ORIGINAL

Child sexual abuse in the context of Nursing: a concept analysis

Tamires Paula Gomes Medeiros1, Igor de Sousa Nóbrega2, Kalyne de Araújo Bezerra1, Rafaella Queiroga Souto3, Gleicy Karine Nascimento de Araújo Monteiro3, Emanuella de Castro Marcolino2, Renata Clemente dos Santos Rodrigues1

1Centro Universitário Facisa, Campina Grande, PB, Brazil

2Universidade de Pernambuco, Recife, PE, Brazil

3Universidade Federal de Alagoas, Maceió, AL, Brazil

ABSTRACT

Objective: To conduct a conceptual analysis of child sexual abuse to identify possible attributes, antecedents, and consequences. Method: A concept analysis was conducted using a scoping review methodology. Searches were conducted in 6 databases, resulting in 17 articles after analysis. Results: Antecedents included children older than 8 years, female gender, the perpetrator often being a relative of the victim or even the biological father. Psychological changes, sexually transmitted diseases, and unwanted pregnancies were identified. The consequences observed were mainly psychological, including depression and suicidal behavior. Conclusions: Nine antecedents were grouped as factors contributing to vulnerability to abuse. In addition, 11 attributes correspond to characteristic signs indicating that a child is a victim of maltreatment. Finally, 12 consequences of child sexual violence were observed.

Descriptors: Sex Offenses; Nursing; Child Abuse, Sexual.

INTRODUCTION

Violence constitutes a sociopolitical issue that impacts various organizational realms, including healthcare. It represents a public and social health problem that affects physical, mental, and sexual well-being(1-2).

The World Health Organization (WHO) defines violence as “the intentional use of physical force or real power, or the threat of the use of force against oneself, another person, a group, or a community, resulting in injury, death, psychological harm, developmental disability, or deprivation.” According to the World Childhood Foundation (CHILDHOOD), sexual violence is a complex phenomenon with multifactorial causes(2-4).

Law No. 13,431/2017 (Article 4, paragraph III) characterizes sexual abuse against children and adolescents as “any conduct that causes embarrassment when engaging in or witnessing sexual intercourse or any other lewd act, including exposing the body in photos or videos through electronic or non-electronic means”(5).

Regarding children and adolescents, precise interventions are necessary to prevent compromising their development and personal growth, as this phase is marked by cognitive construction. According to the Statute of the Child and Adolescent (ECA), individuals up to eleven years old are considered children, and this age group is highly vulnerable to violence(3,6).

Violence represents one of the leading causes of death among the age group of 10 to 19 years old. Sexual abuse constitutes the most frequent typology and mostly occurs against girls. The primary aggressors are often the victims’ parents, stepfathers, relatives, boyfriends, or acquaintances(7).

Among alarming epidemiological data between 2011 and 2017, healthcare units in Brazil received an average of 20,000 cases of sexual abuse against children and 25,000 reports through the Human Rights Helpline, which brings an average estimate of 55 abused children and adolescents per day and 2.3 per hour(4).

Nursing is crucial in providing care for child victims of sexual abuse, as they assume a privileged position within the multidisciplinary team, directly interacting with children/adolescents and their families, thereby strengthening the bond between the professional and the user(8).

In a study conducted with nurses, a lack of knowledge about their role and importance within this theme was observed, including recognizing signs and symptoms and the difficulty of understanding the best approach to deal with such situations, thereby impairing the provision of qualified assistance to the child(9).

Conceptualizing child sexual abuse is challenging, as it requires a comprehensive understanding of the topic, involving aspects of considerable contemporary significance. There is terminological imprecision in definitions due to various derivations(10).

Developing a concept analysis becomes necessary to examine the understanding of the phenomenon and construct an applicable concept for nursing practice within the context, contributing to expanding professionals’ knowledge and their actions in the face of the issue.

Considering the issue, the following objective was outlined: to perform a concept analysis of child sexual abuse, identifying the possible attributes, antecedents, and essential consequences to determine the concept of child sexual abuse in the nursing context.

METHOD

The present study is a concept analysis according to Walker and Avant’s framework(11), which aims to develop, clarify, and promote a standardized language for a concept(12). A scoping review facilitated the collection of material to define the conceptual construct. The Joanna Briggs Institute Manual(13) and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews (PRISMA ScR)(14-15) were used to guide the development of the review. The PRISMA ScR framework reports the number of identified, included, and excluded records and the reasons for exclusions.

