PROSPECTIVE STUDY OF ALLEGED CHILD SEXUAL ABUSE CASES DURING A PERIOD OF ONE YEAR EXTENDING FROM THE BEGINNING OF JANUARY TO THE END OF DECEMBER, 2020 IN AL- SHARQIA GOVERNORATE IN EGYPT

PROSPECTIVE STUDY OF ALLEGED CHILD SEXUAL ABUSE CASES DURING A PERIOD OF ONE YEAR EXTENDING FROM THE BEGINNING OF JANUARY TO THE END OF DECEMBER, 2020 IN AL- SHARQIA GOVERNORATE IN EGYPT

By

Mohamed H. M. Ibrahim*, Fouad H. El-Dabbah, Nagy M. El-Fadaly and Mohamed F. Assasa

*Forensic Medical Examiner in Forensic Medicine Authority, Ministry of Justice and Forensic Medicine and Clinical Toxicology department, Al-Azhar Faculty of Medicine, Egypt

Corresponding author: Mohamed H. Ibrahim

E-mail: hamadahamada_5@yahoo.com

ABSTRACT

Background: Sexual abuse toward children and adolescents has a much too common occurrence that results in harm to millions of children, boys and girls alike, in large and small communities, and across a range of cultures and socioeconomic backgrounds.

Objective: To recognize the number of alleged child sexual abuse cases in Al-Sharqia Governorate in Arab republic of Egypt during a period of time of one year extending from the beginning January to the end of December, 2020.

Patients and Methods: The present work was a prospective study that included 90 alleged child sexual abuse cases referred to the Forensic Medicine Authority, Al-Sharqia Governorate in Egypt for one year. Children were interviewed regarding the circumstances of the assault. General and local examination (examination of the genitalia and anal region with legal documentation) were done and documented.

Results: Our study showed that female victims were more than males (56 cases: 62.3% versus 34 cases: 37.7%) with predominance of adolescents female (34.3%, 31 cases), higher in rural than urban areas.  Interfamilial perpetrators represented only 12.2 %, while extra familial perpetrators were the main perpetrators neighbors (37.8 %), strangers (30%) and adult friends (20%). Vaginal penetration was the highest sexual assault, especially among adolescent group (>12y), while anal penetration was significant among school age (6-12 y).

Conclusion: Sexual abuse of young children was extremely under-reported in Al-Sharqia Governorate.    Abuse was often committed by close persons that exposed the child to endless cycles of violence. The assessment of sexual abuse among young children was a challenging, and cautious interpretation of findings was mandatory. It is important to teach and encourage children to tell their caregivers about any person who tried to sexually abuse them. It is essential to increase public awareness of child abuse in addition; physicians in primary health care facilities and hospital centers should be educated regarding suspected signs of child abuse.

Key Words: Alleged, child, sexual abuse.

INTRODUCTION

     Child sexual abuse is one of the most prevailing violations of human rights that endanger children worldwide. The young children are ideal victims; they could not protect themselves because of limited mental and physical development. Besides, abuse often occurs in private places where the perpetrators are children’s caregivers. The inability of the abused children to self-report violence exposes them to further assaults (Elghossain et al., 2019).

     Sexual abuse toward children and adolescents is a stark reality worldwide. A common misperception about child sexual abuse (CSA) is that it is a rare event perpetrated against girls by male strangers in poor, inner-city areas. To the contrary, CSA is a much too common occurrence that results in harm to millions of children, boys and girls alike, in large and small communities, and across a range of cultures and socioeconomic backgrounds. These acts are perpetrated by many types of offenders, including men and women, strangers, trusted friends or family and people of all sexual orientations, socioeconomic classes, and cultural backgrounds (Murray et al., 2014).

     Young children are more vulnerable to abuse than older children as a result of their marked physical and mental immaturity. Also, little children are unlikely to be engaged in wilful sexual activities because of the non-development of natural sexual drive (Modelli et al., 2012).

     The present study aimed to recognize the number of alleged child sexual abuse cases in Al-Sharqia Governorate in Arab republic of Egypt during a period of time of one year  extending from the beginning January to the end of December , 2020.

PATIENTS AND METHODS

     The present work was a prospective study that included alleged child sexual abuse case referred to the Forensic Medical Authority of Al-Sharqia Governorate in Arab Republic of Egypt, during a period of time of one year extending from the beginning of January to the end of December 2020, for medicolegal evaluation.

     The study complied with codes of Egyptian Forensic Medicine Authority (EFMA) and Ethics Committee of the Faculty of Medicine of Al-Azhar University. An assent of all children and informed consents of their guardians were obtained. Humanitarian aspects were considered during the medicolegal management of children with suspected abuse.

