Risk Factors for Child Sexual Abuse and Perpetrator Related Risk Factors at Adama Hospital Medical College, Adama, Ethiopia

Information regarding risk factors for child sexual abuse and perpetrators related risk factors were scarce in Ethiopia, even not considered as taboos till few decades and now has become one of the most high-profile crimes. The aim of this study is to identify and assess risk factors for child sexual abuse and perpetrators related risk factors in child sexual abuse. To conduct the study, quantitative method was employed and a survey was conducted from October 2016 to April 2017. A sample of 300 sexually abused children was selected for the study. A Questionnaire was developed according to the objective of the study and translated into the local language (Amharic language). To ensure the validity and reliability of developed questionnaire various measures were taken and a pilot study was conducted at the study site. The data were analyzed using frequency, percentage, through Statistical Package for the Social Sciences version 20.0 statistical packages. The results showed that 98% of sexually abused children’s are female, in which 76.7% of them are b/n age 13-18yrs. The mean age of sexually abused children is 14 years and the minimum age is 2 years old. 87.7% sexually abused children do not know their perpetrators, and 10.3% sexually abused in group cohesion. All perpetrators are male sex, age regimen 18-35 years high score for which 8% of them had recognized physical or mental disability. Cousin score 47.6% of the total number of perpetrators who sexually abuses children by family members. 18.6% and 25% of perpetrators consume alcohol and multi drug in their daily life respectively in which 0.3% of them had identified repeated child sexual abuse in their past life. Based on the study finding factors for child and perpetrators risk factors in child sexual abuse in the study area needs collaborative hierarchal response.