The study was conducted with the guiding question, “What are the essential attributes, antecedents, and consequences to determine the concept of child sexual abuse in the nursing context?” The question was developed using the mnemonic PCC (Participants, Concept, and Context). Children up to 12 years of age, as defined by the ECA(6), were included in the concept of child sexual abuse in the nursing context. Studies of any type were included without temporal restrictions.

The search process consisted of three stages. The first stage involved an initial search of databases using the following Medical Subject Headings (MeSH) terms: Child, Sexual Offenses, and Nursing, combined with the Boolean operator AND. This search was conducted in the Latin American and Caribbean Health Sciences Literature (LILACS) and Medical Literature Analysis and Retrieval System Online (MEDLINE) (PubMed) databases.

The keywords were grouped to define the search strategy and applied to the following databases Catalog of Theses and Dissertations from the Coordination for the Improvement of Higher Education Personnel (CAPES), Education Resources Information Center (ERIC), American Psychological Association PsycInfo (APA PsycInfo), and Nursing Database (BDENF). The second stage was a secondary search. In the third stage, the reference lists were examined to select the included and/or excluded documents from the study.

The selected studies were organized into folders and imported into EndNote software (Clarivate Analytics, PA, USA) to detect and remove potential duplicate studies. The remaining manuscripts were imported into Rayyan software (Qatar Computing Research Institute) for more refined selection.

These final analyses were conducted double-blindly, and in cases of disagreement between reviewers, a third reviewer was consulted for a final decision.

These data formed the sample for the scoping review and were structured and distributed across the following variables: author(s), year, language of publication, country of data collection, study type/method, study population and definitions, characteristics, antecedents, and outcomes. All conceptually derived information in the articles was processed by similarity analysis using the Interface de R pour les Analyses Multidimensionnelles de Textes et de Questionnaires (IRAMUTEQ)(16).

Figure 1 shows the structured form of the article results according to the PRISMA ScR criteria. It illustrates the search process based on the identification, selection, eligibility, and inclusion of the articles analyzed for the study.

Source: PRISMA-ScR flowchart adapted from Tricco et al., 2018.

Figure 1 – PRISMA-ScR flowchart showing the results of the searches included in the study. Campina Grande, PB, Brazil, 2021 

Thus, a total of 690 articles were obtained. After applying the selection criteria and steps, which were strictly followed, 17 articles were selected.

RESULTS

The antecedents that lead to abuse vulnerability were grouped into 9 distinct milestones. In addition, 11 attributes were identified that correspond to the characteristic signs exhibited by a child victim of abuse. Moreover, 12 consequences resulting from child sexual abuse were identified. Figure 2 illustrates the antecedents, attributes, and consequences of child sexual abuse in the nursing context.

Figure 2 – Antecedents, attributes, and consequences related to concept analysis. Campina Grande, PB, Brazil, 2021

Figure 3 shows the relationships of the maximum tree related to the concept of child sexual abuse, with branches originating from the most relevant words, such as “sexual abuse,” leading to terms such as “form,” “physical,” “health,” “violence,” and “define.” These branches were identified based on the recurrence of these words, suggesting a possible definition of a specific type of violence. It can be inferred that the representation suggests that the way this violence is perpetrated involves physical actions that affect the victim’s health.

Regarding the word “adolescent”, due to its influence on the concept of child sexual abuse and the incidence of cases, branches emerged with terms such as “sexual act” and “development”. When the word “child” was mentioned, different branches were identified with terms such as “adult”, “perpetrator”, “characterize”, “victim”, “serious”, “relationship”, “sexual”, “threat”, “use”, and “situation”. This analysis suggests that the predominant characteristic of the perpetrator is that he is an adult who satisfies his desires through sexual relations with a child, using threats to conceal his actions. In addition, the term “act” emphasizes the act of sexual abuse itself, referring to the very act of the relationship in which an adult places himself or herself in a position of power over the child or adolescent without the latter’s consent.

Figure 3 – Concept of violence from the analysis on child sexual abuse. Campina Grande, PB, Brazil, 2021

DISCUSSION

Concept of child sexual abuse

Child sexual abuse occurs through acts involving physical force or psychological intimidation, with or without physical contact, resulting in the child being compelled to engage in sexual activities against their will, often by individuals older than the child(9,17-19,23-31).

Looking at the relationships in the maximum tree, it is clear that the central word is “child”, surrounded by keywords such as “adult”, “relationship”, “sexual violence”, and “threat”. These terms are associated with the practice of sexual abuse, in which adults commit acts of sexual violence against minor victims, using threats to coerce compliance with their desires. Closely related to this core of the maximum tree is the term “adolescent”, which, although not the focus of the study, is inextricably linked to child violence in the scholarly literature.

