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Rev. Saúde Pública vol.43 n.3 São Paulo May./Jun. 2009
Fatores de abuso sexual na infância e adolescência de estudantes de Morelos, México
Ruben Chavez AyalaI; Leonor Rivera-RiveraI; Angélica Angeles-LlerenasI; Eva Díaz-CerónII; Betania Allen-LeighI; Eduardo Lazcano PonceI
Nacional de Salud Pública. Cuernavaca, Morelos, México
IIHospital 5 de Diciembre. Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado. Mexicali, Baja California, México
To estimate the prevalence and factors associated with sexual abuse in childhood
METHODS: Study conducted in a sample of students in the state of Morelos, Mexico, in 2004-2005. Participants (n=1730) were drawn from a cohort of 13,293 students aged 12 to 24 years. Data were collected by means of a questionnaire comprising parts of validated scales. The variables studied were: sociodemographic (gender, living area, socioeconomic status), family (parental education, parental addictions, violence between parents), individual psychological factors (self-esteem assessed using the Coopersmith Self-Esteem Inventory, depression, alcohol consumption), intrafamily violence (assessed through Strauss Scale) and sexual abuse. Multiple logistic regression assessed the risk factors associated. Odds ratios (OR) with 95% confidence intervals were estimated.
RESULTS: Of all students studied, 4.7% (n=80) reported attempted sexual abuse and 2.9% (n=50) were victims of consummated sexual abuse. Women had higher prevalence of attempted (6.1%) abuse; 3.6% of females and 1.9% of men were sexually abused. Main perpetrators were boyfriends in women and a stranger in men. Mean age was 12.02 years old among females and 11.71 years old among men. Factors found to be associated with abuse: high parental alcohol consumption (OR = 3.37, 95% CI 1.40;8.07), violence toward the mother (OR = 4.49, 95% CI 1.54;13.10), female gender (OR = 2.47, 95% CI 1.17;5.24), being a victim of great domestic violence (OR = 3.58, 95% CI 1.32;9.67). High self-esteem was a protective factor (OR = 0.27, 95% CI 0.09;0.75).
CONCLUSIONS: Overall sexual abuse occurs at the age of 12 in both males and females, and it is more frequent among females. Most victims do not report abuse.
Descriptors: Child. Adolescent. Child Abuse, Sexual. Sexual Violence. Socioeconomic Factors. Health Vulnerability. Gender and Health.
Estimar a prevalência e fatores associados ao abuso sexual infantil e
MÉTODOS: Estudo realizado em amostra de estudantes do estado de Morelos, México, entre 2004 e 2005. Os participantes (n=1730) pertencem a uma coorte de 13.293 estudantes de 12 a 24 anos. Os dados foram coletados por meio de questionário formado por partes de escalas validadas. As variáveis analisadas foram: fatores sociodemográficos (sexo, zona de residência, nível socioeconômico); familiares (educação dos pais, vícios dos pai, violência entre pais); psicológicos individuais (autoestima- Inventario de Autoestima de Coopersmith, depressão, consumo de álcool); violência intrafamiliar (Escala de Strauss); e abuso sexual. As variáveis dependentes analisadas foram a intenção e o abuso sexual consumado. Os fatores associados foram analisados por meio de regressão logística múltipla, com odds ratios e respectivos intervalos de 95% de confiança (IC 95%).
RESULTADOS: Do total, 4,7% (n=80) dos alunos reportaram terem sofrido intenção de abuso e 2,9% foram vítimas de abuso sexual consumado. As mulheres relataram maior prevalência de intenção (6,1%). Foram abusados sexualmente 3,6% das mulheres e 1,9% dos homens. O principal agressor das mulheres foi o namorado e dos homens, uma pessoa desconhecida. A idade do abuso foi de 12,02 anos para mulheres e 11,71 para os homens. Os fatores associados ao abuso foi o maior consumo de álcool pelos pais (RM = 3.37; IC 95% 1.40;8.07); violência contra a mãe (OR=4.49; IC 95%1.54;13.10); ser mulher (OR= 2.47; IC 95%1.17;5.24); ser vítima de violência intrafamiliar alta (OR=3.58; IC 95%1.32;9.67). Autoestima alta foi um fator protetor (RM=0.27; IC 95% 0.09;0.75).
