Sex crimes have been complex and multidimensional for the past few decades. Child sexual abuse is one of the most stressful life events and is associated with many adverse consequences, including physical and mental health problems, substance abuse, and criminality.1 Sexual abuse occurs when a child is engaged in sexual activity that he/she cannot comprehend and for which he/she is developmentally unprepared and cannot give consent. Child sexual abuse can take place within the family, by a parent, a stepparent, a sibling, or other relative, or outside the home, such as by a friend, a neighbor, a childcare person, a teacher, or a stranger.2,3
Examination of alleged sexual offenses in child victims and those accused, whether alive or dead, is 1 of the most difficult tasks in forensic medicine. The heavy penalties inflicted for such offenses; the personal, social, and familial consequences; the danger of allowing true offenses to go unpunished; and the injustice of wrong conviction make the responsibilities of the physician very heavy indeed.4 Physical finding of sexual abuse is often not present. The most important determinant for abuse is the child’s (or a witness’s) account of the incidence.
In Egypt, there is no accurate Egyptian epidemiologic study assessing the extent of the problem of child sexual assault, and this lack prompted us to conduct the present study. The true prevalence of the many forms of sexual violence against children ranges from 1 place to another. Available data are drawn from different populations using a variety of measures of sexual violence, and data accuracy is affected by nonreporting. Demographic features may exhibit variations between societies and between different regions of the same country depending on various variables.
Child sexual abuse is considered 1 of the greatest threats to a child’s well-being, and safety, prevention, and dealing with this situation are no easy tasks. These require a multidisciplinary approach with great effort and coordination among the public administration, numerous professionals, families, victims, and society in general.
Thus, sexual abuse of children has become the subject of great community concern and the focus of many legislative and professional initiatives. The evaluation of sexually abused children is increasing all over the world.
The aims of the present study were to determine the medicolegal pattern of child sexual abuse, to analyze demographic data related to the victim and the offender, as well as to evaluate the injuries that occurred as a result of sexual assault and to identify the risk factors associated with sexual offenses in children in greater Cairo, Egypt.
MATERIALS AND METHODS
This is a retrospective study from January 1, 2005, to December 31, 2011, in greater Cairo (Cairo city, Giza city, and Shobra Elkhyma). The data of cases were obtained from the Medico-Legal Department, Ministry of Justice, Egypt. Agreement for perusal of records and appropriate data retrieval was obtained from the director of the Medico-Legal Department.
For the victim, age, sex (male or female), social class (low, intermediate, or high), education (in school or out of school), residence, family troubles, and street youth were analyzed.
For the offender, age, sex (male or female), education (educated or uneducated), occupation (student, employed, unemployed, professional, or self-employed), social class (low, intermediate, or high), marital status (married, unmarried, divorced, or widowed), alcohol and drug abuse, number of offenders, victim-offender relationship, and nationality (Egyptian, Arabic, or foreigner) were analyzed.
Clothes (torn, stained, or normal), general examination results, anogenital examination results, time interval before examination, motivations, investigations, and victim disability were analyzed.
The collected data were analyzed using the Statistical Package for the Social Sciences version 16 (Statistical Package for the Social Sciences Inc, Chicago, Ill). The difference between 2 means was statistically analyzed using the Student t test. For qualitative data, number and percentage distribution were calculated. The χ2 test was used to test significance. Significance was adopted at P<0.05 for interpretation of results of tests of significance.
Child sexual abuse generates deep concern worldwide as a social phenomenon and a pressing public health issue. The potentially traumatic impact of child sexual abuse is well documented. The lack of more accurate data hampers the design of intervention and prevention programs, finding a means to evaluate their efficacy, and comparison of regional and international rates.5
The present study was a trial to evaluate the sexually abused children in greater Cairo from January 1, 2005, to December 31, 2011. It faced many difficulties regarding registration. There is no specific scheme to make the process of registration more accurate and convenient. The years 2010 and 2011 accounted for the highest incidence. The males outweigh the females, and the higher rates of cases were found in the age group 6 to 12 years (49%), mostly in the males (71.8%). However, in Sohag and Dakahlia governorates, Egypt, from 2002 to 2003 and from 1996 to 2000, respectively, the females outweigh the males.3 In addition, other authors found that rates were higher for females than for males.6–8
Soothill et al9 suggested that the sexual victimization of males may be underestimated than that of females; he found that the ages of victims were distributed across middle childhood and early adolescence. Haj-Yahia and Tamish10 reported that in Assiut Governorate, Egypt, from 2003 to 2007, the highest percentage of cases was among the age group 15 to 18 years, and Aboul-Hagag and Hamed8 reported that the highest percentage of child sexual abuse was in the age group 10 to 15 years.
Ménard and Ruback11 and Pereda et al12 reported that sexually abused males were more common than sexually abused females. The increased number of males may be due to the increased number of street children in various developing countries, which is estimated to range between 10 and 100 million, and most were males. However, there were no data in the medical files of this study as regards street children. Young males are often playing outdoors, not under the supervision of their families; females of a young age group tend to stay at home close to their mothers.