Medicolegal examination:

1.   History: The children were interviewed regarding the circumstances of the assault, such as the manner of violence; number of the suspect(s) and his/her relationship to the child, venue of the assault, frequency of assault (s). Before the examination, a simple explanation of the required examination positions and procedures was provided (Adams et al., 2016).

2.   General body examination: All children were comprehensively examined for general signs of violence. Any visible injuries were documented appropriately.

3.   Local examination: Examination of the genitalia and anal region

-     In females, a careful genital examination was conducted in lithotomy and knee-chest positions. The perineum, pubic area, labia majora, labia minora, clitoris, posterior fourchette, fossa navicularis and hymen were inspected for any recent or old injuries.

-     In Males, male genitalia were properly inspected for the presence of recent or old injuries.

-     Anal region was examined in the knee-chest and left lateral position for the presence of any injuries. Also, anal sphincter tone and reflex were assessed.

-     All relevant injuries were documented.

Medicolegal findings:

1.   Positive findings: Physical child abuse is confirmed by the presence of recent or old injuries that are consistent with the given history. Nevertheless, sexual child abuse is proved by the presence of any relevant injuries concerning the suspected sexual act.

2.   Negative findings: The lack of any relevant evidence concerning a suspected assault.

Statistical analysis:

     The collected data were statistically studied, tabulated and analyzed and graphically represented. The data were analyzed through SPSS for Windows version 10. Nominal variables were reported as frequency and percentages, and p ≤0.05 was considered significant.

RESULTS

Age and sex: Female victims of sexual abuse were more than males (56 cases: 62.2% versus 34 cases: 37.8%). Significant differences were in gender distribution between age groups of the included study cases (P = < 0.0001) .Females in the adolescents group were more predominant (34.3%, 31 cases) than other groups (Figure 1 & Figure 2).

Figure (1):  Victim cases as regard gender

Figure (2):  Gender to age

Victim residence: there was a significant statistical difference between rural and urban residences of those sexually abused children with higher rate in rural than urban area (Figure 3).

Figure (3):  Victim cases residence

Assailant relationship to the victims: Most of perpetrators of sexual abuse were persons outside the victim’s families, only 12.2 % (11 cases) were abused by interfamilial persons. Neighbor followed by strange and adult friends were the most common perpetrators extra familial with significant higher rate in neighbors perpetrators (37.8 %) (Table 1).

Table (1):   Victim cases and assailant relationship

Age of assailant: Assailants with higher significant rate were in age group 15–20 years (51.2 %) in comparison to other assailant age groups (Table 2).

Table (2):   Age group distribution of assailant in relation to studied victim case

Number of assailant: One assailant was more significant and higher than multiple assailants in child sexual abuse cases (86.7 % versus 13.3%) (Figure 4).

Figure (4):  Number of assailants

Frequency of sexual offense (s): One time sexual abuse was significant than multiple times (75.4% versus 24.6%) (Figure 5).

Figure (5):  Studied victim cases as regard frequency of sexual offense

Place of sexual abuse: Sexual abuse which occurs outside home of studied victims (44.5 %) was significantly higher than assailant home (42.2 %) and victim’s home (13.3 %), respectively (Figure 6).

Figure (6):  Studied victim cases as regard place of sexual abuse.

Figure (7):  Studied victim cases as regard findings of sexual offense

Findings of sexual abuse: Percentage of suspected victim’s abuse without findings were significant higher than children with positive finding of sexual abuse (64.5 % versus 35.5 %) (Figure 7).

     Tears and lacerations were the most common injury findings, in sexually abused victims followed by bruises, abrasions and burns (Figure 8).

Figure (8):  Injury findings

Female victim cases local injuries: Hymen was the most common site of sexual abuse injury among studied cases followed by anus, gluteal region and others (59.3 %, 25 %, 9.5% and 6.2 % respectively) (Table 3).

Table (3):   Female victim cases local injuries

DISCUSSION

     Public prosecution refers to those with reported physical or sexual abuse to forensic investigation shouldn’t be considered an accurate indicator of the prevalence of child abuse in Egypt, as it represents only cases reported to the medico-legal authority.  As reporting of child abuse to the authorities was found to occur in only a small proportion of all cases (Fallon et al., 2010).

     In the Arab world, child abuse is a silent hazard that might result in serious consequences (Zaki et al., 2019). In Egypt, a medicolegal examination of the children is often restricted to notified criminal cases (Sobh et al., 2020). Therefore, for children to disclose their victimization is improbable due to their immaturity along with fear of consequences. Also for a year, only 90 children were notified to be examined in Al-Sharqia government Forensic Medicine Authority to verify their exposure to violence was not acceptable. This could be attributed to the inability of disclosure by a child and the close relationship between the children and their offenders, although they may be exposed to repeated unreported abuse.