Introduction
"Child sexual abuse is any interaction between a child and an adult or older child in which the child is used for the sexual stimulation of the perpetrator or an observer. Sexual abuse often involves direct physical contact, touching, kissing, fondling, rubbing, oral sex, or penetration of the vagina or anus [1]." Sometimes the sex offender may receive gratification just by exposing himself to a child, or by observing or filming a child removing his or her clothes [1]. "Offenders often may not use physical force, but may use play, deception, threats, or other coercive methods to engage youngsters and maintain their silence. Child sexual abuse is a problem that breeds in secrecy. Speaking openly and publicly about it will enhance efforts at prevention [1]." According to United nation international children's emergency fund, 2016 child marriage is one of the main forms of child sexual abuse represents perhaps the most prevalent form of sexual abuse and exploitation of girls".
"The global prevalence of child sexual abuse has been estimated at 19.7% for females and 7.9% for males [2]." Most sexual abuse offenders are acquainted with their victims; approximately 30% are relatives of the child, most often brothers, fathers, uncles, or cousins; around 60% are other acquaintances, such as "friends" of the family, babysitters, or neighbors; strangers are the offenders in approximately 10% of child sexual abuse cases [3]." Most child sexual abuse is committed by men; studies on female child molesters show that women commit 14% to 40% of offenses reported against boys and 6% of offenses reported against girls [3]." Gender is also a major factor in sexual abuse. Females are five times more likely to be abused than males [4]. " "Age is a significant factor in sexual abuse. While there is risk for children of all ages, children are most vulnerable to abuse between the ages of 7 and 13 [5]. The median age for reported abuse is 9 years old [6]. However, more than 20% of children are sexually abused before the age of 8 [7]. "The age of the male being abused also plays a part. 8% of victims age 12-17 are male and 26% of victims under the age of 12 are male [7]." "Child sexual abuse can occur in a variety of settings, including home, school, or work in places where child labor is common. "Most sexual abuse of children occurs in a residence, typically that of the victim or perpetrator. 84% of sexual victimization of children under age 12 occurs in a residence. Even older children are most likely to be assaulted in a residence. 71% of sexual assaults on children age 12-17 occur in a residence [7]." "The risk of sexual abuse is tripled for children whose parents are not in the labor force [4]. Children in low socioeconomic status households are 3 times as likely to be identified as a victim of child abuse [4]." Most studies have reported that children with disabilities are at greater risk for sexual abuse. The latest research identified incidents of child sexual abuse involving children with disabilities at only half the rate of their non-disabled peers. Children who live in rural areas are almost two times more likely to be identified as victims of child sexual abuse [4]. Children who witness or are the victim of other crimes are significantly more likely to be sexually abused [5].
"Most child sexual abusers are men, and may be respected members of the community drawn to settings where they gain easy access to children like schools, clubs and churches. They come from all age groups, races, religions and socioeconomic classes [5]". Researchers attempted to evaluate the predictive accuracy of ten specific risk factors for child molesters [8]. "The risk factors examined were: amount of contact with children, degree of sexual preoccupation with children, impulsivity, juvenile and adult antisocial behavior, frequency of prior sexual offenses, paraphilia's, and history of alcohol use, social competence, and victim gender [8]." "Perpetrators are mainly male adults and youth who are known to the child, in particular relatives and acquaintances [9]". Limited research has been conducted with perpetrators in South Africa. Such studies suggest that perpetrators are more likely to have a history of childhood sexual or physical abuse, as well as witnessing the violence towards their mothers [10]". Perpetrators report that they look for passive, quiet, troubled, lonely children from single parent or broken homes (11). Perpetrators frequently seek out children who are particularly trusting (12) and work proactively to establish a trusting relationship before abusing them [11]. "Not infrequently, this extends to establishing a trusting relationship with the victim's family as well [13]". "Many perpetrators "groom" victims and their families. Many establish a trusting relationship with the victim's family [13], in order to gain access to the child [14]. Perpetrators employ successively inappropriate comments and increasingly inappropriate touches and behaviors so insidious that the abuse is often well under way before the child recognizes the situation as sexual or inappropriate [14]." Child sexual abuse often takes place under specific, often surprising circumstances. It is helpful to know these circumstances because it allows for the development of strategies to avoid child sexual abuse. 81% of child sexual abuse incidents for all ages occur in one-perpetrator/onechild's circumstances. [6][7][8][9][10][11] year old children are most likely and 23% to be abused in multi-victim circumstances [7]". "The impact of child sexual abuse can be understood in terms of who the perpetrator is, the duration of the abuse and the age of the child at the onset and responses to disclosure [15]". For some children this trauma is internalized and they present with severe psychosomatic responses, like headaches, stomach aches, and loss of appetite before disclosure [16]". "Factors such as parent-child relationship and family functioning also play an important role in how a child adjusts post rape, as this directly affects the support the child receives post-disclosure [13]". "These factors have been shown to be particularly pronounced during the adolescent phase, with caregivers more likely to blame the child and thus influence recovery [17]". "Child sexual abuse has a profound impact on the physical and mental health of its victims, with both immediate, as well as longer-term consequences and is of major concern [18]". Health outcomes may include HIV infection, sexually transmitted infection, unwanted pregnancy, unsafe abortion and a range of adverse reproductive health consequences [19]". "The effects of child sexual abuse can include depression, [20], posttraumatic stress disorder [21], anxiety [22] complex post traumatic stress disorder, [23] propensity to further victimization in adulthood, [24] and physical injury to the child, among other problems [25]". Sexual abuse by a family member is a form of incest and can result in more serious and long-term psychological trauma, especially in the case of parental incest [26]". "Societal and cultural norms related to the social position of children, child rearing practices, as well as the breakdown of immediate and extended family systems, orphaned children and child-headed households all contribute to children's vulnerability to child sexual abuse [27]". "In some instances, sexual abuse is used as a means to punish a mother or the girl child, with rape used as a display of control [28]". Children are socialized to respect and to be obedient to their elders, with harsh methods of discipline still used to enforce parental control [29]". This unquestionable authority of adults, allows for sexual violence to occur without much resistance from children [10]". "Teachers, in their position of authority, also hold significant power over school children; therefore, sexual abuse by teachers has been found to be a significant problem in South African schools [28]". These unequal power relations, thus, provides men with the space to sexually abuse children." "There are child and family characteristics that significantly heighten or lower risk of sexual abuse [4]". The following risk factors are based on reported and identified cases of abuse. Family structure is the most important risk factor in child sexual abuse. Children who live with two married biological parents are at lower risk for abuse. The risk increases when children live with step-parents or a single parent. Children living without either parent are 10 times more likely to be sexually abused than children that live with both biological parents. Children who live with a single parent that has a live-in partner are at the highest risk: they are 20 times more likely to be victims of child sexual abuse than children living with both biological parents [4]."

