European Journal of Social Sciences Volume 13, Number 4 (2010)

Sexual Assault in Childhood and Adolescence; a Survey Study

Hakan Kar Corresponding Author, Asist. Prof. M.D. Mersin University Faculty of Medicine Department of Forensic Medicine Mersin / TURKEY E-mail: hakankar@mersin.edu.tr M. Mustafa Arslan Asist. Prof. M.D. Mustafa Kemal University Faculty of Medicine Department of Forensic Medicine Hatay / TURKEY E-mail: mmustafaarslan@yahoo.com Necmi ekin Prof. Cukurova University Faculty of Medicine Department of Forensic Medicine Adana / TURKEY E-mail: ncekin@cu.edu.tr Ramazan Akan Assistant Professor Dicle University Faculty of Medicine Department of Forensic Medicine Diyarbakr / TURKEY E-mail: akcanmd@yahoo.com Ahmet Hilal Assoc.Prof. M.D. Cukurova University Faculty of Medicine Department of Forensic Medicine Adana / TURKEY E-mail: ahilal@cu.edu.tr Abstract Children and especially adolescent females are sexually assaulted more frequent comparatively to adults according to many studies. The aim of the study was to describe demographic features of victim and assailant, sexual assault characteristics, the time between assault and the examination, to determine genital/non-genital injuries and place of assault in child and adolescent sexual assault victims to provide descriptive data on medico-legal findings and health care strategies among them. A prospective survey was carried out among sexually abused child and adolescent cases referred to Forensic Medicine Council Adana Group Administration in the period of January 2007 to December 2007. Of 141 cases, 78 cases that agreed to respond the questionnaire were taken in the scope of the study. Only eighteen (23%) of cases were examined within the first three days of abuse. Forty-two of cases expressed that they were not abused and had voluntary sexual activity. Most of perpetrators were friends of victims. The majority of cases were determined to be young female adults, aged between 16 to 18 years, which had a voluntary sexual activity. The legal issue in these cases was complaint of families of cases to the public prosecutor. In this respect, in our country law should be more tolerant to voluntary sexual activity of close aged individuals. 549

European Journal of Social Sciences Volume 13, Number 4 (2010) Keywords: Sexual assault, child, adolescent, abuse, forensic medicine.

Introduction
Although definition of violence may vary in different societies and cultures, it can be defined as all behavior that affects bio-psycho-social status of individuals. Sexual violence is described as sexually motivated behavior that exerted against ones privacy despite ones resistance. Furthermore, all sexually motivated behavior directed to low aged or mentally retarded individuals included in scope of the term of sexual violence (Herbert et al., 1992, Christian et al., 2000, Chu, Tung, 2005). On the contrary to the idea that, most of sexual violence cases are consequences of uncontrolled impulsive acts, 71% of all sexual assaults were reported to be planed. One in five women is a victim of rape or sexual assault in the world. Approximately 700.000 women in the reproductive age group are victims of sexual assault in the United States and, 25,000 women are raped per year in France. Unfortunately only 16% of rapes are reported to police, however 50% of victims of rape have expressed that, they would report the rape after a warranty of secrecy about their identity (Santiago et al., 1985, Bechtel, Podrazik, 1999). Most of the rape victims do not disclose the assault because of being accused or exposed to repeated assaults (Ledoux, Hazelwood,1995, Crowley, 1999). Children and especially adolescent females are sexually assaulted more frequent comparatively to adults according to many studies (Peipert, Domagalski, 1994, Jones et al., 2003, Navratil, 2003). In this respect, the prevalence of sexual assaults, especially among children and adolescent, is thought to be extremely higher than in literature The aim of the study was to describe demographic features of victim and assailant, sexual assault characteristics, the time between assault and the examination, to determine genital/non-genital injuries and place of assault in child and adolescent sexual assault victims to provide descriptive data on medico-legal findings and health care strategies among them.

Methods
A prospective survey was carried out among sexually abused cases referred to Forensic Medicine Council Adana Group Administration, in the period of January 2007 to December 2007. The questionnaire was developed based on items used in various published studies. The main contents of questionnaire which consists of 35 questions were general socio-demographic features of victims, relationship between victim and perpetrator, clinical symptoms of victims and place of assault. Cases under 18 years of age were accepted as child victim according to the United Nations Child Rights Agreement. Cases over 18 year of age and who did not accept to answer the questions were excluded. All examinations were performed by using colposcopy by physicians with special training in forensic medicine. Survey was conducted by a forensic medicine specialist during an interview with cases aged less than 18 years after informed consent. Obtained data was presented by tables and graphics.

Results
A total of 11047 cases referred to Council of Forensic Medicine Adana Group Administration between January 2006 December 2006 for forensic examination and 162 (%1.47) of them were for sexual assault cases. Of these 141 were under the age of 18, and 129 (%79.63) were female, while 33 (%20.37) were male. Of all cases 78 accepted to respond the questionnaire. The distribution of cases with respect to age, sex and educational levels is shown in table I.

