Child sexual abuse leads to Psychological disorders : Literature review

This scholarly paper explains the relationship between child sexual abuse and psychological disorders. Childhood sexual abuse (CSA) is a forceful sexual contact with a child who is incapable of consenting. The impact of sexual abuse can range from physical to very severe psychological effects. Psychological disorders caused by child sexual abuse include panic disorder, anxiety, depression, substance abuse, low self-esteem and post-traumatic stress disorder. The phenomenon of child sexual abuse is shaped by some important theories like behavioral, psychodynamic, attachment, cognitive and integrated theory. These theories may help to develop a sound empirical base through which cost effective strategies can be made to prevent child sexual abuse. Although child sexual abuse is considered as an offensive act in Pakistan, but it is usually hidden in our society. Approximately 3,861 and 1,204 child sexual abuse cases were reported in 2012 and 2013 respectively from Pakistan. A series of current cases of child sexual abuse has brought the issue to the limelight. Child sexual abuse affects not only the individual but also the families and societies on large scale. Therefore, an integrated approach focusing on the parents, teachers and medical professionals can be proposed to prevent this issue. Prevention programs such as parenting education, home-visiting programs, public education, and training sessions can be developed. Therefore, it is highly important for the families and communities to work together with the support of stakeholders, so that a voice can be raised against CSA and this will ultimately reduce psychological problems in the society.


Introduction
This world would be without love, if young children were endorsed to feel pain.Young children are very important assets of our society and investing in children means investing in our nation's economic success.It is the responsibility of the whole society to take care of their children but unfortunately, society has failed to take an approach to the health of young children.As a result of this, children suffer from multiple problems like substance abuse, unintentional injury, mental health problems and child abuse, which pose serious threats to the young children's health [1].
There are various types of child abuse such as physical abuse, emotional abuse and sexual abuse.Although every type of problem is equally important but child sexual abuse (CSA) is more serious and underreported problem as compared to others [2].Due to CSA, a child not only suffers from physical but also from emotional, social and psychological problems both in short and long term.Therefore CSA should receive appropriate medical and public health attention [3].

Definition
Child sexual abuse has been described as "any sexual contact with a child through the use of force, threat, or dishonesty to secure the child's participation, or any sexual contact with a child who is incapable of consenting due to age, disability or power differential" [4].

Burden of child sexual abuse
Child sexual abuse is highly prevalent in society but this problem is underreported due to stigma associated with it and around 88% of CSA is never reported.However, it has been found that globally 7.9% of the males and 19.7% of females suffer from CSA [5].Another research indicates the prevalence of CSA may vary from 5% to 50%.These variations might be due to difference in definitions, study set-1 Aga Khan University, School of Nursing and Midwifery and Department of Community Health Sciences, Karachi, Pakistan tings and objectives of the study.For example, with a broad definition of sexual abuse as "any sexual involvement", prevalence rates of CSA can go as high as 50% and a narrow definition of sexual abuse as "forced genital activity" yields prevalence rates of about 5% [4].An analysis from 21 countries found 7% to 36% of women and 3% to 29% of men had suffered sexual abuse during childhood [5].More simply, it can be said that one in every four girls and one in every six boys is abused sexually across the world [6].
According to a report, there were 3,861 child sexual abuse cases in 2012 in Pakistan, around 17% increase as compared to 2011 [7].Moreover, approximately 1,204 cases of child sexual abuse were reported from January 2013 to June 2013, with 68% of the sufferers being girls and 32% boys [8].
A series of current cases of child sexual abuse has brought the issue to the attention and there are multiple painful stories of child sexual abuse in Pakistani society.On September 14 th , 2013, gang sexual abuse of a 5-year-old girl in Lahore made headlines in Pakistani newspapers.In the same month, five and six-year-old girls have been sexually abused in Kasur and Gujranwala respectively, while a little boy was sexually abused in Faisalabad [9].Psychologists and social scientists cite social factors as a major cause of increasing sexual abuse of children in the country [10].However, CSA has never received attention it deserves as a horrific crime in Pakistan.

