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ORIGINAL ARTICLE  
Year : 2017  |  Volume : 59  |  Issue : 2  |  Page : 202-207
Silence of male child sexual abuse in India: Qualitative analysis of barriers for seeking psychiatric help in a multidisciplinary unit in a general hospital


1 Department of Psychiatry, M.S. Ramaiah Medical College, Bengaluru, Karnataka, India
2 Department of Forensic Medicine, M.S. Ramaiah Medical College, Bengaluru, Karnataka, India
3 Department of Pediatrics, M.S. Ramaiah Medical College, Bengaluru, Karnataka, India
4 Department of Psychiatry, JSS Medical College, Mysore, Karnataka, India

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Date of Web Publication17-Jul-2017
 

   Abstract 

Introduction: In 2007, Ministry of Women and Child Welfare, supported by United Nations Children's Fund, save the children and Prayas conducted a study to understand the magnitude of child abuse in India, they found that 53.22% children faced one or more forms of sexual abuse; among them, the number of boys abused was 52.94%.
Aim: The aim of this study was to explore the barriers for seeking psychiatric help by qualitative analysis of stake holders of male victims of child abuse.
Materials and Methods: All the statements made by the stakeholders regarding psychiatric assessment and treatment were recorded in each referral made to the psychiatrist. Semistructured interviews and in-depth interviews were conducted to explore the topic of understanding the need for psychiatric treatment to the victims.
Results: Collaborative child response unit, a multidisciplinary team, to tackle child sexual abuse in a general hospital received three referrals of male child abuse among the 27 referrals in 20 months. The main theme of the barrier that was generated by interviewing the stakeholders of male child victims of abuse was the misconception of superiority of a male victim due to gender (patriarchy) an expectation that he will outgrow the experience. In-depth interviews of three cases of homosexual abuse explored the theme.
Conclusion: Patriarchy is oppressing male children and acts as a barrier to seek psychiatric help in collaborative child response unit.

Keywords: Barriers for psychiatric help, collaborative child response unit, male child sexual abuse, patriarchy

How to cite this article:
Subramaniyan VK, Reddy P, Chandra G, Rao C, Rao T S. Silence of male child sexual abuse in India: Qualitative analysis of barriers for seeking psychiatric help in a multidisciplinary unit in a general hospital. Indian J Psychiatry 2017;59:202-7

How to cite this URL:
Subramaniyan VK, Reddy P, Chandra G, Rao C, Rao T S. Silence of male child sexual abuse in India: Qualitative analysis of barriers for seeking psychiatric help in a multidisciplinary unit in a general hospital. Indian J Psychiatry [serial online] 2017 [cited 2017 Dec 13];59:202-7. Available from: http://www.indianjpsychiatry.org/text.asp?2017/59/2/202/210725



   Introduction Top


Child sexual abuse is a traumatic event in the life of a child. According to the WHO (1999), it results in actual or potential harm to a child's health, survival, development, or dignity in the context of a relationship of responsibility, trust, or power.[1]

India houses 40% of children in its total population but is ranked as the sixth most unsafe country for children. In 2007, Ministry of Women and Child Welfare, supported by United Nations Children's Fund, save the children and Prayas conducted a study to understand the magnitude of child abuse in India;[2] they found that 53.22% children faced one or more forms of sexual abuse; among them, the number of boys abused was 52.94% and of girls was 47.06%. Among the 69% of physically abused in 13 sample states, 54.68% were boys and 88.6% were physically abused by parents. Sixty-five percent of school going children reported facing corporal punishment; 50.2% of children worked all 7 days in a week and they never reported abuse to anyone. Children on the street, children at work, and children in institutional care reported highest incidence of sexual assault.[2]

Child sexual abuse is a punishable act as per the Protection of Children from Sexual Offenses Act the bill passed in the parliament in May 2012.[3]

Reporting is a difficult decision to be made by the survivors, many fear revictimizations through the criminal justice system and fear they may be blamed for it.[4]

Aim

By applying qualitative analysis, the barriers to seek psychiatric help among the stake holders of male child sexual abuse victims are explored.


   Materials and Methods Top


All the statements made by the stakeholders regarding psychiatric assessment and treatment were recorded in each referral made to the psychiatrist. Semistructured interviews and in-depth interviews were conducted to explore the topic of understanding the nature, aims, and need for psychiatric treatment to the victims.

