Child Abuse & Neglect 84 (2018) 1–10

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Child Abuse & Neglect

journal homepage: www.elsevier.com/locate/chiabuneg

Research article

A longitudinal perspective on boys as victims of childhood sexual

T
abuse in South Africa: Consequences for adult mental health
⁎
Linda M. Richtera, , Shanaaz Mathewsb, Engelbert Nonteraha, LeeAnne Masilelaa
a
DST-NRF Centre of Excellence in Human Development, First Floor East Wing, School of Public Health, Education Campus, York Road, University of
the Witwatersrand, Johannesburg, 2193, South Africa
b
The Children’s Institute, University of Cape Town, University of Cape Town, 46 Sawkins Road, Rondebosch, 7700, South Africa

A R T IC LE I N F O ABS TRA CT

Keywords: Childhood sexual abuse of boys was examined in a longitudinal cohort in South Africa, with data
Child abuse on abuse collected at six age points between 11 and 18 years. Potential personal and social
Males vulnerability of male sexual abuse victims was explored and mental health outcomes of sexually
Mental health abused boys were examined at age 22–23 years. Reports of all sexual activity – touching, oral and
Longitudinal
penetrative sex – increased with age and sexual coercion decreased with age. Almost all sexual
South Africa
activity at 11 years of age was coerced, with the highest rates of coercion occurring between 13
and14 years of age; 45% of reports of coerced touching were reported at age 14, 41 percent of
coerced oral sex at age 13, and 31% of coerced penetrative sex at age 14. Sexual coercion was
perpetrated most frequently by similar aged peers, and although gender of the assailant was less
often reported, it can be presumed that perpetration is by males. Boys who experienced child-
hood sexual abuse tended to be smaller (shorter) and from poorer families. No relationships to
measured childhood intelligence, pubertal stage, marital status of mother or presence of the
father were found. There was no significant association between reports of childhood sexual
abuse and mental health in adulthood and when personal and social vulnerabilities were taken
into account.

A 10-year-old boy from Thabong, Welkom, whowas playing with friends in a dam on Sunday (29 January 2017) was raped by five
unknown men. Sergeant Mamello Mokhuoane said the boy and his friends were swimming when five men with dogs approached
them. The boy's friends ran away from the men, but the boy was stuck in mud and the men dragged him out of the water.
He was forced to hold on to a pole while the men raped him. After the rape he managed to flee and get help. The boy was then
taken to the Bongani Hospital where police were called. Five counts of rape are being investigated against the men. http://www.
news24.com/SouthAfrica/News/boy-10-raped-by-5-men-20170130.

1. Introduction

Child Sexual Abuse (CSA) is formally defined by the World Health Organization as “the involvement of a child in sexual activity
that he or she does not fully comprehend and to which a child is unable to give informed consent, or for which the child is not
developmentally prepared, or else that violates the laws or social taboos of society” (2003). It includes, among others, attempted and

⁎
Corresponding author at: Room 154 c, 1st Floor, School of Public Health, York Road, University of the Witwatersrand, Johannesburg, South
Africa.
E-mail address: linda.richter@wits.ac.za (L.M. Richter).

https://doi.org/10.1016/j.chiabu.2018.07.016
Received 20 September 2017; Received in revised form 6 July 2018; Accepted 11 July 2018
Available online 20 July 2018
0145-2134/ © 2018 Published by Elsevier Ltd.
L.M. Richter et al. Child Abuse & Neglect 84 (2018) 1–10