CONCLUSÕES: A média de idade do abuso sexual foi de 12 anos em ambos os sexos, sendo mais freqüente entre as do sexo feminino. A maioria das vítimas não denuncia o abuso.
Descritores: Criança. Adolescente. Maus-Tratos Sexuais Infantis. Violência Sexual. Fatores Socioeconômicos. Vulnerabilidade em Saúde. Gênero e Saúde.
Sexual abuse in infancy is recognized as a risk factor associated with mental disturbances, such as depression, anxiety and personality and sexual disturbances, social phobia, addiction and physical suffering, including sexual infections, among others.5,21
In most cases, members of the family or people known to the victim are implicated, which is why cases of abuse are kept secret by the family and are consequently transmitted from generation to generation.18 It is estimated that between 2% and 59% of all children have been victims of this problem.20
In studies carried out with students in Mexico City, it was found that 7% of the women and 2% of the men had suffered some sexual abuse,8 which occurs, on average, between nine and 13 years old.17
Among family risk factors are alcohol abuse by the fathers9 and violence towards the mother.10 Individual factors include: being a female,6 having been victim of family violence and having low self-esteem.
The objective of this study was to estimate the prevalence of sexual abuse during childhood and adolescence and the factors associated with it.
The study involved a group of 13,293 students, between 12 and 24 years old, from the State of Morelos (México), who were randomly selected from 260 high schools, 92 preparatory schools and a university. Of this number only the 1,730 students who were still registered in the schools during the 2003-2004 school year took part. First, the lists of all the students in each school were obtained and all those who had taken part in the study previously were identified. They were invited to continue participating and, when the student was a minor, they were given informed consent and authorization letters for their parents to sign.
Subsequently, adjusting to the students' timetables and organizing them into small groups according to their availability, we carried out the survey using a self-administered questionnaire in 2004 and 2005. The procedure was carried out in each institution until all the students had been surveyed. The average time taken to complete the questionnaire was 40 minutes. Some 3% were questioned in their own homes because they were working or because they could not be located in the school for various reasons, such as temporary leave or pregnancy. The questionnaire the participants received had the following sections: sociodemographic, family and individual psychological factors, family violence and sexual abuse.
The socio-economic level was determined from the following variables: the floor covering of the dwelling where they lived, availability of running water in the home, infrastructure for disposing of sewage, number of people living in the dwelling, number of bedrooms and the educational level of the head of the household.
Among the family factors, the excessive consumption of alcohol by the father was determined by the following question: "Does your father drink alcohol?". To analyze alcohol consumption a three-category variable was constructed: 0 =never (only consumes it once a year), 1= low alcohol consumption, every two weeks to from twice to five times a year) and 2= higher alcohol consumption (every day and every week).
Violence towards the mother was measured with the question: 1. "Does your father beat your mother?".
The family violence index was constructed using 21 process-reactive dimensions from the Strauss Scale,22 which asked if any member of the family (mother/step-mother, father/step-father, brothers, uncles, grandparents) had committed any of the violent acts mentioned on a list, including: insults, physical threats, threats using various types of arm, blows with objects, shaking of the body, blows, intentional burning, attempts at strangling and wounding with arms.
A factor analysis was carried out using the principal components method, with varimax rotation of this scales, to obtain other factors. Factors 1 and 2 were non-severe acts of violence, such as insults, shaking and beating with objects. Factors 3 and 4 grouped together severe acts of violence, like threats of wounding with firearms, death threats, burning, attempts at strangling and wounds caused by arms. To construct the family violence index the process-reactive dimensions of Factors 1 and 2 were considered. To obtain a family violence variable in three categories, the 11 process-reactive dimensions corresponding to Factors 1 and 2 were added together and classified as no violence, moderate violence or excessive violence.