The main Research Question
What are the risk factors for child sexual abuses and perpetrator related risk factors in the unit for treatment of children who needs special attention clinic, at the Adama Hospital Medical College. (1). What are the risk factors for child sexual abuse? (2). What are the perpetrators related risk factors in child sexual abuse? (3). What are the demographic factors for child sexual abuse?

The Major Objective of the Study
The major objective of the study is to identify and assess risk factors for child sexual abuse and perpetrator related risk factors in one center unit for treatment of children who needs special attention clinic at Adama Hospital medical college.

The Specific Objectives Are
(1). To assess risk factors for child sexual abuse (2). To identify perpetrators related risk factors in child sexual abuse (3). To describe demographic factors in child sexual abuse

Research Design
This paper is based on cross sectional study designs to address the objectives of the study: to assess and identify the risk factors for child sexual abuse and perpetrators related risk factors in the unit for children who needs special attention at Adama Hospital medical college. A survey study portrays the status of a phenomenon at a particular time, determines what happened during a given activity and deals with the relationships between variables. It mainly focuses on research design, test and measurement procedure of a reality and statistical analysis to respond to research questions requiring numerical data [30]. Through the application of a survey, generalizations can be developed [31]. The selection of the use of a survey is, therefore, to generalize the findings from the sample to the entire population in the selected area. In addition, a systematic review and descriptive analysis were employed to see the risk factors for child sexual abuse and perpetrator related risk factors in the case of sexually abused children at Adama Hospital Medical College one stop center unit for children who needs special attention clinic.

Population
All sexually abused children were coming to Adama Hospital medical college from Adama city and outreach rural area are the target of the study. From the total population, it has been estimated that 19.7% of females and 7.9% of male children are sexually abused worldwide [2] and about 480 sexually abused children seen at Adama Hospital Medical college as unit for children who needs special clinic 2016 report reveals in which 115 of them are an attempt.

The Sample
The source population to address the objectives was all sexually abused children, who is communicating and ethical, cooperative clients appear in the study area. The selection of these clients was made from age registered in the patient card in the unit for children who needs special attention clinic. Thus, the total number of clients that the researcher enrolled in this study was three hundred samples with the expectation that some of them are non-responsive. Thus, for risk factors of child sexual abuse and their perpetrators sexually abused clients who are found to be responsive or immediate relative were interviewed for six consecutive months. Sexually abused children who are incoherent, lacks complete information, who fails to decide, non -cooperative due to fear of the outcome are not included in the study.

Instrumentation
For the study of the risk factors for child sexual abuse and perpetrator related risk factors, a questionnaire was developed from literature review according to the objective of the study. The questionnaire was used because these types of question format provide the frame of reference for all respondents to use in determining their answers. A questionnaire was used as a means to measure whether any treatments for child sexual abuse were sought. The questionnaire asks respondents to indicate for each of the behavior that are manifested. The instrument is also designed to determine the risk factors for child sexual abuse and perpetrators related risk factors in child sexual abuse. It is further used to determine how parents perceive the physical and emotional problem of sexually abused children, and to manage chronic problem of the sexually abused children. The developed questionnaire has two parts and twenty three items. In the strength of the survey questionnaire, important measuring scale is applied yet manageable for clients to read and complete. The validity of the developed questionnaire was tested by five experts who have second degree and higher (psychologist, psychiatrist, MPh, gynecologist and PhD in public health). The translation of the questionnaire from English to Amharic were done and then converted to the English language by expert professionals to check for language equivalence. A pilot study was conducted prior to the main data collection for 10% of sexually abused children and analyzed to check the reliability of the instruments. The assessment showed that the questionnaire was acceptable and feasible with high reliability of α 0.74. In accordance with findings of pretest, minor modifications were made to the questionnaire. The translated questionnaire was tested for feasibility of use, and acceptability. In accordance with findings of pretest, minor modifications were made to the questionnaire. The question and statements were grouped and arranged according to proposed objective.