completed sex acts, sexual touching, non-contact harassment, exhibitionism and exposure to pornography (Murray, Nguyen, &
Cohen, 2014). In South Africa, any sexual contact and interaction with a child younger than 16 years of age is classified as sexual
abuse. Where consent is not given, any sexual contact and interaction with a child under the age of 18 is also considered sexual abuse
(Criminal Law (Sexual Offences and Related Matters) Amendment Act 5 of 2015).
Across the world, CSA is reported to occur more frequently among girls than boys (Stoltenborgh, van Ijzendoorn, Euser, &
Bakermans-Kranenburg, 2011). According to a global review of 55 studies from 24 countries, the prevalence of different forms of
sexual abuse – penetration, exhibitionism, inappropriate touching and so on - is estimated to be between 8–31 percent for girls and
3–17% for boys. Nine girls and three boys out of 100 are estimated to be victims of forced penetrative sex (Barth, Bermetz, Heim,
Trelle, & Tonia, 2013). That said, boys are sexually abused, more often than supposed (Hunter, 1990), and a small number of recent
studies have drawn attention to the sexual abuse of boys (Turner, Taillieu, Cheung, & Afifi, 2017).
It has been claimed that the sexual abuse of boys is “massively denied, misunderstood and trivialized” (Spiegel, 2013, p. vii), and
that boys suffer less serious consequences of sexual abuse than girls (Spiegel, 2013). However, there are inconsistent findings of
differences between males and females in the reported short and long-term negative effects of sexual abuse i.e. in deteriorating school
performance, depression, problems in social and sexual relationships, and potentially abusive adult behaviour (Briere & Elliott, 2003;
Cecil, Viding, Fearon, Glaser, & McCrory, 2017; Dube et al., 2005; Paolucci, Genuis, & Violato, 2001).
The sexual abuse of both male and female children has been reported on the African continent (Meursing et al., 1995). Though
few studies deal specifically with the sexual abuse of boys, several sub-Saharan African studies, nonetheless, describe relevant results.
In a stratified random sample, Andersson and Ho-Foster (2008) surveyed young people at secondary schools in South Africa, of
whom 126,696 were male. Among 18-year-old boys, 44 percent reported that they had been forced to have sex at some previous time,
and 9% of males aged 11–19 years reported experiencing forced sex in the last year. Perpetrators were indicated to be male in 32
percent of cases, 41 percent were female, and 27 percent of boys said they had been forced to have sex by both male and female
perpetrators. A national survey of 9 730 young people between 15 and 17 years of age in South Africa reported rates of sexual abuse,
around 20%, equivalent among males and females (Ward, Artz, Leoschut, Kassanjee, & Burton, 2018). Retrospectively reported
sexual abuse before the age of 12 years by 11 206, 18–32-year old men and women in Zimbabwe, Tanzania and an urban and rural
site in South Africa indicated that more men than women in Tanzania (4.2% and 2.1%, respectively) and comparable numbers in
Zimbabwe (4.5% and 4.4%) reported being sexually abused as children. In the urban area in South Africa, rates were higher among
women (4.9%, men 4.1%) as well as in the rural site, 2.4% and 1.6% among men (Richter et al., 2014). Lastly, contemporaneous
reports of voluntary and coerced penetrative sexual debut between 12 and 18 years of age were collected in a prospective long-term
birth cohort in South Africa. At all ages, more boys than girls self-reported sexual debut, both voluntary and coerced (Richter,
Mabaso, Ranjith, & Norris, 2015).
Most prevalence surveys of CSA depend on adolescent or adult retrospective reporting, and are subject to recall bias. On the other
hand, contemporaneously collected clinical and police records are likely to seriously under-represent child sexual abuse that is not
reported (Murray et al., 2014). For these reasons, it is very difficult to get accurate information (Goldman & Padayachi, 2000), even
more so with respect to boys because they are less likely to report CSA (Easton, 2013; O’Leary & Barber, 2008). Disclosure of sexual
abuse by boys and men is reported to be inhibited by shame, confusion about sexuality, fear of ridicule and of being labelled
homosexual (Paine & Hansen, 2002).
Although gender-based violence is reported to be more prevalent in poorer communities and families (Jewkes, 2002), socio-
economic status is not consistently associated with childhood sexual abuse, including in sub-Saharan Africa (Yahaya, De Leon,
Uthman, Soares, & Macassa, 2014). Gender and age differences in childhood sexual abuse are observed and in South Africa, Meinck,
Cluver, Boyes, and Loening-Voysey (2016) reported that younger children were more likely to report physical abuse and older
children more likely to report emotional and sexual abuse. To date, the most commonly identified risk factors for sexual abuse are in
the child’s immediate environment, including in the family (Fergusson, Lynskey, & Horwood, 1996), and in or on the way to and from
school (Reza et al., 2009).
Child sexual abuse is generally associated with psychological distress, although findings are less consistent among men (Easton,
2014). Sexual abuse commonly occurs with physical and emotional abuse, including among boys (Cecil et al., 2017; Turner et al.,
2017), and co-occurrence of abuse is reported to increase the likelihood of later mental health problems (Afifi et al., 2014; Easton &
Kong, 2017; Turner et al., 2017). Sexual abuse has long been associated with a power differential between the perpetrator and the
victim, whether emanating from gender, age, or other differences such as a mental ability (Reynaert, 2015; Sobsey & Doe, 1991). This
differential increases the helplessness of the abused individual (Bargh, Raymond, Pryor, & Strack, 1995) and, together with coercion,
fear and stigmatization, is hypothesized to be core to the traumatizing effects of childhood sexual abuse (Finkelhor & Browne, 1985).
Although there is growing recognition of the sexual abuse of boys as a serious problem with potentially debilitating consequences
(Romano & De Luca, 2001), it is clear that we know relatively little about it (Watkins & Bentovim, 1992), especially in low and
middle-income countries. In this paper, we take advantage of a large corpus of longitudinal data collected in the Birth to Twenty Plus
(Bt20+) study to examine the sexual abuse of boys at several points across the timespan of childhood and adolescence, reported
contemporaneously. This data overcomes several limitations of small samples of retrospectively recalled information collected at only
one point in time. We also report on three forms of sexual abuse: coerced touching, oral sex and penetrative sex. The goals of the
present paper are to describe the sexual abuse of boys over time in a large longitudinal urban community study in South Africa,
examine whether social and personal vulerabilties predict childhood sexual abuse between 13 and 18 years of age, and determine
whether childhood sexual abuse is associated with mental health outcomes at age 22 years, controlling for social and personal
vulnerabilities.