Self-esteem was measured using the Coopersmith Self-esteem Inventory. The factor analysis provided a prime factor (α = 0.84) called "negative self-esteem".
Wyatt & Russell's definition of sexual abuse in minors19,25 was used, the limitation being that the age of the aggressor was unknown. Attempted rape was considered to be an attempt at sexual abuse; and sexual abuse actually occurred was considered to be sexual violation carried out without consent on those under 18 years of age. These variables were measured by means of two questions: "Has anyone ever tried to force you to have sexual relations with them?" and "Has anyone ever obliged you to have sexual relations with them against your will?". Two response variables were then created: attempt at sexual abuse (when the person replied in the affirmative to the question on attempt and negatively to the question about whether the abuse actually occurred) and sexual abuse actually occurred (when the person replied in the affirmative to the question about sexual abuse had actually occurred, regardless of how they replied to the question on attempt).
A bivariate analysis was carried out on the independent variables, using the chi-square test proof for analyzing the association between attempt at sexual abuse and sexual abuse actually occurred. Multiple logistic regression analysis was used to control the possible confounding variables, adjusting it for socio-economic level, gender, family violence, self-esteem, violence towards the mother and excessive consumption of alcohol by the father. The analysis was carried out using the Stata version 8.0 statistical package.
The study followed the principles of the Helsinki Declaration and was approved by the Ethics Committee of the Instituto Nacional de Salud Pública.
Of the 1,730 participants, 1,045 (60.4%) students were female; 1,658 (96.1%) were aged between 16 and 24 years; 1,193 (68.8%) came from low to middle socio-economic levels and 589 (34.2%) lived in rural areas.
Table 1 shows the characteristics of the study variables by gender. There were significant differences in alcohol consumption by the fathers, violence against the mother and family violence (p<0.05). With regard to the socio-economic level, most of the students of both sexes belonged to the middle socio-economic level (male 58.5% and female 47.2%). With regard to the type of zone in which they lived 39.1% of the males and 41.0% of the females came from urban areas.
It was found that 4.7% (n=80) of the students had suffered an attempt at sexual abuse and 2.9% (n=50) were victims of sexual abuse that had actually occurred.
There was a higher prevalence of attempts at sexual abuse among females than males (6.1% and 2.6%, respectively). When comparing sexual abuse actually occurred by gender, 3.6% of the females had been victims, compared with 1.9% of the males.
No significant difference by gender in the average age at which both the attempt at sexual abuse was found, as well as sexual abuse actually occurred. In the case of females, the average age at which they experienced an attempt at sexual abuse was 11.85 (SD= 5.19), while for males it was 10.66 (SD= 4.50). With regard to the age at which sexual abuse was actually occurred in females this happened when they were 12.02 (SD= 6.10) and in males when they were 11.71 (SD= 5.60).
Figure 1 provides a description of the aggressors of attempts at sexual abuse. For females the main aggressor was a stranger (30.5%), followed by other unspecified people (20.2%), the boyfriend (19.6%), a neighbor and the uncle (13.7%) and the father, step-father and brother (3.2%). For male victims, the main aggressor was a stranger (37.0%), followed by neighbors (25%), other unspecified aggressors (18.5%), the girlfriend and uncle (11.1%), the aunt (3.7%) and father and step-father (2.4%). In both sexes there were cases of repeated attempts at sexual abuse. In females, the percentage was 11.5% and in males 14.3%.