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Table I:
Age Male 0-6 Female Male 7-12 Female Male 12-15 Female Male 16-18 Female Male Total Female 10 19 22 19 1 3 2 9 1 16 4 14 1 78 (100) 3 6 6 5 3 1 4 1 1 1 3 -

The distribution of cases with respect to age, sex and educational levels
Sex Not Literate 1 Primary School Secondary School High School College / University Total (%) 2 (2.56) 11 (14.1) 22 (28.21) 43 (55.13)

In evaluation of family status, 63 cases were noticed to live with their own parents, while out of remaining 3 stayed with step father, 4 lived in orphanage or adopted, and 8 lived with their own mother. Eighteen (23.08%) of the cases were referred for clinical examination within the first 3 days of sexual assault, while 60 (76.92%) of all referred after the first 3 days of assault (Table II). The causes of delay of forensic and clinical investigation were concealing intentionally in 21 (26.92%) cases, cheating with marriage promise in 18 (23.08%), fear in 15 (19.23%), delayed legal process in 5, and disbelieve of family in one case. Surprisingly there was presence of assent to sexual activity in 42 (53.8%) cases and they have expressed that they were not assaulted as they had a voluntary sexual activity with their friends (partners). Soporific drugs were noticed to given only two cases.
Table II: The duration between sexual assault and clinical examination
Within 72 hours 18 23.08 4-7 days 12 15.38 8-30 days 11 14.1 31-180 days 19 24.36 180 days and over 18 23.08 Total 78 100

Number of cases %

In genital examination, old hymeneal tear was detected in 22 cases, while fresh hemorrhagic tear detected in 3 cases. Furthermore, anatomic virginity, which allows penile-vaginal penetration without any rupture of hymen, was found in 13 of all. There were only vulvae and hymeneal ecchymosis in one case. In anal examination, perianal scar was detected in one case, yet acute anal intercourse findings were noticed in 4 cases. There were no findings attributable to physical or sexual violence in 34 of all cases. There was physical violence history in 22 cases, yet clinical examination revealed traumatic findings in only 5 cases. Out of five cases which had traumatic findings, two were accompanied by sexual assault findings as well. Since one of the perpetrators was missed, data about perpetrators based on 77 cases. The disparity between the age of victims and perpetrators was detected to be 1-2 years in 11 (14.29%) cases, 3-5 years in 20 (25.97%), 6-10 years in 25 (32.47%), and 11 years and over in 21 (27.27%) cases. Evaluation of the relationship between victims and perpetrators revealed that, 73 cases were acquaintance sexual assault, stranger assault were only in 4 cases. Perpetrator was mostly the friends or partners of victims with 26 cases. Out of perpetrators who were the relative victims, two were fathers of victims (Table III).

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Table III: Relationship between victims and perpetrators with respect to sex and age groups
Types of acquaintanceship / Age , sex M 0-6 F M 7-12 F M 13-15 F E 16-18 K Total (%) 1 5 7 14 8 16 1 1 2 2 5 7 18 26 4 2 3 5 2 8 1 1 3 1 1 1 2 1 1 2 1 1 11 (14.28) 22 (28.58) 42 (54.54) 77 (100) Husband religiously but not registry married Friend or beloved

Relative 1

Neighbor

Non Relative acquaintance

Adjunct

Fianc

Stranger

Step father

Total(%)

2 (2.6)

The place of sexual assault was perpetrators home in 31 cases (39.74 %), followed by outdoor in only 18 (23.08 %) of the cases. The distribution of place of sexual assault is shown in table IV.
Table IV: The distribution of place of sexual assault
Perpetrators A place insured Victims home by assailant home 31 13 10 39.74 16.66 12.82 Work place 3 3.84 Deserted premises 2 2.58 Orphanage 1 1.28 Outdoor 18 23.08 Total 78 100

Number of cases (%)

Discussion
Sexual assault is a sociological problem affecting individuals in all age groups. Different studies reports different percentages of child and adolescent sexual assault. For example its reported that % 43 of 766 cases of sexual assault were under 18 age in a study of Michigan State University (Jones et al., 2003). Its mentioned that 178 of 405 victims were adolescent in another research (Peipert, Domagalski, 1994). Teenagers 16-19 are reported to be victims of rape or sexual assault more than twice as likely as any other age group in USA. (Gursoy, Vural, 2003). Most of the sexual assault victims (78.72%) were less than 18 years of age, in our series. % 55.13 of the patients which are included to our study were in 16-18 years period. Children and especially adolescent females are sexually assaulted more frequent comparatively to adults in our region. A review of the literature showed that, 3-9% of males were sexually abused in childhood. Furthermore, 78% of rape victims had a previous sexual assault history in childhood and adolescence (Ledoux, Hazelwood, 1995). A study by Frank MW et al. reported the frequency of sexual harassment among high school girls as 49% (Frank et al., 1999). In a study dealing with adult age group 59% of females were sexually assaulted in adulthood, while 61% of males victimized in childhood (Pelin, 1999). Out of 1395 females 8% had sexually abused in childhood, in a review of cases examined in a gynecology department (Alkan et al., 2002). In the present study, out of all cases (n:162) referred to our department, 141 (87.03%) were less than 18 years of age. This finding might show special interest given to child cases by legal authorities and parents. Voluntary sexual activity is accepted as criminal issue by Turkish law, as a consequence most of (54.54%) cases, referred for clinical and forensic investigation was aged between 16 and 18 years and had a voluntary sexual activity, in our series. Complaint of families was the main cause of starting legal process in these cases. Sexual intercourse with a person between the age of 15 and 18 was also 552

