Notifications of sexual violence against children and adolescents in Rio Grande do Sul, Brazil: a descriptive study, 2014-2018

OBJECTIVE

to describe characteristics of notifications of sexual violence against children and adolescents according to race/skin color and their distribution in the state of Rio Grande do Sul, Brazil, between 2014 and 2018.

METHODS

this was a descriptive study of data retrieved from the Notifiable Health Conditions Information System (SINAN). Frequency distributions, prevalence and statistical differences were analyzed using Pearson's chi-square test.

RESULTS

of the 8,716 notifications, most occurred in the state capital (48.2%) and related to female victims (82.2%) aged between 10 and 14 years (38.1%). There was a higher prevalence (370/100,000) and relative frequency of rape (84.5%), sexual exploitation (5.8%) and neglect/abandonment (4.6%) among victims of Black race/skin color (p-value < 0.05). Only 4.6% of notifications occurred in primary health care services.

CONCLUSION

notifications were more frequent among female pre-adolescents and prevalence was higher among Black people, who should be a priority target for protective measures. Surveillance of this form of violence needs to be strengthened in primary care.

Abordaje de la violencia sexual infantil: un llamado a la acción para los profesionales de América Latina

El objetivo de esta comunicación es delinear los elementos clave de la capacitación en violencia sexual infantil (VSI) para profesionales de la salud en diferentes disciplinas medicina, psicología, odontología, enfermería, trabajo social, nutrición, fisioterapia, terapia ocupacional, química, bioquímica y obstetricia incluidas las parteras, entre otras y el desarrollo de protocolos de atención con base en las prácticas basadas en evidencia, así como proporcionar recursos que permitan optimizar ambos procesos. La capacitación sobre la violencia sexual hacia niñas, niños y adolescentes (NNA) es esencial para enfrentar este gran desafío en América Latina y permitir al personal de salud cumplir su función en defensa de la seguridad y el bienestar de NNA. El desarrollo de protocolos ayuda al personal de salud a definir las funciones y responsabilidades de los miembros del personal, resumir los posibles indicadores de VSI y describir las estrategias para identificar y abordar mejor las necesidades de salud y seguridad del paciente y su familia, por lo que deben incluir el enfoque informado sobre el trauma. El trabajo futuro debe centrarse en desarrollar y evaluar estrategias nuevas para aumentar la capacidad del sector de la salud para atender a los NNA que experimentan VSI y optimizar las formas de capacitar al personal. Apunta, también, a mejorar la generación de investigación y evidencia sobre la epidemiología y atención de la VSI en América Latina, incluidos los niños y adolescentes varones, grupos minoritarios y de atención prioritaria (p. ej. NNA migrantes, con discapacidad, en situación de calle, privados de la libertad, pertenecientes a comunidades indígenas y a la comunidad LGBTIQ+).

Donovanosis in a child victim of sexual abuse: response to doxycycline treatment

Donovanosis is a chronic infectious disease caused by the Gram-negative bacteria Klebsiella granulomatis, which mainly affects the skin and mucous membranes of the genital, perigenital, and inguinal regions. Also known as venereal granuloma or granuloma inguinale, it is endemic in tropical and subtropical regions of the globe and often associated with sexual transmission. We report the case of an 11-year-old female victim of chronic sexual abuse, who was diagnosed with donovanosis and presented a good therapeutic response to doxycycline.

Screening for Child Sexual Exploitation in Online Sexual Health Services: An Exploratory Study of Expert Views

BACKGROUND

Sexual health services routinely screen for child sexual exploitation (CSE). Although sexual health services are increasingly provided online, there has been no research on the translation of the safeguarding function to online services. We studied expert practitioner views on safeguarding in this context.

OBJECTIVE

The aim was to document expert practitioner views on safeguarding in the context of an online sexual health service.

METHODS

We conducted semistructured interviews with lead professionals purposively sampled from local, regional, or national organizations with a direct influence over CSE protocols, child protection policies, and sexual health services. Interviews were analyzed by three researchers using a matrix-based analytic method.

