Child sexual abuse : The relationship between the type of abuse and the risk factors

Aim: The objective is to determine whether there is a relationship between the type of abuse and the risk factors. Method: The population of the study consists of 39 sexually abused children. The questionnaire form consisting of 40 questions related to the children’s sociodemographic characteristics and family structures, the type and frequency of sexual abuse, and the identity of abuser was filled in based on the file information of sexually abused victims brought to the Children’s Branch of Sivas Security Directorate. Conclusion: It was determined that there was a significant relationship between the gender and age of the victim and socio-economic level of his/her family and the type of abuse, except for the cases of disability and parents’ living together. Discussion: In this study, it was determined that some risk factors are related to some types of abuse, and the results were evaluated in terms of possible risk factors.


INTRODUCTION
In general terms, child sexual abuse can be defined as sexual contact with a child (Finkelhor, 1997: 101).Child sexual abuse 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.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 (WHO).
The term child sexual abuse (CSA) includes intercourse, attempted intercourse, oral-genital contact, fondling of genitals directly or through clothing, exhibitionism or exposing children to adult sexual activity or pornography, and the use of the child for prostitution or pornography (Putnam, 2003: 269).
The age and gender of the child, the age and gender of the perpetrator, the nature of the relationship between the child and perpetrator, and the number, frequency, and duration of the abuse experiences all appear to influence some outcomes.Thus, sexually abused children constitute a very heterogeneous group with many degrees of abuse about whom few simple generalizations hold (Putnam, 2003: 269).On the other hand, perpetrators of CSA come from different age groups, genders, races and socio-economic backgrounds.Women sexually abuse children, although not as frequently as men, and juvenile perpetrators comprise as many as one-third of the offenders (Finkelhor, 1994: 27-28).One common denominator is that victims frequently know and trust their abusers.Child abusers coerce children by offering attention or gifts, manipulating or threatening their victims, using aggression or employing a combination of these tactics (Henderson, 2000: 311).
Studies (Finkelhor, 1994;Putnam, 2003;Henderson, 2000) have not found differences in the prevalence of CSA among different social classes or races.CSA occurs across all socioeconomic and ethnic groups.A number of factors, however, have been identified that increase risk for child sexual abuse.

Gender
Gender is an important risk factor for CSA.According to estimations, one out of every four girls (25%) and one out of every ten boys (10%) are sexually abused (Lanning et al.1999: 3-8).Girls are at about 2.5 to 3 times higher risk than boys, although approximately 22% to 29% of all CSA victims are male (Finkelhor, 1994: 409;Gorey and Leslie, 1997: 391-398) Studies conducted in our country have also reported that girls are subjected to more sexual abuse (Ayaz et. al., 2012: 33-40;Köse et. al., 2011: 221-225;Fiş et. al., 2010Fiş et. al., : 1285Fiş et. al., -1290)).Unfortunately, abused boys are less likely to disclose or be detected, so they are underrepresented among cases that come to professional attention.They constitute at the most about one fifth or less of clinical case (Finkelhor, 1997: 102,103).

Age
The child's age is an important factor in the exposure to abuse.Children of all ages may be exposed to sexual abuse, but studies conducted show that the risk increases with age in CSA (US Department of Health and Human, 1996). 13Data from 1996 indicate that approximately 10% of victims are between ages 0 and 3 years.Between ages 4 and 7 years, the percentage almost triples (28.4%).Ages 8 to 11 years account for a quarter (25.5%) of cases, with children 12 years and older accounting for the remaining third (35.9%) of cases.Although there is no comprehensive and sufficient study on CSA in our country, the mean age of cases of sexual abuse who apply to child psychiatry has been determined to be 10.9 and 11.4.However, this ratio is not constant and may vary according to the research pattern (Çengel et. al. 2007: 256-62;Koten et. al., 1996: 154;Alpaslan, 2014: 194-201;Yıldırım et. al., 2013: 354-361).Adolescent children are particularly vulnerable to sexual assault at the hands of peers (Finkelhor, 1997:103).Some authorities believe that, as a risk factor, age operates differentially for girls and boys, with high risk starting earlier and lasting longer for girls (Putnam, 2003: 270).