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L.M. Richter et al. Child Abuse & Neglect 84 (2018) 1–10

2. Method

Bt20+ is a longitudinal study of singleton children born in 1990 in the greater Johannesburg-Soweto metropolitan area, South
Africa, within a 7-week period (23 April – 8 June 1990), whose mothers were planning to reside in the Greater Johannesburg
Metropolitan area for at least the first six months of the child’s life. Pregnant women estimated to deliver within a specified period
were recruited through public health antenatal facilities, and 3 273 singleton children and their families were enrolled. At the time of
this analysis, about 2000 participants had been assessed 21 times over the course of the study. The enrolment methods, attrition, and
profile of the Bt20+ cohort are documented in detail elsewhere (Richter, Norris, Pettifor, Yach, & Cameron, 2007). Attrition, assessed
at age 16 years, was 28% (Norris, Richter, & Fleetwood, 2007), and has remained relatively stable since then. At the start, the cohort
was demographically representative of the study area with the majority of participants being Black African and comprising roughly
equal numbers of male and female children. Bt20+ is the largest and longest running study of child and adolescent health and
development in Africa and tracks exposures and outcomes in physical, educational, social and psychological domains (Richter et al.,
2007). Ethical approval for the study as a whole was obtained from the Human Research Ethics Committee of the University of the
Witwatersrand in Johannesburg (M010556), and individual rounds of data collection have ethical approval.

3. Sexual abuse

Questionnaires administered during consecutive data collection waves of the study were scrutinised for items relating to child
sexual abuse. Some of the material was collected through surveys to examine violence as a specific topic, for example, in data waves
at 15 and 18 years. Questions on sexual experiences were introduced by a screening question asking if the participant had or had not
experienced a particular form of sexual behaviour (touching, oral and penetrative sex) during the previous 6 months. If a child
answered in the affirmative, they were asked if this was something they wanted to participate in or not. The sexual activity was
classified as coercive if the respondent indicated that they had not wanted to participate in the activity. The types of sexual abuse and
the ages at which questions were asked about them are shown in Table 1.
Variables relating to sexual abuse between 11–18 years were categorized into three forms of sexual encounters – touching, oral
sex and penetrative sex, and into voluntary or coerced sexual encounters. When included in the questionnaire, the age differences
between sexual partners (voluntary or coerced) were identified and assigned to one of the following four categories: younger partner,
same aged partner, partner 1–4 years older, and partner ≥5 years older.

4. Potential social and personal vulnerabilities of boys to sexual abuse

In order to assess the role of power and powerlessness in the sexual abuse of boys, variables were identified that, on face value,
indicate potential social and personal vulnerability that may moderate or confound the relationship between CSA and mental health
(Turner et al., 2017).
Social vulnerability was defined using four variables indicating social and economic standing, assessed through questionnaires
administered to the mother when the child was 5 years old: marital status and education of the mother, presence of the father, and
socioeconomic status measured by a household asset score, the sum of a list of household goods such as a television, a refrigerator and
a telephone (Booysen, Van Der Berg, Burger, Von Maltitz, & Du Rand, 2008).
Personal vulnerability was defined as looking and acting younger and weaker than same-aged males. This was assessed using three
measures: height-for age z-score and pubertal stage using a validated self-rated pubertal Tanner rating (Norris & Richter, 2005), both
assessed at 13 years of age; together with a lower score on a test of general intelligence validated for South African children, the
Raven’s Coloured Progressive Matrices (Knoetze, Bass, & Steele, 2005), administered when children were 7 years of age.

5. Mental health in young adulthood

Mental health at age 22–23 years was measured using the General Health Questionnaire 28 (Goldberg & Hillier, 1979), which has
been used extensively in Africa (Sawyer, Ayers, & Smith, 2010) and in South Africa (de Kock, Görgens-Ekermans, & Dhladhla, 2014).
The GHQ-28 consists of 28 questions relating to general mental health, distributed among four sub-categories: somatic symptoms,
anxiety and insomnia, social dysfunction and severe depression. Scoring is from 0 to 3 (0= not at all; 1 = no more than usual; 2 =

Table 1
Examples of sexual abuse covered in questionnaires.
Age Examples of abuse covered in questionnaires

11, 13, 14, 15, 16, 18 years – during the last 6
months
15, 17–18 years – during the last 6 months
Coerced touching
Coerced oral sex
Coerced penetrative sex
Coercion was scored if the child answered NO to the question “was this something you wanted to do?”
Sexual harassment (including unwanted touching) by staff or student at school, by a family member at home
or by someone in the neighbourhood
Sexual attack by staff or student at school, by a family member at home or by someone in the neighbourhood

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L.M. Richter et al. Child Abuse & Neglect 84 (2018) 1–10

rather more than usual, and 3 = much more than usual), with scores ranging from 0 to 84. A total score of 23–24 using the Likert
scores is suggestive of mental health impairment (Goldberg et al., 1997). The internal consistency of the GHQ-28 was tested using
Cronbach’s alpha analysis. An alpha coefficient of 0.9013 was obtained for the correlation between all 28 items and values of 0.7649,
0.8541, 0.7608 and 0.8802 were obtained for the somatic, anxiety, social dysfunction depression subscales, respectively. The total
GHQ-28 score and the score for each sub-category were used to examine mental health outcomes of boys who did or did not report
childhood sexual abuse, controlling for personal and social vulnerability.