RESULTS

Our respondents described two different approaches to safeguarding. The "information-providing" approach considers that young people experiencing CSE will ask for help when they are ready from someone they trust. The primary function of the service is to provide information, provoke reflection, generate trust, and respond reliably to disclosure. The approach values online services as an anonymous space to test out disclosure without commitment. The "information-gathering" approach considers that young people may withhold information about exploitation. Therefore, services should seek out information to assess risk and initiate disclosure. This approach values face-to-face opportunities for individualized questioning and immediate referral.

CONCLUSIONS

The information-providing approach is associated with confidential telephone support lines and the information-gathering approach with clinical services. The approach adopted online will depend on ethos and the range of services provided. Effective transition from online to clinic services after disclosure is an essential element of this process and further research is needed to understand and support this transition.

Pharmacological interventions for those who have sexually offended or are at risk of offending

BACKGROUND

Sexual offending is a serious social problem, a public health issue, and a major challenge for social policy. Victim surveys indicate high incidence and prevalence levels and it is accepted that there is a high proportion of hidden sexual victimisation. Surveys report high levels of psychiatric morbidity in survivors of sexual offences.Biological treatments of sex offenders include antilibidinal medication, comprising hormonal drugs that have a testosterone-suppressing effect, and non-hormonal drugs that affect libido through other mechanisms. The three main classes of testosterone-suppressing drugs in current use are progestogens, antiandrogens, and gonadotropin-releasing hormone (GnRH) analogues. Medications that affect libido through other means include antipsychotics and serotonergic antidepressants (SSRIs).

OBJECTIVES

To evaluate the effects of pharmacological interventions on target sexual behaviour for people who have been convicted or are at risk of sexual offending.

SEARCH METHODS

We searched CENTRAL (2014, Issue 7), Ovid MEDLINE, EMBASE, and 15 other databases in July 2014. We also searched two trials registers and requested details of unidentified, unpublished, or ongoing studies from investigators and other experts.

SELECTION CRITERIA

Prospective controlled trials of antilibidinal medications taken by individuals for the purpose of preventing sexual offences, where the comparator group received a placebo, no treatment, or 'standard care', including psychological treatment.

DATA COLLECTION AND ANALYSIS

Pairs of authors, working independently, selected studies, extracted data, and assessed the risk of bias of included studies. We contacted study authors for additional information, including details of methods and outcome data.

MAIN RESULTS

We included seven studies with a total of 138 participants, with data available for 123. Sample sizes ranged from 9 to 37. Judgements for categories of risk of bias varied: concerns were greatest regarding allocation concealment, blinding of outcome assessors, and incomplete outcome data (dropout rates in the five community-based studies ranged from 3% to 54% and results were usually analysed on a per protocol basis).Participant characteristics in the seven studies were heterogeneous, but the vast majority had convictions for sexual offences, ranging from exhibitionism to rape and child molestation.Six studies examined the effectiveness of three testosterone-suppressing drugs: cyproterone acetate (CPA), ethinyl oestradiol (EO), and medroxyprogesterone acetate (MPA); a seventh evaluated two antipsychotics (benperidol and chlorpromazine). Five studies were placebo-controlled; in two, MPA was administered as an adjunctive treatment to a psychological therapy (assertiveness training or imaginal desensitisation). Meta-analysis was not possible due to heterogeneity of interventions, comparators, study designs, and other issues. The quality of the evidence overall was poor. In addition to methodological issues, much evidence was indirect.

PRIMARY OUTCOME

recividism. Two studies reported recidivism rates formally. One trial of intramuscular MPA plus imaginal desensitisation (ID) found no reports of recividism at two-year follow-up for the intervention group (n = 10 versus one relapse within the group treated by ID alone). A three-armed trial of oral MPA, alone or in combination with psychological treatment, reported a 20% rate of recidivism amongst those in the combined treatment arm (n = 15) and 50% of those in the psychological treatment only group (n = 12). Notably, all those in the 'oral MPA only' arm of this study (n = 5) dropped out immediately, despite treatment being court mandated.Two studies did not report recidivism rates as they both took place in one secure psychiatric facility from which no participant was discharged during the study, whilst another three studies did not appear directly to measure recividism but rather abnormal sexual activity alone.