Disabilities
Studies have demonstrated that certain groups of children appear to be at higher risk for abuse than other.Among them are children who are disabled or impaired, due to mental retardation or a physical problem (Westcott and Jones, 1999;Finkelhor, 1997;Putnam, 2003;Gorey andLeslie, 1997¸ Page, 2004;Pereda et. al., 2009;Zoroğlu et. al., 200;Spencer et. al., 2005).It has been stated that mentally disabled individuals are 4-10 times more likely to be exposed to sexual abuse than the normal population because these children accept a proposal or intimacy for sexual intercourse without knowing that they will be sexually abused (Sobsey et. al., 1997: 707;Morano, 2001: 126-135).

Socioeconomic Status
Although low socioeconomic status is a powerful risk factor for physical abuse and neglect, it has much less impact on CSA (Putnam, 2003: 270;Henderson, 2000: 311).Sexual abuse of children appears to be much less concentrated among children of disadvantaged social classes than other forms of child maltreatment.But sexual abuse in upper social classes is often overlooked because professionals assume it is rare Finkelhor, 1997: 104).

Family Constellation
Family constellation, particularly the absence of one or both parents, is a significant risk factor for children who have experienced parental divorce or; children whose parents are violent or hostile toward one another or toward their children; children whose parents have an alcohol, drug abuse problem or some debilitating psychiatric condition.The presence of a stepfather in the home doubles the risk for girls Finkelhor, 1993Finkelhor, , 1994Finkelhor, , 1997;;Sobsey et. al., 1997;Mullen et. al., 1993) .
The above-mentioned risk factors are the risk factors of the victim that are thought to be effective in the child's exposure to sexual abuse and that are repeatedly emphasized in many studies.What is the effect of these factors on the types of sexual abuse in a more specific form?For example, for which types of abuse does the age of a child pose a greater risk?

AIM
The objective of this study with reference to these questions is to determine whether there is a relationship between the risk factors that are found to be effective in the children's exposure to sexual abuse and the types of abuse they are detected to be exposed to.The reference types of abuse in the study are anal penetration (AP); oral penetration (OP); vaginal penetration (VP); touching, fondling, kissing and rubbing (TFKR); genital exhibitionism (GE), and sexually explicit speech (SES) that are observed within the study population.The study was conducted considering the low number of studies associating the risk factors considered to be effective in child sexual abuse with the type of abuse.

METHODOLOGY
The study population consists of the file information of 39 cases who have been sexually abused and who are between 1-18 years of age, and who have been directed to the Children's Branch of Sivas Security Directorate from different individuals and institutions between January 2016 and January 2017.
A questionnaire form was used in obtaining the data.Questionnaires were filled in based on the file information of sexual abuse victims brought to the Children's Branch of Sivas Security Directorate between January 2016 and January 2017.

Questionnaire Form
It consists of 40 questions related to the information about the children's sociodemographic characteristics and family structure, type and frequency of sexual abuse, and the identity of the abuser.
The Chi-square analysis was applied to the data obtained from the study to determine whether there was a significant relationship between the types of sexual abuse that the victims were exposed to and the risk factors considered to be influential on them.The SPSS package 16 program was used for the analysis.