     Our study showed that female victims were more than males (56 cases: 62.3% versus 34 cases: 37.7%). It also showed significant differences in gender distribution between age groups of the included study cases where adolescents female group were more predominant (34.3%, 31 cases) than other school and preschool age groups. This agreed with Arif et al. (2014) who revealed that the highest incidence of child sexual assault was found in female age group (11-18years).

     The present study showed that rate of sexually abused children was higher in rural than urban areas which was the same as Aboul-Hagag and Hamed. (2012), who showed that the overall prevalence rates for CSA were more in rural than urban.

     As regards perpetrators, our study showed that they were interfamilial in only 12.2 %, and while extra familial perpetrators were the main perpetrators. Neighbors were the highest abusers (37.8 %) followed by strangers (30%) and adult friends (20%). This agrees with Sharaf El-Din et al. (2015), Shetty et al. (2017), and Abo-Seria et al. (2019) who showed that perpetrators from outside the family were more predominant than from inside. In contrary, Al Madani et al. (2012) found that most perpetrators of child sexual abuse were strangers, followed by adult friends and neighbors, but it is important to note that the findings of the current study may underestimate the real prevalence of child sexual abuse by relatives, neighbors, and persons normally trusted by children. This is due to the shame, secrecy, and denial associated with familial sexual violence against children that prevent it being reported. However, multiple other studies suggest that perpetrators of child sexual abuse tend to be known by their victims.

     The present study showed that assailant age group (15–20) years represented 51.2%, and assault by one assailant was higher than assault by multiple assailants (86.7 % versus 13.3%). In contrast to Manzoor et al. (2010) and Arif et al. (2014) they observed that the majority of child sexual abuse cases were committed by more than one perpetrator.

     No positive findings were present in the present study in 64.5 % of suspected victim’s abuse, while positive findings were detected in 35.5 % of sexually abused cases. Greater frequency of genital injuries in adolescent girls may be due to the assault’s circumstances as the offenders may use greater force to overcome any resistance from the victims. Also, in some cases, penetration of the hymen occurred several times in the same assault, which resulted in more severe injuries. Acute injuries (both anal and genital) were more frequent than chronic injuries in all age groups except adolescent groups, where chronic injuries were more common. Since chronic injuries indicate repeated sexual activity, those adolescent victims were seen as having been subjected to sexual abuse for longer periods of time (Herman et al., 2015).

     The present study showed that tears and lacerations were the most common injury finding in sexually abused victims followed by bruises, abrasions and burn. Concomitant physical violence with sexual abuse was evident in about 15% of victims of sexual abuse in the study of Abd El Rahmana et al. (2017). The evident wounds in victims of sexual abuse and sexual assaults may be due to resistance or to accidental wounding during the sexual violence or in an attempt by the perpetrator to prevent the victim from crying or calling for help.

     Our study found that vagina was the most common site of injury among sexually abused female cases followed by gluteal region and anus. Adams et al. (2018) found that only 2.2% had signs of genital or anal injury of non-acute cases, whereas acute cases had the prevalence of injuries of 21.4%.

     The present study detected that vaginal penetration was the most significant manner of sexual assault. Vaginal penetration was significant among adolescent group (>12y) than other groups and anal penetration was significant among school age (6-12 y). Hymen followed by anus, gluteal region and others (59.3 %, 25 %, 9.5% and 6.2 % respectively) were sites of injury. Adams et al. (2018) reported that penetration by older children could be more likely associated with actual penetration.

     Many reasons could explain the high negativity of medicolegal evidence in sexual child abuse. Children might not understand what happened exactly and they could describe inter-labial (vulvar) or inter-gluteal penetration as vaginal or anal intercourse. Also, the perpetrator could be concerned to obtain sexual gratification with minimal force. Besides, the delayed presentation allows the healing of injuries and loss of evidence (Tener, 2018).

     Our study showed local anal findings in positive victim cases. Ten cases showed positive anal findings (8 male cases and 2 female cases). Chronic cases showed evidences of old tears with piles, wide anal opening, weak sphincter tone and reversed anal reflex Herrmann et al. (2015) found that anal injuries were apparent in 15% of victims of sexual abuse while genital injuries were found in 26.6% of female victims of sexual abuse.

CONCLUSION AND RECOMMENDATION

     Sexual abuse of a young child was extremely under-reported in Al-Sharqia government. Abuse was often committed by close persons that expose the child to endless cycles of violence. Thus, only cases of medico legal aspects were notified to authorities. The assessment of sexual abuse among young children was a challenging and cautious interpretation of findings was mandatory. It is important to teach and encourage children to tell their caregivers. It is essential to increase public awareness of child abuse. In addition, physicians in primary health care facilities and hospital centers should be educated regarding suspected signs of child abuse.

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