• Majority of the perpetrators known to the victims
• Delayed disclosure high in cases of penetrative abuse, multiple incidents of abuse, and abuse by a known person 

A study on cases of child sexual abuse presenting to a Colombo-based hospital found that the rate of sexual abuse of females and those older than 12 years, was high, while the majority of the perpetrators were known to the child, with delayed disclosure being significantly higher in cases of penetrative abuse, multiple incidents of abuse, and abuse being committed by a known person. However, psychological consequences are seen only in less than 30%. 

These findings were made in an original article on “Child sexual abuse presenting to a teaching hospital in Colombo” which was authored by Y.M. Rohanachandra and I. Amarabandu (both attached to the Sri Jayewardenepura University), and P. Dassanayake (attached to the Colombo South Teaching Hospital, Kalubowila), and published in the Sri Lanka Journal of Child Health's 50th Volume's Fourth Issue in December, 2021. 

Child sexual abuse is a major public health problem worldwide. Globally, according to J. Wihbey's “Global prevalence of child sexual abuse”, 7.9% of males and 19.7% of females are sexually abused before the age of 18 years. A Brazilian study noted that child sexual abuse accounts for about 1% of the global burden of diseases. An average of 1,297 complaints related to child sexual abuse have been received by the National Child Protection Authority from 2015 to 2019, per annum, with the majority of the complaints being related to sexual harassment. The Police Department received an average of 1,593 complaints related to child sexual abuse, per year, from 2015 to 2019, with the majority of these being related to statutory rape.

The prevalence of child sexual abuse in Sri Lanka, per studies (A. Abeywardene, S. Atukorale, K. Abeynayaka and T. Athauda's “A study on the knowledge and prevalence of sexual harassment and abuse among schoolboys in the Colombo District”, A. Fernando and W. Karunasekera's “Juvenile victimisation in a group of young Sri Lankan adults”, and B. Perera and T. Østbye's “Prevalence and correlates of sexual abuse reported by late-adolescent schoolchildren in Sri Lanka”) ranges from between 14-44% with rates of sexual harassment being as high as 78.5%. A higher prevalence has been reported in Northern Sri Lanka (D. Somasundaram's “Short and long-term effects on the victims of terror in Sri Lanka”) and in areas associated with the tourism industry (D.H. de Silva's “Some reflections on child abuse in Sri Lanka”). Hospital-based studies have shown a wide variation in the number presenting to hospitals with alleged abuse, with the numbers ranging from 84 cases over 15 years, which is an average of 5.6 cases per year in P. Ginige, S. Tennakoon, F. Perera and A. Baminiwatta's “Characteristics of children who have been sexually abused, incidents of abuse and perpetrators: A study from a tertiary care clinic sample in Central Sri Lanka”, to 183 over 18 months, which is an average of 122 cases per year per R.R.G.S. Amararatne and M. Vidanapathirana's “Child sexual abuse in Puttalam: A medico-legal analysis”. 

This retrospective, case review study was done in the Colombo South Teaching Hospital, by Rohanachandra et al. and it included all children and adolescents (under 16 years of age) who were referred to the Judicial Medical Officer (JMO) of the Hospital, due to alleged sexual abuse from 2015-2019. The type of sexual abuse in this context included vaginal penetration, anal penetration, oral penetration, digital penetration and/or non-penetrative sexual abuse.

The child’s clinical diagnosis was recorded by the Consultant Psychiatrist according to the American Psychiatric Association's Fifth Edition of The Diagnostic and Statistical Manual of Mental Disorders criteria. 

Over the five years period from January 2015, to December 2019, a total of 164 children and adolescents were presented to the JMO for assessment following alleged sexual abuse. The majority (136/82.9%) were female and 67.1% were older than 12 years. Only 49.4% were living with both parents. Of the children, 18.3% were not attending school. A significantly higher number of females were not attending school compared to males.

The perpetrators were male in 163/99.9% of the cases. In 31.1% of the instances, the child had been threatened and in 15.2% of the cases, the child had been given a reward such as a toy or food. Females were significantly more likely to be abused at home than males. 