According to the Sistema de Informação de Agravos de Notificação (SINAN), in 2021, 8.201 cases of sexual abuse of children aged 0 to 9 years were reported in Brazil. Of these, 4.75% were children under 1 year of age, 41.22% were between 1 and 4 years of age, and 54.01% were between 5 and 9 years of age(33). It is crucial to consider the indicators that influence the incidence of child sexual abuse, considering factors such as age, gender, living environment of the victim, socioeconomic status, and family context, among others(34).

The incidence of sexual abuse is also high during adolescence, a period marked by significant physical and emotional changes, and sexual development and maturation. This phase is associated with lower physical strength than adults, making them more vulnerable to aggressors(17,24,35).

Antecedents of child sexual abuse

The construction of antecedents in concept analysis involves the identification of incidents or events that occur prior to the phenomenon of interest(36). Following the structure in Figure 2, a list of antecedents contributing to child sexual abuse was compiled.

Among the antecedents associated with increased vulnerability to child sexual abuse, some stand out: children older than 8 years(17-20) and female gender(17,19,21-22,29). This can be attributed to the difference in physical strength between the sexes, which favors the risk of victimization among females, even among children(17). An analysis of the Programa Nacional de Enfrentamento da Violência Sexual contra Crianças e Adolescentes showed that 38% of victims were male and 62% were female, indicating a higher rate of reported cases among girls(37).

A study in Brazil between 2015 and 2016 found that 59% of the reports of sexual violence involved the victim’s own parents as suspects, and in 53% of the cases, the abuse occurred in the victim’s own home, while in 26% it occurred in the perpetrator’s home. This indicates that the home environment is not always safe for children and adolescents(24). The involvement of key emotional figures, such as parents, presents a complex challenge, as victims may experience confusion and fear towards those who should be symbols of trust in their homes. It is estimated that up to half of perpetrators are the victims’ own parents, and in 30% to 80% of cases, the violence occurs within incestuous father-daughter relationships(24,38).

Victims are often exposed to long and continuous periods of violence, making them vulnerable and afraid to report or seek help due to a variety of factors, including difficulties in recognizing that they are victims of abuse or being disbelieved by adults, as well as threats from perpetrators(38).

A gap that contributes to the perpetuation and increase of cases is characterized by the lack of preventive measures(25-27), low socioeconomic conditions, and inadequate education(25-28). These factors result in a lack of resources or strategies for effective action, leading to consequences such as psychological problems, abandonment, and neglect(22,39).

Health services play a crucial role in the search for comprehensive and multidisciplinary preventive measures. In this context, nurses have a prominent role as key players in the care scenario. Their communication and caring skills, developed through their education and professional practice, are crucial in this process(38,40-41).

Features of child sexual abuse

Attributes are “words or phrases that capture the essence of a concept”(36). Their identification is of great importance for developing a care plan during the victim’s support and subsequent management(38).

Specific symptoms and complaints include manifestations in the digestive, musculoskeletal, and genitourinary systems(18,20,25,27-28,30-31); fear of specific environments such as bedrooms, bathrooms, or places where the abuse occurred(20,24,26-27,31); injuries such as bites, hair pulling, bleeding, wounds, and bone fractures(25,27,29-30); sexually transmitted diseases(24-26,28-31); unwanted pregnancy(24-26,28-31); discrepancies in the victim’s discourse and lack of trust(17,19); constant feeling of dirtiness on the body(19); drawings with disturbing themes(31); expression of the event through children’s drawings with scary characteristics(31); binge eating(24).

The perpetrator is often characterized as an adult(23,29) and of male gender(18-19,30). It is noticeable that the perpetrator is often a relative of the victim(19-20,30-31) or even the victim’s own father(19,20,30-31). The intrafamilial context is particularly concerning, as the kinship relationship can mask the problem and lead to cases being ignored.

When specifically dealing with children, it is crucial to be alert to any abrupt changes in their behavior, as many victims demonstrate fear of specific environments, such as bedrooms, bathrooms, or places where the abuse occurred(20,24,26-27,31), suggesting the locations where the violence occurred.

Specific symptoms of abuse were observed in complaints related to the digestive, musculoskeletal, and genitourinary systems(17,20,25,27-28,30-31). This is partly due to the child’s anatomical and physiological immaturity, making them more vulnerable to premature sexual activities. These symptoms are also associated with the appearance of injuries such as bites, hair pulling, bleeding, wounds, and bone fractures(25,27,29-30), which may occur during the sexual act and be noticeable during the child’s evaluation.

Non-consensual sexual acts often result in genital and anal injuries, irritations in the genital area, mouth or throat, swelling, itching, and pain during urination(20,27-29,31), requiring immediate assessment to minimize harm and complications in the child’s development.