Figure 2 shows the type of aggressor of sexual abuse actually occurred by gender. In females, the main aggressor was the boyfriend (37.8%), followed by other individuals (30.3%), among whom were the priest, cousin and teacher, followed by a stranger (16.2%), uncle (13.5%), neighbor (5.4%) and brother, father and step-father (2.7%). Sexual abuse by fathers and step-fathers was greater among males (15.4%) than females (2.7%). On the other hand, it was not only the father alone who was the sexual violator of the females, but also the uncle (13.5%) and brother in some cases (2.7%). Of the women in the home (mother, sister and aunts), only the aunt was found to be an abuser both in attempt (3.7%) as well as abuse actually occurred (7.7%), and this was exclusively against a male minor.
When asked about whether they had mentioned the sexual abuse they had experienced to someone else, only 32.7% had, of which 70.6% were female. A total of 15.4% of the people had asked for help (62.5% of whom were females). Only 1.9% of the victims of abuse actually occurred had reported it to the police; this was a 14 year old male.
Table 2 shows the prevalence of sexual abuse relative to the different study variables. There were significant differences between the prevalence of sexual abuse and violence towards the mother, family violence, gender and self-esteem (p <0.05).
Table 3 gives the results of the analysis of the multiple logistic regression, adjusted by socio-economic level, alcohol consumption by the father, violence towards the mother, gender, self-esteem and family violence.
Family factors associated with the attempt at sexual abuse and sexual abuse actually occurred were the consumption of alcohol by the father and violence towards the mother. The individual factors associated with sexual abuse actually occurred were gender, self-esteem and family violence.
Students with average to high self-esteem were less likely to be victims of sexual abuse than those with low self-esteem.
With regard to the family violence variable, Table 3 shows that students living with a small degree of family violence were more likely to suffer an attempt at sexual abuse and sexual abuse actually occurred than those [male and female] from families where there is no violence. The likelihood of becoming a victim increases when the students come from families where there was much violence.
The results of this study indicate a significant prevalence of cases of attempt at sexual abuse and sexual abuse actually occurred against students while they are still minors. The prevalence is similar to that reported by other investigations carried out in Mexico, like that of Ramos-Lira et al,17 with 4.3% of the students suffering from sexual abuse. In general terms, when comparing the results of this study with similar ones worldwide, the prevalence of sexual violence actually carried out against the population of Mexican students of both sexes whom we studied is less than in the majority of studies reviewed: in studies carried out in the United States the prevalence of sexual abuse was found to vary between 7.1%3 and 31%;4 in South Africa it was 5.9%;11 and in Costa Rica, 10.8% of the females and 6.4% of the males were victims.13
In our study, the problem was more frequent among females, thus corroborating other investigations.8 For example, in a survey carried out in Barbados, one in every three women and one in every two men reported sexual abuse.9 These findings may be related to a power imbalance in gender relations,12 with fewer males reporting abuse. The construction of male identity is defined by distancing oneself from homosexuality and femininity, so that reporting that one has been victim of sexual abuse is to announce that one has had an enforced homosexual experience.16
With regard to age, the range at which the abuse occurred is similar to other studies in Mexico,8 where it was found that 28.4% of all victims had suffered sexual abuse before they were ten and 40% between ten and 13.
When analyzing the type of aggressor, it was found that with regard to the attempt at sexual abuse in both sexes the aggressors were unknown to the victims. But when analyzing those who were the victims of sexual abuse actually occurred, both for males and females, the main aggressors did not come from the home, although with females the main aggressor was someone they knew (the boyfriend). In general, our findings differ from the results of other studies where, for both males and females, the main aggressors are known to them.17
In this study, various family and individual factors were found to be associated with sexual abuse. Within the family environment, those students who had fathers who consume alcohol had a higher possibility of being sexually abused. These results are consistent with other investigations7 that indicate that the risk of being sexually abused is five times greater in adolescents who have fathers who consume alcohol. Even so, in this study, the incidence of sexual abuse within the home committed by both parents was low, which is similar to other population studies.14
Another factor of the family environment associated with sexual abuse is the violence towards the mother. In this study, students who report violence against their mothers showed 4.49 times higher risk of them being the victims of sexual abuse. It was also found that family violence increases the probability of there being sexual abuse within the family, which is consistent with other investigations.15
On the other hand, having higher self-esteem is a protective factor against sexual abuse, which coincides with investigations carried out in various countries on the association between self-esteem, ways of facing up to it and their effects on the post-traumatic stress of sexual abuse.2 In Mexico, it has been found that in the child population, the higher the levels of self-esteem the more probable it is that the person has a style of facing up to such a situation aimed at directly controlling the problem. This is a mediating variable in the development of the psychopathology derived from negative experiences, like sexual abuse.24 By directly facing up to it, the victim can reduce the risk of stress1 and stop development of the pathology. These results suggest how important it is to investigate child sexual abuse and to include in the measures taken for preventing and dealing with it tools that develop cognitive behavioral skills for directly controlling the problem of abuse in minors. As a consequence, self-esteem is strengthened, thus reinforcing the use of this type of strategy for facing up to the situation.