Data Processing and Analysis
With regard to data management, all completed questionnaire forms was reviewed by data collector and checked by a researcher. Forms with missing data returned to the interviewer immediately for correction. The data were categorized and coded on the well-defined coding sheet. Later it was exported to SPSS statistical software for windows version 20 for analysis. Descriptive statistics as frequency, percentage, means, and median range was generated. The analysis focuses on the pretest conceptual analysis and descriptive analyses were done based on the objective of the study.

Ethical Consideration
To conduct the study, the research proposal was examined and screened for scientific and ethical clearance by institutions, research highest body for approving research in the college of medical science, Adama Hospital Medical College. Prior to administering the survey and collecting data, permission letter was given to, Adama Hospital medical college and authorities of different levels including the department where the study was conducted. The researcher also asked permission from respondents' parent and sexually abused a client to gain full commitment about the study. According to table 1 majority of risk factors for child sexual abuse and perpetrators related risk factors in the unit for children who needs special attention clinic is assessed, identified and stated clearly. From the total of 300 sexually abused children, 294 of them are female sex and only 6 of them are male. In 89.7% of the case victims do not know their perpetrators. 241 of sexually abused children are at grade level 1-8. 20% of sexually abused children had previous episode in their past life. 95.7% of sexually abused child's family monthly income is bellow 130$ and lives in ways that is comfortable for offenders to sexually abuse children. 24 children out of 300 who sexually abused suffer from any physical or mental disability. Regarding perpetrators 131 of them use alcohol and multi drug abuser in their daily life.