European Journal of Social Sciences Volume 13, Number 4 (2010) accepted as a criminal issue for individuals five years older than victim, according to Turkish Penal Code which is valid in 2005. However this paragraph was cancelled later on by constitution court, because of another article that enables marriage of 16-17 years old adolescents by the permission of family. A number of studies have stated that, victims of sexual assault are generally do not disclose the assault. However, most of victims applied to legal authorities disclose the assault because of secondary psychiatric problems and fear, and 55.6% of these had noticed to be assaulted many years before reporting (Safran, 1998, Jones et al., 2003). Similarly, 76.92% of cases referred to our department later than three days after assault, in this study. The main cause of delay in cases was the decision of victims as they were voluntary. Furthermore, 19.23% of cases explained the cause of delay as, they were anxious about being accused or punished, which support the idea of victims might conceal the assault because of the fear of being accused, punished or injured by perpetrators. Interestingly, delay in legal process caused delayed clinical examination in 6.41% in our series, despite the necessity of early and complete examination of such cases. Yet, there is no national sexual assault prevention program nor is there sexual assault crisis center which provides early clinical evaluation and could give bio-psychosocial support to the victims, in Turkey. Most often, sexual assault victims are assaulted by an acquaintance. A number of studies revealed the percentages of acquaintance assailants as changing from 56% to 78% (Dube, Hebert, 1988, Peipert, Domagalski, 1994, Muram et al., 1995, Lauritsen, Christian et al., 2000, Meldgaard, 2000, Grossin et al., 2003, Csorba et al., 2005, Sahu et al., 2005) This value was considerably higher (94.8%) than literature (Table III). Three out of four cases which assaulted by strangers were aged between 7 and 12 years. This finding might be connected with characteristics of these age groups such as physically weakness, low comprehension about the abusive acts. The assailants home was the most frequent place of sexual assault in 31 (39.74 %) of the cases. Sexual assault occurred outdoors only 18 (23.08 %) of the cases (TableIV). This situation is wellknown characteristic of child sexual assault and our indoor-outdoor ratios are concordant with other studies (Nduati, Muita, 1992, Sahu et al., 2005, Csorba et al., 2006). But approximately 50% of all sexual assaults occur in victims home (Carlstedt et al., 2001). On the contrary, the place of assault was victims home in 12.99% of cases, which may be a consequence of case sample, in our series. Different studies repot various percentages of genital injuries depend on time of examination after assault. Hymenal and/or perineal tears was found in 14 cases among 27 child female victim in Cameroon (Koki Ndombo et al., 1992) and 14 genital injury was found in 14 cases among 21 children mostly examined within two days after assault in Kenya (Nduati, Muita, 1992). Percentage of anogenital injuries was reported 84%, and average interval of medical evaluation after assault is 17 hours in a study of Michigan State University (Jones et al., 2003). Some form of forensic evidence was identified in 24.9% of children, all of whom were examined within 44 hours and over 90% of children with positive forensic evidence findings were seen within 24 hours of their assault, presence of genital injury was %23 and in another child sexual assault series (Christian et al., 2000). It is reported that only 1 traumatic lesion with rupture of hymen, and in 13 nonspecific findings were seen in 34 sexually abused child in Denmark yet most of these were examined at least one week after assault (Lauritsen, Meldgaard, 2000). We detect genital injuries in 31 (39.74%) cases, yet 8 of these detected to be in acute period (fresh injury), and 5 had additional physical violence findings, in the present study. There were no traumatic changes in 22 cases despite history of alleged physical trauma. Eighteen (23.08%) of the cases were referred for clinical examination within the first 3 days of sexual assault, while 60 (76.92%) of all referred after the first 3 days of assault in our series (Table II). These findings clearly show the importance of early clinical examination in determining genital or non-genital traumatic changes.

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Conclusion
The majority of cases were determined to be young female adults, aged between 16 to 18 years, which had a voluntary sexual activity. The legal issue in these cases was complaint of families of cases to the public prosecutor. In this respect, in our country law should be more tolerant to voluntary sexual activity of close aged individuals. In addition, sexual assault crisis centers which provide early clinical evaluation and could give bio-psycho-social support to the victims should be set up, legal procedure steps must be reduced and shortened.

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