In this study, it was found that only a third of those who are sexually abused mentioned what happened to anyone. Of the students who were sexually abused, only 15.4% asked for help, most of them being females. As far as reporting it to the police, only one of the victims, a 14-year old boy, did so. According to Summit,23 the non- reporting of sexual abuse is linked to the process of cognitive-emotional accommodation on the part of the victim. This could even become part of a personality development disorder derived from the same abusive sexual experience. If it is frequent, it affects the self-image and self-esteem when the victim does not report the abuse because he/she sees themselves as being responsible for what happened. Furthermore, within the family context, abuse may begin to function as a stability factor in family interaction. This study found uncles, aunts, brothers, fathers and step-fathers who were the abusers in the family home, and revealing the secret could lead to a breakdown in the family unit, which implies a risk to the very safety of the victim when they lose emotional family support. This often happens when the victims denounce what has occurred and have to face rejection by their own family because they are not believed.
Among this study limitations are the fact that the prevalence of sexual abuse might be underestimated because of the way in which this variable was measured, which was limited to the indicators attempt at rape and sexual rape actually carried out. Sexual abuse manifests itself in other ways, such as touching, obscene verbal expressions, exhibitionism or obliging the victim to look at pictures that have an erotic content. Other variables that might be of interest to this study were also not measured, such as the profile of the aggressor, absence of the mother in the home, psychological damage to the victims and the personality of victims who were abused on several occasions. Another limitation is the design of this study, since no causality can be established when a cross-sectional design is used and our sample may represent not represent the population of young people living in better family and economic conditions.
In conclusion, it can be shown that sexual abuse is present from the early stages of life, with the average age at which it occurs being 12. Both sexes are the victims of sexual abuse in the State of Morelos, Mexico, but it is more frequent among girls. Young people should be taught the skills needed for reporting this crime. With regard to the characteristics of the aggressor, we only asked who he/she was. In cases where there was an attempt at abuse, they were mainly found to be strangers. Among females, the boyfriend was one of the main aggressors when the sexual abuse was actually consummated. Sexual abuse is a problem that remains hidden because most of those who suffer do not mention it and do not ask for help. There are family environments that foster sexual abuse; they are associated with the consumption of alcohol by the fathers, which may lead to violent behavior towards the mother. There are also other factors relating to the individuals themselves, which in some way have their origin in violent behavior within the home, such as for example, the violence of family members towards the children. However, developing good self-esteem in children may provide them with a self-defense resource they can use in situations of abuse.
This line of investigation needs to be gone into in greater depth at the general population level, because the data of this study only represent a sector of the young people who attend public schools in the State of Morelos, Mexico. Nevertheless, our results are very useful so that the Ministry of Public Education, in collaboration with other institutions, can establish measures for detecting, preventing and reducing sexual abuse.
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Leonor Rivera Rivera
Sta. Ma. Ahuacatitlán. CP 62508
Cuernavaca, Morelos, México
Research financed by Consejo Nacional de Ciencia y Tecnología de México (Process N. 37207-M).