The nursing team must conduct data collection and physical examinations with precision and attention to detail. Several markers are indicative of a possible victim of sexual abuse, and professionals need to demonstrate sensitivity and empathy toward the child. Listening to their concerns and reports is crucial, showing that they are willing to assist them in this context and identify possible discrepancies or differences in what is reported by family members(17,19,38).

Certain characteristics can be expressed by the child, such as the constant feeling of dirtiness on their body(19) or binge eating(24). Expressions like children’s drawings with scary characteristics(31) can also be used by the child to communicate traumatic situations, although they often go unnoticed by both healthcare professionals and family members.

During the examination, it is important to observe the presence of sexually transmitted diseases(24-26,28-31), such as syphilis, HIV, and chlamydia infection, excluding the possibility of vertical transmission. These infections can provide clues of sexual abuse, indicating the need for more specific assessments, such as identifying child genital warts, redness, bruising, abrasions, lacerations, and tissue fragility. Additionally, the presence of semen can confirm the sexual act(42).

Refusal regarding pregnancy can be an indicator of sexual abuse against the child(24-26,28-31). In a study in Chile, which followed 48 girls who became pregnant due to sexual violence, behaviors of denial were observed, along with feelings of guilt and frustration. This context also presented a higher incidence of factors that contributed to the mortality of victims during pregnancy, childbirth, and the postpartum period(43).

Thus, it is essential to conduct a differential diagnosis and comprehensive analysis to recognize that some aspects go beyond clinical findings, involving psychological, behavioral, and traumatic factors. This can be achieved during the patient interview and history-taking process(44).

Consequences of child sexual abuse

Consequences are the set of events or incidents that occur as a result of a phenomenon(36). The care team must identify physical, psychological, social, sexual, and other manifestations that may affect the victim’s quality of life. The first consequence regarding the victim’s health is the violation of human rights(45).

Psychological consequences have been observed(17-19,21-23,25-28,32), including depression(17-18,20,22,24-26,30,32), anxiety(18,22,25,30), borderline personality disorder(22,24,32), and suicidal behavior(17-20,22,24,30). These reactions are often triggered by feelings of guilt or shame. The child may feel trapped and not verbalize the abuse situation, leading to the development of psychosomatic symptoms due to emotional withdrawal. In addition, the child may try to disclose the abuse to someone but not be properly supported, further exacerbating his or her psychological condition(46).

Children may also experience trauma and post-traumatic stress disorder(9,18,21-22,24-25,32) as well as sleep disturbances(22,26,30-31) and low self-esteem(22,26). Ongoing exposure to the violent act can negatively affect psychopathology, manifesting as repetitive play, nightmares, and anxiety(47). In addition, abrupt changes in behavior and anxiety can affect academic development, family relationships, sexual health, sleep, eating habits, social interaction, and other areas(48).

The identification of indicators promotes better coordination between health services, various agencies and ministries, intending to establish interrelated initiatives to form a network that implements and strengthens care and social protection. This promotes comprehensive care for children and adolescents who are victims of sexual abuse(17). The network approach provides comprehensive and dynamic care, intending to reshape and systematize responses to this complex phenomenon(28).

Nurses play a key role within the interdisciplinary team in addressing the phenomenon and its consequences. Their direct contact with the victims and frequent follow-up allows for effective recognition of the signs of violence(49).

CONCLUSION

The concept of child sexual abuse in the context of nursing includes any act perpetrated through the use of physical force or psychological intimidation, with or without physical contact, in which the child is forced to perform a sexual act against his or her will and involving persons of an older age.

Nine antecedents, eleven attributes, and twelve consequences were identified. Among the antecedents, the age of children over 8 years, especially females, stands out. Attributes include the perpetrator being a relative of the victim or the victim’s father, psychological changes, sexually transmitted diseases, and unwanted pregnancy. Predominant consequences are related to psychological aspects such as depression and suicidal behavior.

A clear understanding of the concept, characteristics, antecedents, and consequences of this type of abuse is crucial for effective and appropriate treatment of victims. Therefore, discussing sexual abuse and highlighting the critical role of nurses in this process raises awareness and establishes a distinct approach within this professional area that plays a central role in the care and support of victims.

*Paper extracted from the monograph “Sexual abuse against children in the context of nursing: a concept analysis according”, presented to the University Center Facisa, Campina Grande, PB, Brazil.

CONFLICT OF INTERESTS

The authors have declared that there is no conflict of interests.

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Submission: 06/29/2023

Approved: 08/07/2023