The time taken for disclosure ranged from immediately after the incident to more than a year. The majority of the children had revealed about the incident to their mother (40.9%), followed by the grandmother (13.4%) and sister (9.1%). Delayed disclosure (i.e. after a week) was significantly higher in children who suffered penetrative abuse, those who had suffered multiple incidents of abuse and where the abuse was perpetrated by a known person. Spontaneous disclosure was significantly lower in children who disclosed about the incident after more than a week.

Psychological consequences were seen in 47/28.7% of the children, with depression being the commonest (8.5%), followed by adjustment disorder (7.3%) and acute stress reaction (6.7%). Psychological consequences were significantly higher in victims who had physical evidence of abuse, delayed disclosure of the incident (after a week) and in children who did not disclose the abuse spontaneously.

In this study, the rate of sexual abuse was 82.9% in females and 67.1% in those older than 12 years. Of the perpetrators, 94.5% were known to the child.

In the present study, 164 children and adolescents presented with alleged child sexual abuse during a five years period, which is much higher than two case review studies previously carried out in teaching hospitals in Colombo (Y. Rohanachandra, D. Dahanayake, P. Pathigoda and G. Wijetunge's “Characteristics of victims of alleged child sexual abuse referred to a child guidance clinic of a children’s hospital” found only 35 children presenting within a five-year period from 2010-2015 while M.  Vidanapathirana's “Child sexual abuse: A medico-legal analysis” found 78 children and adolescents presenting over a three-year period from 2011-2013). These findings, Rohanachandra et al. opine, may be due to an increase in the prevalence of child sexual abuse or may reflect increased public awareness of child sexual abuse. 

In the present study, the majority of the victims were female and older than 12 years. The absence of one or both parents has also been described as a risk factor for child sexual abuse. In the instant study, only 49.4% of children lived with both parents, in contrast to 78% in the national figure per the Health Ministry's “Sri Lanka – Global school-based student, Health survey of 2016”. In addition, in this study, only 81.9% of children were attending school in contrast to 90.1% in the national figure. Not attending school may also be a risk factor for child sexual abuse in Sri Lanka (per M. Chandrasiri, D. Wijewardena, S. Lanerolle, S. Chandrasiri, K. Wijewardena and R. Cooray's “Child sexual abuse presenting to the District General Hospital, Chilaw”, M. Sathiadas, S. Mayoorathy, K. Varuni and S.S. Ranganathan's “Child abuse in Northern Sri Lanka”, and a South African study). This study also found that most perpetrators are male and known to the child. In the present study, a significantly higher number of females were not attending school compared to males. Gender inequality within the education system, Rohanachandra et al. observe, may be a possible explanation for this.

The study showed a delay in the reporting of child sexual abuse and that disclosure is prompted by questions from caregivers. In the present study, most children disclosed to the mother followed by the grandmother. Disclosure to the father was very low (3.7%). In Sri Lankan culture, the extended family plays a greater role in a child’s life and grandmothers often care for the children in the mothers’ absence and this, Rohanachandra et al. point out, may be the reason for the disclosure to the grandmother being more common in Sri Lanka. Being abused by a known person, being abused on multiple occasions and penetrative abuse were associated with delayed disclosure in the study.

Studies done in Sri Lanka (Ginige et al., and Rohanachandra and Dahanayake et al.) show that 16-68% of children have a psychological impact following abuse. The most commonly reported psychological consequences are depressive disorder, adjustment disorder and post-traumatic stress disorder (PTSD). The present study also revealed depression and adjustment disorder to be the common psychological sequelae following child sexual abuse, followed by acute stress reaction. However, there were no children diagnosed as having PTSD, and this, Rohanachandra et al. elaborate, is possibly due to the differences in the time of presentation of the victims. 

Delayed disclosure is common and is associated with a higher psychological impact. As disclosure of abuse is often delayed and often follows direct questioning, parents should be aware of the signs suggesting possible sexual abuse, so that the children can be referred for services in a timely manner. Rohanachandra et al. recommended in conclusion that given the wide variety in the numbers of children and adolescents presenting with alleged abuse within different regions of the country, there is a need for nationwide studies to assess the prevalence of the problem across Sri Lanka.