Discussion
The findings from this study indicate that the risk factors for child sexual abuse and their perpetrators in one stop center unit for children who needs special attention clinic at the Adama Hospital Medical College are as the research literatures indicate. The resulting data closely mirrored national statistics for what is intended to measure, which suggests that the group that responded reasonably matches the national population as it is corresponded in the literature. Even though Child sexual abuse definitions have changed over the years as have the organizations that investigate child sexual abuse cases so statistics on child sexual abuse may inherently fluctuate, Natasha Tracy, [2015]. As was stated in the literature, the global prevalence of child sexual abuse has been estimated at 19.7% for females and 7.9% for males [2]". Child sexual abuse only accounts for about 8% of child abuse cases, Natasha Tracy, [2015]. In fact, only 30% of child sexual abuse cases are thought to be disclosed during childhood Natasha Tracy, [2015]. Previous 2015 document analysis study of the area by melal Bekele [MPH] reveals 94.1% and 5.9% female and male children respectively. In this study (294) 98% of sexually abused children's are female and only (6) 2% of them are males.
Age is a significant risk factor in sexual abuse. While there is risk for children of all ages, children are most vulnerable to abuse between the ages of 7 and 13 [5]. The median age for reported abuse is 9 years old [6]. However, more than 20% of children are sexually abused before the age of 8 [7]. In the study done at unit for children's who needs special attention clinic 2-6yrs score (16) 5.3% of the case, 7-12yrs score (54) 18% and 13-18yrs score (230) 76.7% out of 300 sexually abused children. The mean age of sexually abused children is 14 years and the minimum age is 2 years old during this study period in the area. According to Statistics done on Perpetrators of Child Sexual Abuse, Offenders are overwhelmingly male, ranging from adolescents to the elderly and some perpetrators are female. It is estimated that women are the abusers in about 14% of cases reported among boys and 6% of cases reported among girls [65]. In this study, even though all perpetrators are male, (292) 97.3% of being in b/n male perpetrators and female child and (8) 2.7% of the perpetrators are b/n male and male anal intercourse. Except (30) 9.9% of an attempt trial all in all as physical examination detects complete vaginal or anal tear is confirmed by gynecologist who are assigned in the clinic. Internationally one-third of offenders are themselves juveniles, 23% of reported cases of child sexual abuse are perpetrated by individuals under the age of 18yrs [65]. In this study juvenile perpetrators scores (33) 11%, 18yrs-35yrs score (241) 80.3%, 36-45yrs (20) 6.6% and above 45yrs (6) 2%. The outcome study by the national center for crime, 14% of children who suffered sexual abuse were violated by unknown perpetrator whereas in this study (269) 87.7% and (31) 10.3 children's sexually abused by the perpetrators they do not know and they know each other's respectively with perpetrators at least once in their daily life.
Child sexual abuse often takes place under specific, often surprising circumstances. It is helpful to know these circumstances because it allows for the development of strategies to avoid child sexual abuse. 81% of child sexual abuse incidents for all ages occur in one-perpetrator/one-Childs' circumstances. 6-11 year old children are most likely 23% to be abused in multi-victim circumstances [7]. Child sexual abuse is tripled for children whose parents are not in the labor force [4]. With regard to this study, parents of sexually abused children (227) 75.7% of them are married, (47) 15.7% are widowed, (16) 5.3% divorced/separated, (5) 1.7% single parenthood and (5) 1.7 of them are self-child headed family. The current living condition while they are sexually abused (246) 82.0% lives with their parents, (10) 3.3% with their friends, (33) 11% fostered (9) 3.0% and (2) 0.7% at an orphanage. Constraints family life is one of the reasons in sexual abuse. According to this study (133) 44.3% sexually abused children, family size, in the household is (133) 44.4% >6 individuals in a single house, (163) 54.4% 2-5 individuals in a constrained family and only (4) 1.3% of them live in a single isolated room family size which create a good opportunity for children to be perpetrated. Children in low socioeconomic status households are three times as likely to be identified as a victim of child abuse [4]. In this study from the total of 300 sexually abused children (106) 35.3% family income /month is <45$ (1000 Eth. Birr), (181) 60.3% per monthly income family generation is b/n 46-136$(1001-3000 Ethi Birr) and only (13) 4.3% of sexually abused children's parent earn >136$(>3000) Ethio Birr /month. This implies that child sexual abuse in the study area is associated with low socioeconomic family background in which children's are participating in risky labor force.
Most studies have reported that children with disabilities are at greater risk for sexual abuse. The latest research identified incidents of child sexual abuse involving children with disabilities at only half the rate of their non-disabled peer [4]. However, in this study (24) 8% of sexually abused children have at least one or more recognized physical and mental disability and (276) 92% of them respond to none to sever physical or mental disorders.
Children who live in rural areas are almost two times more likely to be identified as victims of child sexual abuse [4].