6. Statistical analysis

All analyses were performed using STATA version 13 (StataCorp, 2013). Demographic characteristics of the cohort are described
as frequencies and proportions for categorical variables, and continuous variables as medians and interquartile range (IQR) due to the
non-normal distribution of the data. Missing data are reported in the descriptive statistics. Proportions tests were used to compare
males who reported sexual abuse and those who did not, and to compare boys who reported coerced and voluntary sexual encounters.
Gender and age differences of the sexual partner of children for voluntary and coerced sexual activity (touching, oral and pe-
netrative sex) are reported in frequencies and proportions. Gender of partner was asked only at 13 and 16 years. Because of small
numbers, significance testing of this was not undertaken.
To determine potential social and personal vulnerability factors associated with sexual abuse, univariate and multivariate logistic
regression models were fitted. The outcome for the logistic regressions model is sexual abuse, scored as a composite binary variable
(touching, oral sex and anal sex) recorded as ‘1’ for all males who experienced sexual abuse at least once between age 11 and 18 years
and ‘0′ for males who did not report sexual abuse. The univariate models were computed to determine the independent associations
between sexual abuse and social and personal vulnerability factors. Variables to include in the multivariate analysis were chosen on
the basis of the theoretical plausibility of power relations playing a role in sexual abuse and in order to retain important confounding
variables regardless of their significance in the univariate analysis (Bursac, Gauss, Williams, & Hosmer, 2008; Julious & Mullee,
1994).
To determine the association between sexual abuse and mental health outcomes (GHQ-28 and subscales), univariate and mul-
tivariate linear regression models were fitted using mental health outcomes as the dependent variable. Two models were fitted; the
first includes sexual abuse as a composite binary variable consisting of all forms of sexual abuse, and the second included only
coerced penetrative sex as a binary variable. The social and personal vulnerability factors described earlier were adjusted for in the
multiple linear regression analysis in order to investigate whether these factors moderate orconfound the relationship between CSA
and mental health. An interactive selection method, which entailed a backward elimination process based on the Wald test, was used
to reduce the social and personal vulnerability factors to those that can account for most of the variance in the mental health
outcomes. In these models, non-significant predictors were removed one at a time, starting with the factor that had the largest p-
value, until all remaining factors had a two-sided p-value of less than 0.20 (Derksen and Keselman (1992). For interpretation of the
results, an association was deemed significant at the 5% significance level. For the inferential statistics, analysis was restricted to
individuals with complete data on all variables required for the analysis (Vandenbroucke et al. (2007).

7. Results

Characteristics of boys at enrolment into Bt20+ in 1990 and at indicated ages for particular measures are shown in Table 2. The
demographics of a small proportion of the sample change over the long time scale under consideration, for example, the marital
status of a few mothers, but this detail is not included here.

8. Sexual abuse

Table 3 shows sexual abuse among boys 11–18 years of age. Close to 5% of 11 year-old boys reported sexual abuse, increasing to a
high of 37.7% at 14 years of age.

9. Voluntary and coerced sexual touching, oral sex and penetrative sex

Table 4 shows the proportion of boys who experienced voluntary and coerced sexual touching, oral sex and penetrative sex
between 11 and 18 years of age.
Table 4 indicates that all reported forms of sexual activity increased with age, while reports of coercion decreased after age 14
years. However, at 11 years of age almost all reported sexual activity was coerced, and about a third of all forms of sexual activity up
to age 16 years was reported to be coerced. Even at 18 years of age, 17.2% of boys reported coerced oral sex, 6.7 percent coerced
touching, and 5.4% coerced penetrative sex.

10. Reported age and gender differences between young people and their sexual partners

Amongst sexual experiences that were reported to be coerced rather than voluntary, most partners were reported to be within a 4-
year age difference of the informant, with the exception of 2 of 8 14-year-old boys who reported being coerced into oral sex by older
individuals, and 1 of 19 boys at 15 years; as well as 1 of 24 boys who reported being coerced into penetrative sex at 14 years of age by

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L.M. Richter et al. Child Abuse & Neglect 84 (2018) 1–10

Table 2
Characteristics of boys in the Bt20 sample at enrolment and at indicated ages for individual measures (N = 829).
Demographic Characteristic n (%) Median (IQR)

Population group (n = 829)