Giza, Matarya, and Bolack, which had the lowest socioeconomic status categories, had the highest number of victims. Moqutam, which had a high social class, had the lowest number of victims. Mullen et al13 reported that low social class associated with high incidence of sexual abuse. Chalk et al14 found that sexually abused children were more likely to have offenders whose occupations fell into the lowest socioeconomic groups.
Joyce15 and Brownlie et al16 found that victims with disability are at great risk for sexual abuse. They found that males and females with disability are equally at risk for sexual abuse. In this study, mental disability was recorded in 1.9% of the victims.
In the present study, most (95.3%) victims were abused by 1 offender, and all the offenders were males, mostly Egyptians of low class, uneducated, and aged 18 to 30 years. Smallbone and Wortley17 reported that most sexual offenders are males. Females have not been viewed as sexual abuse offenders except in unusual circumstances. Females who did sexually abuse children were considered to have serious mental disturbance.
There was a significant relation between marital status and sex of the victim, where the unmarried offenders assaulted the females more than the males and the married assaulted the males more than the females. These results are in agreement with Soothill et al.9 Smallbone and Wortley17 reported that a majority of offenders were uneducated.
The place of the assault in this study was unknown for most cases; this can be explained by the increased number of stranger offenders. The assailants’ residence was 16.3 % while the victims’ residence accounted for a small number of cases 3.9%. There was a statistically high significant association between victim-offender relationship and sex of the victim. Smallbone and Wortley17 and Laraque et al5 reported that in the case of intrafamilial abuse, females are more likely to be victims.
In addition, Aboul-Hagag and Hamed8 found that strangers abused females, whereas classmates and friends abused males. Finkelhor and Baron (1986)18 showed that, in the United States, males were more often sexually abused by strangers, whereas females were more often sexually abused by family members. This may be related to different cultural backgrounds and traditional moral values in different countries. Soothill et al9 found that abuse by intrafamilial offenders was more common than that by extrafamilial offenders.
Haj-Yahia and Tamish,10 Niu et al,19 and Hagras et al3 reported that stranger offenders were more common than familial offenders. However, in a Nicaraguan study, the most common perpetrators of abuse on children younger than 12 years were male family members including uncles, cousins, and fathers20 (66%).
The most frequently reported types of abuse were anal assault (52.3%) followed by incomplete vaginal penetration (32%). Complete vaginal penetration and mixed vaginal and anal assaults occurred in a small number of cases. However, clinical findings were reported to be negative in 87.7% and positive in 12.3% in the form of general, clothing, and anogenital findings. These results are in accordance with those of Cheung et al.21 Aboul-Hagag and Hamed8 reported that hugging and kissing represented the most reported types of child sexual abuse; only 1.1% of the participants experienced complete sexual relation. Ingemann et al22 reported that the most common types of sexual activities reported were exhibition of sexual organs, kissing, hugging, and fondling; 6% reported accomplished vaginal penetration with a penis.
There was no relation between clinical finding and investigation and time of examination, where in the first 24 hours, only a small number of cases of sexual abuse showed positive findings. Wiley et al23 found that negative results of investigation in victims may be due to washing or bathing after abuse, so any forensic evidence would be removed. Hagras et al3 reported that samples collection and examination of clothes showed negative results for sexually related material.
Some victims have positive results of both clinical examination and investigation, others have positive clinical findings but negative results of investigation, whereas others are normal clinically but have positive results of investigation. There were also general findings without anogenital findings. These results correspond with those of Al Essa and Al Muneef.24
Wiley et al23 and Jejeebhoy and Bott25 reported that victims with positive clinical findings and negative results of investigation can be explained by long time interval between clinical examination and investigation; bad preservation of samples; and some victims washing, bathing, or douching after abuse, so any forensic evidence would be removed. Many forms of sexual abuse do not cause physical injury, and sexual abuse may be nonpenetrating contact and may involve fondling; oral-genital, genital, or anal contact; and genital-genital contact without penetration.
Finally, diagnosis of child sexual abuse includes history taking, forensic interviewing, physical examination, and laboratory investigations. However, diagnostic physical findings and results of investigation are lacking in most cases; therefore, it is recommended that history taking is often the most important thing of information in determining the likelihood of child sexual abuse. Limitations of this study is not possible neither to draw robust conclusions nor generalize from the findings, due to limit the sourcing of the data collected from the medicolegal department Ministry of justice only. Therefore, a strict system of registration should also be initiated to avoid personal variations and sometimes laxity in registering data. Forensic physicians and other health professionals need to be competent in the basic skills of history taking, physical examination, selection of laboratory tests, and differential diagnosis of child sexual abuse. This may be done by providing training for personnel working to diagnose and rehabilitate child victims of sex offenders. Governments, national nongovernmental organizations, and civil society organizations should use the data collected by researches to develop policy and legislation.
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