GENERAL FINDINGS
71.8% of the victims were girls, 28% were boys, and the mean age was 12.02±2.96years.The sampling rate of those who do not go to school is 5.1%.Of the mothers and fathers, 43.6%-48.7%are primary school graduates, 38.4%-38.5% are secondary school and high school graduates, respectively, and the sampling rate of illiterate individuals is 10.3%-2.6%.66.7% of mothers are housewives, and 30.7% are workers and officials.38.5% of fathers are workers, 25.6% are selfemployed, 15.4% are officials, and 12.8% work in temporary jobs.Of the victims' families, 46.2% are at the lower, 46.2% are at the middle, and 5.1% are at the upper economic level.82.1% live in a nuclear family, and 15.4% live in a fragmented family.Violence was observed in the family of 2.6%.71.8% of the victims have their own room in the house.5% are physically, 5.1% are mentally, and 2.6% are both physically and mentally disabled.When the risk factors in the family were examined, it was determined that 5.1% of parents used cigarettes and alcohol, 30.8% lived in inadequate physical conditions, and 48.7% had a low educational level.38.5% of the abuse was VP, 33.3% was TFKR, 20.5% was AP, 2.6% was OP, 2.6% was GE, and 2.6% was SES.41% of the abusers are lovers, 20.5% are strangers, 15.4% are neighbours, 7.7% are school friends, 7.7% are teachers, 5.1% are brothers, 2.6% are step-fathers.59% of the victims were abused once, and 20.4% were abused five and more times.89.7% of the victims were abused by one person, 7.7% by two, and 2.6% by five persons.53.8% of abuse occurred in someone else's house, 17.9% at school, 12.8% in the house where the victim lived, 12.8% in a wasteland, and 2.6% in a private vehicle.76.9% of parents knew about the abuse.69.2% of the abuse was revealed by the statement of the victim, 10.3% by someone else's witnessing it, 10.3% by pregnancy, 7.7% by a vaginal discomfort, and 2.6% by the deterioration of the victim's mental health.

CHI-SQUARE ANALYSIS
It was determined that there is a significant relationship between the gender and age of the victim and socio-economic level of his/her family and the type of abuse, except for the cases of victim's disability and parents' living together.X 2 =16.07 P=0.007≤0.05

Table 1-Gender of the victim and the type of abuse
It was determined that there is a significant relationship between the gender of the victim and the type of abuse at X 2 =16.07,P=0.007≤0.05level.It is observed that according to the type of abuse, girls were exposed to VP (100%) and TFKR (69.2%) at most.The most common type of abuse for boys is AP (62.5%), followed by exposure to TFKR (30.8%).A significant relationship was found between the age of the victim and the type of abuse (X 2 =79.4 P=0.000≤0.05).Individuals who were exposed to VP (100%) and TFKR (69.2%) are girls in the adolescence period between the ages of 13-17 years.Individuals who were exposed to AP (62.5%) at most are boys in the adolescence period.Boys who were exposed to TKFR (30.8%) are between eight and thirteen years of age.It is observed that there is a significant relationship between the type of abuse and the socio-economic status of the victim's family (X 2 =27.021P=0.003≤0.05).Of the individuals exposed to VP, 66.7% are at a lower, and 33.3% are at a middle socio-economic level, and of the individuals exposed to TKFR, 69.2% are at a middle, and 30.8% are at a lower socio-economic level.

Table 2-Age of the victim and the type of abuse
On the other hand, there was no significant relationship between the victim's being disabled (X 2 =1.812P=0.874≤0.05)and parents' living together (X 2 =10.098P=0.07≥0.05) and the status of being exposed to abuse.