Theories of Child Sexual Abuse
Considering the burden and significance of CSA, it is highly important to focus on some cost effective preventive strategies, but developing effective preventive strategies require a sound empirical base which is based on some theories related to the CSA.Without adequate understanding of these theories, the preventive strategies would be more focused on the consequences of the CSA rather than the causes [11]. http://www.mednifico.com/index.php/elmedj/article/view/317 One of the important theories is the "integrated theory" that proposes that CSA occurs as a result of interactions between individual, ecosystem and situational factors, which means that CSA cannot occur without interaction between biological, developmental, sociocultural and situational factors [12].
The other important theory is "biological theory" in which theorists propose the organic explanations of human behavior.Biological theorists assume that physiological factors, such as hormone levels (androgens) and genetic makeup have an effect on the behavior [11].Androgens increase sexuality and ejaculation and regulate aggression, cognition, emotion and personality [13].Researchers have also suggested a relationship between aggression and high testosterone levels [14].
The third relevant theory is "psychodynamic theory" which explains that sexual deviation is a manifestation of the unsettled problems experienced during the developmental stages.Human psyche is made up of three principal elements, id, ego and superego.According to psychodynamic theory, sexual deviance occurs when the id is overactive [15].The fourth important theory is behavioral theory, in which behavioral theorists explain that sexual behavior is a learned condition.A theoretical model of sexually deviant behavior states that sexual deviancy may be learned through the same mechanisms by which sexuality is learned [15].The fifth important theory relevant to CSA is attachment theory, according to which humans have a tendency to form solid emotional connections with others and when individuals suffer emotionally, they act as a result of their loneliness and isolation [16,17].

Child sexual abuse and psychological disorders
Based on the literature review, it has been found that CSA is a traumatic childhood life event in which the negative consequences increase with increasing severity of abuse [18].These disorders include panic disorder, anxiety, anger, depression, substance abuse, phobias, low self-esteem/self-hatred and post-traumatic stress disorder [4,19,20].A longitudinal study of 30 years from New Zealand showed that CSA was associated with increased rates of major depression, anxiety disorder, alcohol dependence, suicidal ideation, suicide attempt and drug dependence.Moreover, 47% of all childhood-onset psychological disorders and 26% to 32% of adult-onset disorders are attributed to child sexual abuse [21].
In conservative societies like Pakistan, child sexual abuse is considered as an offensive act.Child sexual abuse and sexual maltreatment are usually concealed in Pakistan [22].Due to this conservative attitude, people do not talk about this issue in our society, including the victims themselves.There is very limited and scarce research in Pakistan, related to CSA.No national survey or official statistics are available in Pakistan regarding CSA, and only limited kind of qualitative reports are published by some private organizations [22].Moreover, multiple factors like izzat (honor), haya (modesty) and sharam (shame) prevent the victims from disclosure of child sexual abuse [23].
Child sexual abuse is a serious problem at individual, familial and societal level.Therefore, prevention measures at different levels are of paramount importance [22].Numerous prevention programs such as education of parents, home-visiting programs, public education and training sessions for teachers can be developed [24].Awareness can be created about CSA through school-based domestic abuse prevention programs and prevention campaigns [25].In addition, community empowerment and participation can also play an important role in prevention of CSA [26].
Currently, few NGOs like Sahil are working entirely on the subject of child sexual abuse in collaboration with UNICEF.These private organizations are running different programs regarding child sexual abuse such as "Social Legal and Educational Program" and "Mass Media Awareness Program".These NGOs have developed some guidelines and education material for the children as well as for their parents to prevent their children from sexual abuse [27].

Recommendations
Considering the sensitivity and burden of the CSA, an integrated approach, focusing on the parents, teachers and medical professionals can be proposed [28].Moreover, Government should make some laws and policies through which an immediate action can be taken against the criminals and abusers.Strong political commitment and specialized expertise on the subject, as well as special laws on CSA should be developed.There should be some safety mechanisms which enable the children to live freely in the society.Moreover, statistics regarding child sexual abuse need to be gathered and compiled at national and provincial levels to estimate the true burden of problem in the society so that appropriate actions can be taken accordingly [22].

Conclusion
In short, child sexual abuse is an alarming issue which spoils the life of children who have just started the journey of their life and are not aware about such habits and behaviors.Despite the above mentioned series of cases and reports, the problem is not highlighted much and gets ignored many times by higher authorities.Moreover, there is lack of research in this area in developing world, and particularly in Pakistan.
Thus, it can be concluded that children are vulnerable group, whose proper growth and development can decide the future of the society.The way we take care of our children today, will have a major impact on the society tomorrow.Therefore, it is highly important for the families and communities to work together with the support of stakeholders, so that a voice can be made against CSA, as this will ultimately reduce psychological problems and will improve the harmony in society.