent sexual assault on south west nigeria girls. European Scientific Journal 2014; 10(7):471-481
2. Hagan JE, Buxton C. Contraceptive knowledge, perceptions and use among adolescents in selected senior high schools in the central region of Ghana. Journal of Sociological  Research  2012;  3(2)

www.macrothink.org>home>Vol  3, no 2 (2012) > Hogan accessed 07/01/2015

1. Amazigo U, Silva N, Kaufman J, Obikeze DS. Sexual activity and contraceptive knowledge and use among in-school adolescents in Nigeria. International Family Planning Perspectives 1997; 23:28-33
2. Muula AS. Trends in contraceptive knowledge and use among adolescent married women in Malawi. Croat med J2008; 49(4):561-563
3. Lalor K. Child sexual abuse in sub- Saharan Africa: a literature review. Child abuse & neglect 2004;28(4):439-460
4. WHO. Guidelines for medico-legal care for victims of sexual violence. www.who.int/violence_injury_preve ntion/ …/en/guidelines_chap7.pdf accessed 24/07/2014
5. Pereda N, Guilera G, Forns, M, Gómez-Benito J. The prevalence of child sexual abuse in community and

student samples: A meta-analysis. Clinical  psychology  review 2009; 29(4): 328-338.

1. WHO Sexually transmitted infections among adolescents. www.who.int/child_adolescent_heal th/documents/9241562889/en/ accessed 07/01/2015
2. Child Sexual Abuse Statistics www.victimsofcrime.org/...child- sexual-abuse/child-sexual-abuse- statistic accessed

03/08/2014

1. Wyatt GE, Burns LT, Solis B, Vargas Carmona J, Romero G. The prevalence and circumstances of child sexual abuse: Changes across a decade. Child abuse & neglect 1999; 23(1): 45-60.
2. WHO | Adolescents falling through gaps in HIV services

www.who.int/mediacentre/news/releases/ 2013/hiv-adolescents. accessed 07/01/15

1. Samkange-Zeeb FN, Spallek L, Zeeb

H. Awareness and knowledge of sexually transmitted diseases among school-going adolescents in Europe: a systematic review of published literature. BMC Public Health 2011; 11:727

1. Yahaya I, Soares J, Ponce De Leon A, Macassa G. A comparative study of the socioeconomic factors associated  with  childhood  sexual abuse in sub-Saharan Africa. Pan Afr Med J. 2012; 11: 51
2. Moore AM, Awusabo-Asare K, Madise N, John-Langba J, Kumi- Kyereme A. Coerced first sex among adolescent girls in sub-Saharan Africa: prevalence and context. Afr J Reprod ealth. 2007;11(3):62-82
3. Odeyemi KA, Onajole AT, Ogunnowo BE. Sexual behavior and the influencing factors among out of school female adolescents in Mushin market, Lagos, Nigeria. Int. J. Adolesc Med. Health, 2009;21(1): 101-109
4. Ogunyemi B. Knowledge and perception of child sexual abuse in urban Nigeria: Some evidence from a community-based project. African Journal of Reproductive Health 2000; 4(2), 44-52
5. Ikechebelu JI, Udigwe GO, Ezechukwu CC, Ndinechi AG, Joe– Ikechebelu NN. Sexual abuse among juvenile female street hawkers in Anambra State, Nigeria. African journal of reproductive health. 2009; 12(2): 111-119
6. Obisesan AA, Adeyemo RA, Onifade

K. Childhood sexuality and child sexual abuse in southwest Nigeria. Journal of Obstetrics & Gynecology 1999; 19(6): 624-626