DISCUSSION
The risk factors examined are the risk factors of the victim.Gender is an important risk factor for CSA.Studies (Finkelhor, 1997;Mullen et. al., 1993) show that girls constitute a higher risk group for sexual abuse.In this study, the number of girls exposed to abuse is about three times that of boys.On the other hand, there was a significant relationship between the gender of the victim and the type of abuse (Table 1).All of the individuals exposed to VP are girls between 13 and 17 years of age.In a study conducted in Turkey, it was found out that as age increased in girls, abuse in the form of VP also increased (Akbaş et. al., 2009;24-32).
The type of abuse that boys are most exposed to is AP.In a study, it was also found out that boys experience more physical and sexual force and threats than girls.The second most common type of abuse in both genders is TFKR.In a study conducted in our country, it was stated that all children were exposed to sexual abuse including contact and anal rubbing was detected at high rates in boys, touching, fondling, and kissing were detected at high rates in girls (Vander, 1998: 61-72).Sexual activities between two children in the literature are addressed as sexual abuse when the age difference is at least 5 years and when the young child is exposed to sexual pleasureintentional activities by forcing or persuasion (Alpaslan, 2014: 194-201).The facts that majority of the abusers in VP are lovers, and there is a small age difference between the abuser and victim in almost half of TFKR and AP, and that the abuser is often an acquaintance or a person who is in regular contact with the child are results supporting the literature (Köse et. al., 2011;Fiş et. al., 2010;McCourt et. al., 1998;Keskin, 2005;Çengel et., al., 2007).
The second variable found to be effective on the type of abuse is the age of the victim.In the study (Table 2), the age of being a victim at most in both girls and boys is 14-15-16 and 17 years of age for VP and AP.It is observed that exposure to TFKR is at earlier ages for boys than for girls.The studies conducted have shown that the risk of sexual abuse in children increases with age, that children are more exposed to abuse in certain age groups, that the age works differently for girls and boys, and that adolescent children are particularly vulnerable to sexual assault at the hands of peers (Finkelhor, 1993(Finkelhor, , 1997;;Putman, 2003).In the present study, it is observed that the status of being a victim increases with age for girls according to the type of abuse and that being a victim is experienced in almost all age groups for boys.
Although the studies (Putman, 2003;Finkelhor, 1994;Topçu, 1997) conducted show that the socioeconomic level of the family is usually less determinative for CSA according to other types of abuse of the child, the low socioeconomic level and poverty are the major risk factors for CSA.In this study, it was found out that there is a significant relationship between the type of abuse and the socio-economic status of the family (Table 3).While 5.1% of the victims were AP and SES victims from the upper socio-economic level, it was determined that the majority of the VP victims were from the lower and the majority of the TFKR victims were from the middle socio-economic level.These data show that the probability of being a victim at the lower and middle socioeconomic level is higher.It was determined that according to the type of abuse and gender, VP and AP victim girls were more from the lower socio-economic level and TFKR victim girls were more from the middle socio-economic level.It was observed that TFKR victims, including boy AP victims, were at close rates to each other at both socio-economic levels, and there were no girl victims in the upper socio-economic level.
On the other hand, although the studies (Putman, 2003;Alpaslan, 2014;Spencer et. al., 2005) conducted show that the child's being physically or mentally disabled increases the risk of abuse due to his/her being dependent, having communication difficulties, and needing institutional care (Putman, 2003: 270), there was no significant relationship between the type of abuse and the child's being physically or mentally disabled in this study.
Another risk factor that could be associated with the type of abuse is the status of parents' being together.The studies conducted (Putman, 2003;Topçu, 1997;Abel and Harlow, 2001;Bulut, 2007) show that children, whose parents are divorced, live separately, who do not have any parents, have a stepfather, have parents that exhibit violence and hostility towards each other, have drug addicted or substance abuser parents, constitute a greater risk group for sexual abuse due to poor parental supervision and emotional deprivation.In this study, a small number of parents with these characteristics may have affected the result, but the data are important in showing that the lack of these characteristics does not prevent the child from being sexually abused.
As a conclusion, sexual abuse is a type of abuse that contains all the risk factors associated with other types of abuse against the child and is the abuse that is most harmful to the physical and mental development of the child in terms of outcomes.The results of the study, such as the facts that the most common type of abuse is VP, the age difference between victims and abusers is small, emotional intimacy was found between victims and abusers, and that the majority of them were from the lower and middle socio-economic level, etc. are important in that they show that emotional relationships among (peers) adolescents can turn into sexual abuse.This may be due to a number of reasons, but the studies conducted show that socio-cultural factors come to the forefront of the factors that determine the direction, quality, and competency of a sexual behaviour and that the effect of cultural factors overcomes the genetic ones in the case of deviant behaviours (Varış, 1968;Eagly, 1969).As stated in a study (Finkelhor, 1997;101-115), large amounts of underlying sexual abuse can occur in an area with few official reports, especially if the culture is one that treats sex with a great deal of shame or secrecy.Although cultural factors are not included among the risk factors for sexual abuse in this study, the results achieved are important in showing that the sexual role is problematic in influencing behaviours related to the social development in accordance with the cultural characteristics in some adolescents.At this point, it is inevitable to include the gender culture, from which the child obtains the gender role, as a risk factor in studies on child sexual abuse.