The framework of themes and patterns generated an index of major themes. This index was applied to all the statements recorded in brief summaries of the interviewee's thoughts about abuse, victim, and victimization. The sample size required to reach saturation based on data collection method of in-depth interview was thirty for the parents and other focus groups of law enforcement and team members of multidisciplinary team (MDT) was ten.[5]

The topic guide for semistructured interview is as follows:

  • Do you think counseling or psychotherapy could be helpful or useful to the victim and the family?
  • If no is your answer, substantiate the reasons.


Aims and process of psychotherapy were explained to the caregivers as providing a holding environment for the child to facilitate the narration of the context of the relationship in which abuse occurred and to educate the child consequences in his own behavior due to the trauma.


   Results Top


Collaborative child response unit, a MDT, to tackle child sexual abuse in a general hospital received 3 referrals of male child abuse among the 27 referrals in 20 months [Table 1].
Table 1: Results: After 20 months (n=27)

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Qualitative analysis was done, using “frame work” method. The hypothesis/framework was that barriers to psychiatric treatment were exhibited by all the stake holders. Combination or mixed purposeful sampling (in qualitative analysis, the sample that reflects the barrier to treatment is selected) was made; using both stratified purposeful sampling of subgroup (focus group) and intensity sampling was done choosing information rich cases that manifest the phenomenon intensely.[5]

The main theme of the barrier that was generated by interviewing the stakeholders of male child victims of abuse was the misconception of superiority of a male victim due to gender (patriarchy); hence, an expectation that he will outgrow the experience. Minimization of abuse as his development ensured that he would be a dominant partner in the social world. The following three cases reported to collaborative child response unit illustrate the same.[5]

In-depth interviews of all three cases are presented below [Table 2] and [Table 3].
Table 2: Topic guide of the interview for qualitative analysis

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Table 3: Results of the interview

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Case 1

A 9-year-old boy, D, was brought to the collaborative child response unit with complaints of school refusal, academic decline, sleep disturbances, marked social anxiety, and withdrawal. According to the father, owner of a groceries shop, patient was being bullied by older boys in the neighborhood for money as he used to work in the shop. One day, patient's older brother aged 14 years alleged that patient was doing “dirty activities.” On questioning the brother, he reported that he had seen a mobile video where patient was performing fellatio on a guy who was above 18 years and known for petty crimes in that area. The video was shot by another boy of 12 years and the brother said that it was deleted by him. The incident had occurred 3 months ago. The video was used to blackmail the child and make him steal money from the shop to supply the abusers.

The father of the patient had assaulted the offender as he was told that it was by force and to extort money. Family was willing to press charges as per the Prevention of Sexual Offenses against Children Act 2012.[1]

Since the incident had occurred 3 months ago, no forensic evidence could be obtained and the mobile video recording was also deleted. The family was not interested in follow-up of psychiatric care.

“He is a boy; he neither lost a hymen nor will get pregnant. He should behave like a man, not a sissy” (father of the victim).

This is one of the very few cases of male child sexual abuse that was reported. Resistance to avail treatment was because of a gender bias. Patient had Axis 1 diagnosis of posttraumatic stress disorder, disabling symptoms of insomnia, school refusal, and academic decline.

Case 2

A 4-year-old boy was referred to the collaborative child response unit by another hospital with complaints of fever, excoriation in the anal region. Informant was the father. He told that he was sexually abused in the school toilet by two older boys, one of them beat him, holding him down, and the other sodomized him.

The child was clinging to the parents and was able to reply to yes/no questions about abuse and unable to report the events without leading questions from the psychiatrist and the forensic expert. The child refused to play with an anatomically correct doll of the male gender and preferred to play with a polar bear that was sexless in appearance. Child refused school, had sleeplessness, would watch cartoons on TV till 3 am, and suffered constipation for the past 8 days since the occurrence of abuse. On examination, there was no evidence of injury or sexual contact. Mother had applied soframycin ointment mixed with coconut oil from the day of assault, and child was treated for fever with antipyretics. The abdominal–pelvic ultrasound showed fecal impaction of the colon, was released by laxatives. The child showed interest in the lessons learnt at school, was able to reproduce rhymes, sums, and spellings. Due to lack of evidence, the abusers could not be brought to justice, the parents decided to relocate to their native place as the father lost his job due to litigation and stigma. Father was clinically depressed and decided to leave the city.

” If he was a 4-year-old girl, raped by two older boys, school would be afraid of a scandal, because he is a boy no one cares or accepts the crime” (father of the victim).

Here, the system consisting of school was indifferent because the victim was a male.

Case 3

A 7-year-old boy was referred by the police from an orphanage with reports of sexual abuse by a 14-year-old boy another inmate of the same orphanage.