SECONDARY OUTCOMES

The included studies report a variety of secondary outcomes. Results suggest that the frequency of self reported deviant sexual fantasies may be reduced by testosterone-suppressing drugs, but not the deviancy itself (three studies). Where measured, hormonal levels, particularly levels of testosterone, tended to correlate with measures of sexual activity and with anxiety (two studies). One study measured anxiety formally; one study measured anger or aggression. Adverse events: Six studies provided information on adverse events. No study tested the effects of testosterone-suppressing drugs beyond six to eight months and the cross-over design of some studies may obscure matters (given the 'rebound effect' of some hormonal treatments). Considerable weight gain was reported in two trials of oral MPA and CPA. Side effects of intramuscular MPA led to discontinuation in some participants after three to five injections (the nature of these side effects was not described). Notable increases in depression and excess salivation were reported in one trial of oral MPA. The most severe side effects (extra-pyramidal movement disorders and drowsiness) were reported in a trial of antipsychotic medication for the 12 participants in the study. No deaths or suicide attempts were reported in any study. The latter is important given the association between antilibidinal hormonal medication and mood changes.

AUTHORS' CONCLUSIONS

We found only seven small trials (all published more than 20 years ago) that examined the effects of a limited number of drugs. Investigators reported issues around acceptance and adherence to treatment. We found no studies of the newer drugs currently in use, particularly SSRIs or GnRH analogues. Although there were some encouraging findings in this review, their limitations do not allow firm conclusions to be drawn regarding pharmacological intervention as an effective intervention for reducing sexual offending.The tolerability, even of the testosterone-suppressing drugs, was uncertain given that all studies were small (and therefore underpowered to assess adverse effects) and of limited duration, which is not consistent with current routine clinical practice. Further research is required before it is demonstrated that their administration reduces sexual recidivism and that tolerability is maintained.It is a concern that, despite treatment being mandated in many jurisdictions, evidence for the effectiveness of pharmacological interventions is so sparse and that no RCTs appear to have been published in two decades. New studies are therefore needed and should include trials with larger sample sizes, of longer duration, evaluating newer medications, and with results stratified according to category of sexual offenders. It is important that data are collected on the characteristics of those who refuse and those who drop out, as well as those who complete treatment.

Prevalence and correlates of child sexual abuse: a national study

BACKGROUND

This study examines the prevalence, correlates, and psychiatric disorders of adults with history of child sexual abuse (CSA).

METHODS

Data were derived from a large national sample of the US population. More than 34000 adults 18 years and older residing in households were interviewed face-to-face in a survey conducted during the 2004-2005 period. Diagnoses were based on the Alcohol Use Disorder and Associated Disabilities Interview Schedule-Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, version. Weighted means, frequencies, and odds ratios of sociodemographic correlates and prevalence of psychiatric disorders were computed. Logistic regression models were used to examine the strength of associations between CSA and psychiatric disorders, adjusted for sociodemographic characteristics, risk factors, and other Axis I psychiatric disorders.

RESULTS

The prevalence of CSA was 10.14% (24.8% in men and 75.2% in women). Child physical abuse, maltreatment, and neglect were more prevalent among individuals with CSA than among those without it. Adults with CSA history had significantly higher rates of any Axis I disorder and suicide attempts. The frequency, type, and number of CSA were significantly correlated with psychopathology.

CONCLUSIONS

The high correlation rates of CSA with psychopathology and increased risk for suicide attempts in adulthood suggest the need for a systematic assessment of psychiatric disorders and suicide risk in these individuals. The risk factors for CSA emphasize the need for health care initiatives geared toward increasing recognition and development of treatment approaches for the emotional sequelae CSA as well as early preventive approaches.

The decade dance

This essay portrays the moment an adult survivor of childhood sexual abuse tells his physician about his traumatic past. Because of denial by both parties, the diagnosis had remained buried for years, and opportunities for appropriate intervention were repeatedly missed. When the patient is finally able to face his past, it unleashes a torrent of potentially lethal anger that challenges everyone involved.