White 48 (5.8) –
Black 711 (85.8) –
Colored 65 (7.8) –
Indian 5 (0.6) –
Maternal marital status (n = 779)
Single 426 (51.3) –
In a committed relationship 324 (39.1) –
Living together 19 (2.3) –
Married 10 (1.2) –
Maternal education status (n = 770)
No formal education 54 (7.0) –
Grades 5–7 93 (12.1) –
Grades 8–10 349 (45.3) –
Grades 10–12 226 (29.4) –
Post-school training 48 (60.2) –
Household asset index at 13 years (n = 756)
Low 316 (41.8) –
Middle 267 (35.3) –
High 173 (22.9) –
Presence of father at 13 years (n = 776)
Minimal or no contact 312 (38.8) –
Father present 464 (57.7) –
Pubertal stage (Tanner self-rating) at 13 years (n = 736)
Pubertal 48 (5.8) –
Pre-pubertal 137 (17.0) –
Early puberty 491 (61.1) –
Late pubertal 60 (7.6) –
Height-for-age at 13 years (n = 827)
Stunted 296 (35.7) –
Normal 530 (64.1) –
Tall 1 (0.1) –
Raven’s Coloured Progressive Matrices at 7 years (n = 705) – 16.57 (0–37.36)
GHQ Total score (n = 811) 16 (6-20)

Table 3
Reported sexual abuse among boys.
Age in years Sexual abuse

Total No Yes Did not report a sexual experience during the previous 6 months
n (%) n (%)

11 505 481 (95.3) 24 (4.8) 324 (39.1)

13 129 108 (83.7) 21 (16.3) 700 (84.4)
14 167 104 (62.3) 63 (37.7) 662 (79.9)
15 310 247 (79.7) 63 (20.3) 519 (62.6)
16 321 238 (74.1) 83 (25.9) 508 (61.2)
18 450 319 (70.9) 131 (29.1) 379 (45.7)

Table 4
Proportion of boys who experienced sexual touching, oral sex and penetrative sex between 11 and 18 years of age (coerced or voluntary).
Age in Foreplay Oral Penetrative
years
Total Voluntary Coerced p-value Total Voluntary Coerced p-value Total Voluntary Coerced p-value
engaged n (%) engaged n (%) n (%) engaged n (%) n (%)
n (%) n (%) n (%)

11 15 (2.9) 3 (20.0) 9 (60) 0.025 – – – – 11 (2.2) 2 (18.2) 9 (81.8) 0.003

13 88 (20.2) 45 (51.1) 21 (23.9) < 0.001 27 (18.5) 15 (55.6) 11 (40.7) 0.276 27 (18.5) 12 (44.4) 8 (29.6) 0.260
14 158 (41.9) 78 (49.4) 71 (44.9) 0.430 31 (8.6) 17 (54.8) 8 (25.8) 0.098 79 (21.2) 50 (63.3) 24 (30.4) < 0.001
15 282 (53.4) 194 (68.8) 79 (28.0) < 0.001 87 (18.0) 48 (55.2) 19 (21.8) < 0.001 157 (31.5) 115 (73.2) 25 (15.9) < 0.001
16 267 (49.6) 189 (70.8) 71 (26.6) < 0.001 76 (15.8) 47 (61.8) 25 (32.9) < 0.001 193 (6.9) 143 (74.1) 47 (24.4) < 0.001
18 432 (71.6) 139 (32.2) 29 (6.7) < 0.001 169 (28.3) 139 (82.2) 29 (17.2) < 0.001 405 (67.3) 128 (31.6) 22 (5.4) < 0.001

Note. Not all boys who indicated that they had engaged in a particular form of sexual activity indicated whether it was voluntary or coerced.

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Table 5
Univariate logistic regression model for social and personal vulnerability factors associated with sexual violence perpetrated on boys, 11–18 years.
Vulnerability No Yes OR (95% CI) p-value
n (%) n (%)

Height
Stunted (n = 232) 192 (35.0) 62 (32.5) 0.90 (0.63 - 1.28) 0.558
Normal / tall (n = 446) 357 (65.0) 129 (67.5) 1 1
Puberty
Pre-pubertal (n = 104) 80 (16.1) 40 (23.0) 1.38 (0.89–1.88) 0.150
Early puberty (n = 409) 330 (66.4) 120 (69.0) 1 1
Late puberty (n = 49) 39 (7.9) 14 (8.1) 0.99 (0.52–1.88) 0.969
Ravens Coloured Progressive Matrices at 7 years, median (IQR) 16.8 (12.9 – 21.7) 16.2 (14.1 – 20.5) 1.02 (0.99–1.05) 0.131
Marital status
Single (n = 352) 238 (54.2) 114 (56.7) 1 1
In a committed relationship/living together/married (n = 278) 201 (45.8) 77 (40.3) 0.82 (0.59–1.15) 0.259
Maternal education
No formal education (n = 54) 53 (10.4) 1 (0.6) 0.05 (0.01–0.37) 0.003
Grade 5–7 (n = 72) 49 (9.7) 30 (16.9) 1.64 (0.98–2.76) 0.061
Grade 8–10 (n = 286) 228 (44.9) 85 (47.8) 1 1
Grade 11–12 (n = 181) 145 (28.5) 54 (30.3) 1.00 (0.67–1.49) 0.996
Post school training (n = 38) 33 (6.5) 8 (4.5) 0.65 (0.45–1.46) 0.299
Fathers presence
Minimal/no contact (n = 224) 190 (41.6) 52 (31.9) 0.66 (0.45–0.96) 0.030
father present (n = 346) 267 (58.4) 111 (68.1) 1 1
Household asset index
Bottom tertile (n = 257) 191 (34.8) 94 (48.7) 1 1
Middle tertile (n = 226) 184 (33.5) 63 (32.6) 0.70 (0.48–1.02) 0.060
Highest tertile (n = 149) 126 (23.0) 36 (18.7) 0.58 (0.37–0.91) 0.017