The police had received a complaint from the father of the boy who was a native of another country because he was ill and his wife died while they came to India, he had housed his son in the orphanage. He usually took the son home during the weekends and while bathing him claimed to have noticed abrasions on the private parts of his son, while questioned the son alleged this other boy of sexual misconduct. The victim had several advantages over other inmates of the orphanage, he had facile command over spoken English, could play the piano, was kind and gentle. He was the favorite of most of the teachers. He had few good friends in his own class and reported being bullied by several older boys on a regular basis. On examination, no abrasions were found since several days had elapsed before the complaint was lodged. The victim also alleged that the older boy was being physically and emotionally abusive whenever he was alone. The child had newly learned to play cricket and was excelling at it too. He said that the other boy was rubbing himself on the child with all his clothes intact, it was coercive-induced fear and shame. The child expressed a wish to return to his motherland once the father got well. He had symptoms of complicated grief over the loss of mother. He reported feeling numb and disconnected. He was diagnosed with dissociative subtype of posttraumatic stress disorder.

The boy, who was accused, reported feeling jealous of the younger boy as he was the favorite of teachers and also as the father of the boy showed interest, took him home often. The older boy had no father and his mother visited him once a year, never got him gifts. His jealousy made him angry with the victim, and hence, he tried to dominate the boy by force, sexually. He was referred to another psychiatrist for correctional therapy. Because of the poor health of the father, follow-ups did not occur.


   Discussion Top


In the first case, the parents were keen on using the victim to sue the abuser and his family but were not sensitive to the psychological distress of the child who showed all the symptoms of posttraumatic stress disorder. They were under the false presumption that being a male made the victim resilient.

In the second case, the parents were disempowered due to lack of evidence. They felt a pathological sense of responsibility for not being able to bring the abusers to justice. Other stakeholders were perceived as hostile by the parents since they felt traumatized by the legal proceedings demanding the child to identify the abusers repeatedly. Moreover, school authorities were not fearful of public opinion as the gender of the victim was male and did not arouse as much public sympathy as in a girl child.

In the third case, the child was vulnerable because of exceptional abilities, death of mother, cultural disparity, and institutionalization. Moreover, children when institutionalized suffer serious physical and sexual abuse,[2],[6] reporting is unusual [3] because the father continued to be involved in the child care, and the case was reported to the police.

In all three cases, a social barrier to psychiatric treatment existed [4] though in the second case, the delay in the legal procedures toward justice to the victim was perceived to be due to the gender of the victim by the family. Moreover, relocation was the reason for not receiving help.[5]

Although India has the lowest sex ratio in the world at 914:1000 and the only country where prenatal sex determination is illegal and 48.4% of girls even now wish they were boys,[2] the “patriarchal social structure” of India has done little to protect the male children as revealed by the fact that the percentage of boys abused sexually are equal to girls. According to the study, they tend to be more often physically abused by parents, subjected to corporal punishment in school, often left to fend for themselves on the streets, and made to earn a living without having any control over their earnings.

The word “patriarchy” literally means the rule of father or the “patriarch,” and originally, it was used to describe specific type of “male-dominant” family. However, recently, it is used as a social, ideological construct that refers to the dominance of male and to the power relations that are hierarchical and unequal.

Benewick, a feminist psychologist, uses the word patriarchy to refer the kinship systems in which men exchange women and to the symbolic power that father exercises within these systems.[7] Kinship as the basis of society has been outlined in “the early history of institutions,” and patriarchy has been derived from the notion that wife is the property of the husband; hence, her offsprings are in his power too and it is a proprietary right. Walby, in her book, “Theorizing Patriarchy,” called it the system of social structure and practice of males to dominate, oppress, and exploit women. The concept of patriarchy has been indispensable to the understanding of gender inequalities.[8]

Patriarchal ideas blur the distinction between sex and gender and assume that all socioeconomic and political distinctions between men and women are rooted in biology or anatomy.[9] To analyze the origin of patriarchy, most sociologists reject predominantly biological explanations of patriarchy and contend that social and cultural conditioning is primarily responsible for establishing male and female gender stereotypes. According to standard sociological theory, patriarchy is the result of sociological constructions that are passed down from generation to generation.

These constructions are most pronounced in societies with traditional cultures and less economic development.[9],[10],[11] However, even in modern developed societies, gender messages conveyed by family, mass media, and other institutions largely favor males having a dominant status.