1. Ebigbo PO. Street children: The core of child abuse and neglect in Nigeria. Children, Youth and Environment 2003;13(1):22-31
2. Abajobir AA, Seme A. Reproductive health knowledge and services utilization among rural adolescents in east Gojjam zone, Ethiopia: a community-based cross-sectional study. BMC Health Services Research 2014; 14:138 doi:10.1186/1472-6963-14-138
3. Nnorom CPC, Bammeke F. Extent of adolescents’ knowledge of sexual and reproductive health and rights in Nigeria: implications for development. epc2008.princeton.edu/papers/807 07 accessed 12/10/2014
4. Adeokun LA, Ricketts OL, Ajuwon AJ, Ladipo OA. Sexual and reproductive health knowledge, behaviourand education needs of in-school adolescents in northern Nigeria. Afr J Reprod Health. 2009; 13:37-49
5. Dominquez RZ, Nelke CF, Perry BD. Child Sexual Abuse. In: Levinson D, ed. Encyclopedia of Crime and Punishment Vol 1. Sage Publications, Thousand Oaks 2002: 202-207
6. Lalor K, McElvaney R. Child sexual abuse, links to later sexual exploitation/high risk sexual behavior and prevention/treatment programmes. Trauma, Violence and Abuse 2010; 1: 159-177.
7. Terry KJ, Tallon J. Child Sexual Abuse: A Review of the Literature https://www.ncjrs.gov/App/publicat ions/Abstract.aspx?id=207964 accessed 10/10/2014

1. Hymel KP, Jenny C. Child Sexual Abuse. Pediatrics in Review 1996;17:236-249
2. Child Maltreatment Report. (2001). Washington DC. Published by Children’s Bureau, Administration on Children, Youth and Families.
3. Silent Tears Abuse Statistics. silenttearssc.org/sample-page- 2/stats/ accessed 24/12/14
4. Iaccino L. Child sexual abuse: top 5 countries with the highest rates. International Business Times www.ibtimes.co.uk>Society>Crime accessed 26/12/2014
5. Sexual abuse, a public health challenge NSPCC

www.nspcc.org.uk > Preventing abuse > Research and resources accessed 12/10/2014

1. Lalor K, McElvaney R. Overview of the nature and extent of child sexual abuse   in   Europe   2010

arrow.dit.ie/cgi/viewcontent.cgi?arti cle=1003&context=aaschsslbk accessed 12/10/2014

1. Summit RC. The child sexual abuse accommodation syndrome. Child Abuse Negl 1883; 7(2):177-93
2. PAHO/WHO. A Portrait of Adolescent Health in the Caribbean. 2000.

new.paho.org/…/APortraitofAdolesc

entHealth accessed 27/12/2014

1. Carl-Goran S. Sexual Abuse of Children, causes and risks-Child Centre:  Expert   Report  2001

• www.childcentre.info/research/abusedchil/ifid 1 358.html accessed 12/10/2014

1. US Department of Health and Human Services NCoCAaN (2010), Fourth National Incidence Study of Child Abuse and Neglect (NIS-4): Report to Congress, Executive Summary. Washington, DC: US Government Printing Office
2. Putnam FW. Ten-Year Research Update Review: Child Sexual Abuse.

J. Am. Acad. Child Adolesc. Psychiatry, 2003; 42: 269-278

1. Banwari M. Poverty, child sexual abuse and HIV in the Transkei region, South Africa. Afr Health Sci. 2011; 11(1):S117-S121
2. Hsu E. Sedlar G, Flood M, HansenDJ. "Child Sexual Abuse" (2002). Faculty Publications,Department of Psychology. Paper 138

• http://digitalcommons.unl.edu/psyc hfacpub/138

1. WHO. HIV and young people. www.who.int/maternal_child_adole scent/topics/adolescence/hiv/en accessed 27/12/2014
2. Hansen DJ, Wilson KR. Child Sexual Abuse Faculty Publications, Department of Psychology. 2007; Paper 484.

• http://digitalcommons.unl.edu/psyc hfacpub/484 accessed 16/10/2014

1. Telegraph. South African men rape babies as cure for AIDS. 2001. www.telegraph.co.uk>...>Africa and Indian Ocean> South Africa accessed 28/12/2009

46. Vernon IS, Bubar R.Child sexual abuse and HIV/AIDS in Indian Couhtry. Wicazo Review 2001;16:44- 63
47. Yampolsky L, Lev-Wiesel R, Ben-Zion IZ. Child sexual abuse: is it a risk factor for for pregnancy? J Adv Nurs 2010 66(9):2025-37
48. Kumar A, Singh T, Basu S, Pandey S, Bhargava V. Outcome of teenage pregnancy. The Indian Journal of Pediatrics 2007;74(10):927-931
49. Ampolo EK, Omotara BA, Out T, Uchebo G. Risk factors of vesico- vaginal fistulaein Maiduguri, Nigeria: a case-control study. Tropical Doctor 1990; 20(3):138-9