an older partner.
A question regarding the gender of the abuser/coercive partner was only asked at age 16 years. Among boys, most coercive
partners were other males, although a small number of boys reported coercion into sexual experiences by girls.

11. Personal and social vulnerability

In the univariate analysis (Table 5), boys whose mothers had only primary education (< grade 8–10) were less likely to ex-
perience childhood sexual abuse than boys whose mothers indicated having completed junior secondary schooling (grade 8–10).
Males who had minimal or no contact with their father were less likely to experience CSA in comparison to boys whose fathers were
present. Boys with a household asset index in the highest tertile were less likely to experience CSA in comparison to boys with a
household asset index in the lowest tertile. In the multivariate analysis, stunted males were twice as likely to experience CSA in
comparison to males of normal or taller height. The other vulnerabilities were tested but not found to be significant, as shown in
Table 6
Table 6 shows the results of the multivariate logistic regression analysis for the association between personal and social vul-
nerabilities and a composite measure of all forms of sexual abuse at all ages, adjusting for each type of vulnerability.

12. Mental health outcomes at age 22–23 years

Table 7 shows the GHQ 28 total and subscale scores, assessed at 22–23 years of age, of young men who reported experiencing
sexual abuse in childhood, compared to those who did not report abuse.
Table 7 shows the association between mental health outcomes at 22–23 years and a composite measure of child sexual abuse
(coerced touching, oral sex and penetrative sex at any age). The univariate analysis results show boys who were sexually abuse had
higher GHQ total scores and significantly lower somatic subscale scores. However, there was no significant association between
sexual abuse and mental health outcomes at 22–23 years when adjusted for social and personal vulnerabilities. There was also no
association between penetrative sex, examined separately from other forms of sexual abuse and mental health at 22–23 years,
adjusted for personal and social vulnerabilities (results not shown).

13. Discussion

From longitudinal data collected prospectively at a number of points during childhood, from 11 to 8 years, this paper examined
three forms of sexual abuse amongst boys: coerced touching, oral sex and penetrative sex. We classified as child sexual abuse all
sexual experiences which the respondent said were unwanted. We explored personal and social factors that may render boys vul-
nerable to sexual abuse because they enable power to be exerted over them by others, and we assessed the mental health of young
men at age 22–23 years of age, comparing those who reported sexual abuse during childhood with those who did not report being

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Table 6
Multivariate logistic regression model for social and personal vulnerability factors associated with a composite measure of
sexual abuse of boys 11–18 years.
Vulnerability OR (95% CI) p-value

Height
Stunted (n = 232) 2.16 (1.06–4.41) 0.034
Normal/tall (n = 446) 1 1
Puberty
Pre-pubertal (n = 104) 1.55 (0.79–3.05) 0.203
Early puberty (n = 409) 1 1
Late puberty (n = 49) 1.80 (0.73– 4.46) 0.203
Ravens Coloured Progressive Matrices at 7 years 0.96 (0.91– 1.01) 0.139
Marital status
Single (n = 352) 1 1
In a committed 0.65 (0.38– 1.11) 0.114
relationship/living
together/married (n = 278)
Maternal education
Grade 5-7 (n = 126) 1.64 (0.73– 3.69) 0.231
Grade 8-10 (n = 286) 1 1
Grade 11-12 (n = 181) 0.90 (0.48–1.67) 0.734
Post school training (n = 38) 0.85 (0.26–2.84) 0.794
Fathers presence
Minimal/no contact (n = 224) 0.68 (0.39– 1.21) 0.189
Father present (n = 346) 1 1
Household asset index
Bottom tertile (n = 257) 1 1
Middle tertile (n = 226) 0.67 (0.37– 1.21) 0.183
Top tertile (n = 149) 0.77 (0.35– 1.68) 0.511

Table 7
Univariate and multivariate linear regression analysis to determine the association between a composite measure of childhood sexual abuse and
mental health outcomes at age 22 years.
Univariate analysis Multivariate analysis