Almost in this study, they are near to equal in which (141) 47% of them are from urban area and (157) 53% of children resident in the rural area, because lifestyle in rural and town is similar in developing countries even sometimes vice versa. Children who witness or are the victim of other crimes are significantly more likely to be sexually abused [5]. By this study (20) 6.7% of sexually abused children had experienced later life episode and (280) 93.3% had never experienced in their life.
Sexual abuse of children occurs in a residence, typically that of the victim or perpetrator residence. 84% of sexual victimization of children under age 12 occurs in a residence. Even older children are most likely to be assaulted in a residence. 71% of sexual assaults on children age 12-17 occur in a residence [7]. The study analysis (139) 46.3% of sexual abuse committed at perpetrators own residence, (74) 24.7% are at victim own home, (15) 5% at the garden while on daily activities, (12) 4% at the school environment while academic learning and (60) 20% at bush while on their journey for functional purposes. For all 300 sexually abused children an event happens (185) 61.7% during the day time and (115) 38.3% performed by using night time as their shadow.
Studies indicate that children are sexually abused by perpetrators of all ages. Accordingly, children are not only abused by adults but by fellow children. Sariola and Uutela (1994) have found out that there exists an age gap of five to sixteen years between the abuse and the abuser parties. In this study, the range of the abuser party was found to extend from 9 to 60 years old, with a mean age of 30 years during this study period. However, this clinical area study result indicates that young people between 18 and 35 commit (242) 80.7% of the offenses and the age range <18 yrs accounts for (33) 11% of the total offenses. Thus, it could be said that the perpetrators are usually young people.
Sexual abuse by stranger is not usually common and rather it starts in the near home surrounding settings. According to Melal Bekele 2015 conducted a similar study the most common perpetrators include neighbor 38.95%, teachers 7.9%, relatives at 13.4% and the remaining are other professionals. The study done by this research identifies the most common perpetrators are neighbor (146) 48.5%, family members (25) 8.3%, friends (13) 4.3%, teachers (2) and the remaining percent do not mentioned by sexually abused children or their families. The study also tries to assess family members who committed sexual abuse on children. From the total of 25 sexually abused victims 47.6% is by cousin, 14.3% father, 4.8% by brothers, 14.3% uncle and the remaining percentage accomplished by other family members who have a close attachment with children's.
An international review and meta-analysis of risk factors for the perpetration of Child sexual abuse found that a history of sexual abuse, harsh discipline as a child, and difficulty with intimate relationships, antisocial behavior and loneliness were found to be positively associated [61]. Caregiver, alcohol or drug abuse is a child abuse risk factor putting kids at much higher risk of being abused, [58]. Alcohol and multi drug abuser commit child sexual abuse due to despaired mental activity and some of them present substance use as a defense mechanism for their guilty feelings. In the study done on perpetrators (56) 18.6% of them consume alcohol and (75) 25% of them are multi drug abuser in a daily life in which 1 (0.3%) had identified repeated child sexual abuse in his past life. Concomitantly collected data also identify the social status of child sexual abuse perpetrators. Based on the study finding (5) 1.7% of sexual offenders are office managers, (1) 0.3% religious leader, (14) 4.7% are civil servants, (44) 14.6% are students, and the other remaining (173) 57.7% incorporate drivers, farmers and jobless individuals.
Finally the study generalizes its discussion on female sex, minimal age, constricted family life, low monthly income of the parents, low level of education attained by children's, parents unhappy marriage, participation of children in risk labor force, mental or physical disability of children are among the possible risk factors for child sexual abuse in one stop center unit for children who needs special attention clinic at the Adama Hospital Medical College. Similarly the perpetrators amount of contact with children, degree of sexual preoccupation with children, antisocial behavior, frequency of prior sexual offenses, psychiatric problems, and social status of perpetrators and history of alcohol and substance use disorders are perpetrators related factors in child sexual abuse that affects the life of children in any important part of their life.

Conclusion
As can be seen from the study findings, risk factors for child sexual abuse and perpetrators related risk factors in child sexual abuse are identified. Risk factors for child sexual abuse are female sex, minimal age, constricted family life, low monthly income of the parents, low level of education attained by children's, parents unhappy marriage and participation of children in risk labor force, physical and mental health of children collectively. The perpetrators amount of contact with children, degree of sexual preoccupation with children, juvenile and adult antisocial behavior, frequency of prior sexual offenses, psychiatric problems, and social status of perpetrators and history of alcohol and substance use disorders are perpetrators related factors in child sexual abuse that affects the life of children in any important part of their life. from governmental or non governmental, or elsewhere to conduct this study. Interest emanate from the wish to show participation in creating advanced turning point toward child sexual abuse to see disable free next generation from the trauma.