Unadjusted coef (95% CI) p-value Unadjusted coef (95% CI) p-value

GHQ total Sexual abuse

No (n = 537) 1 1 1 1
Yes (n = 190) 1.97 (0.13–3.80) 0.036 1.50 (−0.87–3.86) 0.214
Somatic Sexual abuse
No (n = 547) 1 1 1 1
Yes (n = 193) 0.81 (0.21–1.40) 0.008 0.05 (−0.32– 1.22) 0.253
Anxiety Sexual abuse
No (n = 544) 1 1 1 1
Yes (n = 192) 0.29 (−0.44– 1.03) 0.433 0.35 (−0.65– 1.35) 0.491
Dysfunction Sexual abuse
No (n = 545) 1 1 1 1
Yes (n = 191) 0.39 (−0.17– 0.94) 0.174 0.60 (−0.14– 1.34) 0.109
Depression Sexual abuse
No (n = 548) 1 1 1 1
Yes (n = 193) 0.46 (−0.05–0.98) 0.082 0.10 (−0.60– 0.80) 0.786

sexually abused.
Sexual abuse was reported by 5% of boys at 11 years of age. By age 13 and rising to 18 years, between 16 and 29% of boys
reported sexual abuse, either in the form of unwanted touching or coerced oral or penetrative sex. As expected, all sexual activity
among boys increases with age (Wiederman, 1997), but at 11 years of age, almost all reported touching and penetrative sex was
coerced. Coerced touching, oral and penetrative sex remained high throughout the adolescent years, comprising roughly a third of all
sexual encounters.
Importantly, the majority of coerced acts, of all kinds, up to the age of 18 years, reported in this study, are perpetrated by same-
age contemporaries. Similarly, Meinck et al. (2016) reported that 31% of sexually abusive acts in South Africa were perpetrated by
peers, and Finkelhor, Shattuck, Turner, and Hamby (2014) found that over half of the total offences they examined were perpetrated
by peers. In the original Finkelhor estimates, it was reported that 1 in 4 girls and 1 in 20 boys had experienced sexual abuse during
their childhood years. When restricted to adult abusers, the estimates changed to 1 in 9 girls and 1 in 53 boys, indicating the high
rates of peer abuse. As a consequence of their finding, Finkelhor et al. (2014) recommended that, alongside the total rate of abuse,
researchers should also separately report the rates of abuse perpetrated by adults and peers.

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L.M. Richter et al. Child Abuse & Neglect 84 (2018) 1–10

It was hypothesized that power relations play a role in childhood sexual abuse. We found some indications that boys who are
sexually abused are both personally and socially more vulnerable than their non-abused peers. Controlling for each type of vul-
nerability, we found that smaller boys, as indicated by their lower height compared to peers, were twice as likely to be abused than
taller boys. Intelligence, at least as measured at 7 years of age, did not appear to make boys more vulnerable, when other factors are
considered. Of the social factors, the education of a mother was associated in the unadjusted analysis with abuse, with sons of less
educated mothers being less vulnerable to abuse than educated mothers, possibly because they were more likely to be at home than
working outside the home. Similarly, without adjustment, household wealth was also found to be significantly associated with CSA,
with males from higher wealth tertiles being less likely to be abused in comparison to poorer males, and males whose fathers were
absent were also less likely to be abused. These findings are in contrast to those of Holmes and Slap (1998), who found that boys at
highest risk were not living with their fathers, however Homes and Slap did find that males who were at highest risk were of lower
socioeconomic status which correlates with our study findings.
Sexual abuse is perpetrated not only by adults, or significantly older individuals. In this study the vast majority of sexual abuse
was perpetrated by peers within a 4-year age range of the child who reported the abuse. Neither is sexual abuse limited to penetrative
sex. Sexual abuse takes many forms, including unwanted touching and oral sex. More attention needs to be given in schools and
communities to prevent same-aged sexual abuse through school policies, life skills programmes in schools, awareness programmes
through community organizations, and through services which encourage disclosure and prosecution of offenders, as well as support
and assistance to prevent re-occurrence and mental health problems in young adulthood.
What we don’t know is whether any of the reported sexually abusive acts were committed by a single individual or by more than
one person. That is, whether the sexual abuse of boys is committed by individual bullies or by gangs of adolescent or older males who
victimize a more vulnerable boy. We also do not know if physical force was used, an important determinant of mental distress in a
study in the United States (Easton, 2014). Both require further exploration, especially in the South African context where very high
rates of bullying and physical violence are reported (Andersson & Ho-Foster, 2008; Townsend, Flisher, Chikobvu, Lombard, & King,
2008; Ward et al., 2018).
In adulthood, in adjusted analysis, men who reported sexual abuse as children, scored higher on an overall measure of psy-
chological distress, as well as higher on Anxiety and Depression sub-scales than their peers who did not report childhood abuse. These
findings support study results of significant associations between the experience of sexual abuse in childhood by boys and their later
mental health (Easton, 2014). However, these associations do not remain significant when social and personal vulnerabilities are
taken into account in multivariate analysis.
Several factors could account for the finding in this study that mental distress is not significantly associated with child abuse when
childhood personal and social vulnerabilities are taken into account. While the GHQ-28 is a robust measure and has demonstrated
applicability across a wide range of cultural contexts, including in South Africa (de Kock et al., 2014; Mendenhall, Richter, Stein, &
Norris, 2013), it may underestimate the psychological effects of the childhood sexual abuse of boys assessed in adulthood. This is
because the GHQ-28 does not assess acting out behaviour and aggression. It has been suggested that the sequelae of childhood sexual
abuse of boys is manifest in externalizing behavior, including becoming a perpetrator of violence and sexual acts against others (Davis
et al., 2015).
It is also possible that childhood vulnerabilities, in addition to childhood sexual abuse, contribute substantially to mental health
outcomes in adulthood,. For example, Easton (2014) found associations between childhood sexual abuse and adult mental distress
were stronger when physical force was used, and Turner et al. (2017) report that child sexual abuse that co-occurred with other forms
of abuse increased the odds of mental distress in adulthood. The severity or force of the abuse and the extent of the trauma ex-
perienced were not assessed in the current study, though it is clear that poverty and other social and personal factors are important in
how children are affected comparatively by abuse.
Other limitations include the fact that we used a binary measure of all forms of sexual abuse to predict mental distress in
adulthood. However, a binary measure that included only forced penetrative sex, which may be associated with more trauma than
forced touching, was also not significantly associated with mental health outcomes. We also did not measure all sexual experiences
during adolescence as questions were limited to a recall period of 6 months prior to the interview, and events in longer intervals
between data collection waves would have been excluded.
It is known that boys are reluctant to divulge childhood sexual abuse (Easton, Saltzman, & Willis, 2014), and that an unknown
proportion of sexual abuse within the 6-month recall periods may not have been reported. Information on the gender of the abuser or
circumstances of the abuse was not collected at all ages, and abuse reported at one age was also not distinguishable as a repeat report
from an earlier age or a new report. We were thus unable to distinguish which abuse was repeated or chronic. For this reason, each
age at which sexual activity and abuse was reported, was treated as independent of all other ages at which reports were made. We
also did not enquire whether physical force was used, and childhood sexual experiences were only recorded as abuse if they were self-
reported to be coercive. Thus sexual experiences with older individuals and adults were not recorded as abuse if they were reported to
be voluntary, though the numbers of sexual experiences with older individuals in this study were very small.
The strengths of the study include information on sexual abuse being collected from males at several points across childhood, the
attempt was to test the power-differential hypothesis of sexual abuse being associated with childhood social and personal vulner-
ability, and the follow up of mental health sequelae into young adulthood in a low- to middle-income country in the global south.

14. Conclusion

“Not long ago, the sexual abuse of boys was considered a rare or even non-existent public health problem” (Easton, 2014, p. 243).

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L.M. Richter et al. Child Abuse & Neglect 84 (2018) 1–10

This perception has changed substantially in recent years, and international studies lead to an estimate of 5–10% of boys being
sexually abused in childhood (Butchart et al., 2006). Findings from a longitudinal study across several points in childhood indicate
that, in this South African sample, boys experience high levels of sexual abuse. Roughly a third of boys report being subject to
unwanted touching and/or coerced oral and penetrative sex. Boys who are sexually abused tend to be smaller and shorter for their
age than boys who do not report abuse, with some indications of being more socially and personally vulnerable. Their abusers are
generally same-aged males who coerce them mainly into unwanted sexual touching and oral sex.
In the context of the high prevalence of childhood sexual abuse among boys, childhood sexual abuse was found to be associated
with mental distress in adulthood, especially in respect of anxiety and depression. However, these associations fell away when
considered in the context of a range of other social and personal vulnerabilities in childhood. Much remains to be explored in this
sample, including the role of normative masculine values and the use of violence during sexual coercion, and how such values affect
psychological distress following childhood sexual abuse, as well as unmeasured outcomes in the form of violence and acting out,
inclusive of the sexual abuse of others.
Many studies in sub-Saharan Africa draw attention to the high rates of gender-based violence perpetrated by men (Jewkes et al.,
2006). In contrast, the high prevalence of the sexual abuse of boys is not yet as well-recognized, despite evidence becoming clearer of
a link between the experience of sexual violence by boys in childhood, mental distress in adulthood and later perpetration of sexual
aggression (Espelage, Basile, & Hamburger, 2012; Widom, Czaja, & Dutton, 2014). Prevention of the abuse of boys, including their
childhood sexual abuse, has to be integral to all efforts to reduce gender-based and inter-personal violence, especially in countries like
South Africa with very high rates of violence.

Funding

The Birth to Twenty Plus study has been funded by the Wellcome Trust (UK). This paper was supported by a grant from the
European Union [EuropeAid/134258/M/ACT/ZA PSPPD2/CfP2/2014/15/3], through the Programme to Support Pro-Poor
Development (PSPPD) in South Africa.

Acknowledgements

The Birth to Twenty Plus study has been funded by the Wellcome Trust (UK). This paper was supported by a grant from the
European Union, EuropeAid/134258/M/ACT/ZA PSPPD2/CfP2/2014/15/3, through the Programme to Support Pro-Poor
Development (PSPPD) in South Africa.
The assistance of Dr Sahba Besharati is gratefully acknowledged.

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