Similarly, the patriarchal nature of Indian society has led to very different expectations from boys and girls. Boys are expected to be “men” hence not cry or complain when abused. Many instances of corporal punishment are meted out to boys till they learn not to cry, and the abuser saying that he has taught the boy to be a man. Although the patriarchy in India is heterogeneous, classified as brahmanical, Dalit, and tribal patriarchies, they cut across family, religion, caste, to control women's production, reproduction, and sexuality.[11]

In any child protection service rendered by nongovernmental organization or hospital, utilization of services is more by girl victims than boys [12] so the iceberg phenomenon of child abuse, where we see merely the tip, in cases of male children is even more hidden, and perhaps, we do not even see the tip. Many cases of female child sexual abuse are accidentally discovered due to pregnancy and familial abuse is stopped by marriage, but disclosure rate among boys seems to be lower and accidental disclosure becomes more of a rarity leading to years of abuse.[13],[14]

Unlike females who often get abused in a heterosexual context, males tend to be abused by men leading to confusion in the sexual orientation of the victims, many of them doubting if they are homosexuals.[15] Patriarchy further condemns homosexuals as less of men, delaying disclosure further. Homophobia can lead to over sexualized behavior in the male survivors and boys tend to blame themselves more than girls for not being able to stop the abuse.[16]

Boys are often subjected to physical abuse along with sexual abuse, are abused forcefully, and often have been abused by a gang. Orogenital abuse is more common; hence, there is no forensic evidence as salivary specimen of semen is not available by the time reporting is done. Noncontact abuse is rare among boys; this makes the abuse to be more severe in boys.[17] Society is more dismissive of male child sexual abuse than that of girls as patriarchy has chivalry as a value attached to protecting girls and not boys.[18]

If we study Finkelhor's four preconditions for any abuse to occur, patriarchy renders it easier for the offender to overcome internal inhibitors, external inhibitors (boys are less watched and less protected than girls by their families), and overcome the resistance of the child, who because of his developmental immaturity, is equally vulnerable.[19]

Combination or mixed purposeful sampling (In qualitative analysis, the sample that reflects the barrier to treatment is selected) was made. Both stratified purposeful sampling of subgroup (focus group) and intensity sampling was done choosing information rich cases that manifest the phenomenon intensely.”[20],[21]

A society that restricts the expression of female sexuality by males but allows males to explore their sexuality through pornography or commercial sexual contacts and sells adult toys to aid male sexuality and capsules to enhance male virility places enormous pressure on males to perform sexually and does not protect them, equating sexual potency with male identity.[22],[23],[24]

There is a popular misconception that all adult sexual offenders were sexually abused as children, but 50% of child molesters were abused as children.[25] In this study, the total sample size of child molesters was 16, and among them, eight were found to have sexual abuse in their childhood history. Since the number reported is low and the number convicted is lower, these statistics must be viewed with caution.

Sexual misbehavior occurs in a continuum as outlined by Johnson ranging from inappropriate sexual behavior based on curiosity, sexually reactive behavior, extensive mutual sexual exploratory behavior, and sexually aggressive behavior.[26] She has outlined several factors leading to sexually aggressive behavior. Juvenile offenders have similar characteristics as adult offenders and harsh physical punishment, witnessing domestic violence, lack of empathy is more of a predictor than sexual victimization.[27],[28]


   Conclusion Top


To make this world safer for children, we need to protect our sons and daughters equally. Patriarchy is not protecting our boys more than our girls in childhood. The very low rates of reporting and help seeking among victims of sexually abused boys in India could be due to the hegemony of patriarchy. This social construct is usually being applied to understand the subordination of girls and women, the fact that it is oppressing all children who are perfect victims irrespective of their gender is being ignored in male children who are expected to be superior due to their biology and also because of this myth of superiority, there are unethical expectations for them to overcome the harmful effects of sexual abuse of childhood without treatment.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
World Health Organization. Definition of child maltreatment. Geneva, Switzerland: World Health Organization; 1999.  Back to cited text no. 1
    
2.
Ministry of Women and Child Development, Government of India. Study on Child Abuse: India 2007. New Delhi: Ministry of Women and Child Development, Government of India; 2007. Available from: http://www.wcd.nic.in/childabuse.pdf. [Last accessed on 2012 Jan 28].  Back to cited text no. 2
    
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Ministry of Law and Justice, Government of India. Protection of Children from Sexual Offences Act, 2012. New Delhi: Ministry of Law and Justice, Government of India; 2012. Available from: http://www.wcd.nic.in/childact/childprotection. [Last accessed on 2012 Nov 28].  Back to cited text no. 3
    
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Behere PB, Sathyanarayana Rao TS, Mulmule AN. Sexual abuse in women with special reference to children: Barriers, boundaries and beyond. Indian J Psychiatry 2013;55:316-9.  Back to cited text no. 4
[PUBMED]  [Full text]  
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Subramaniyan VK, Mital A, Rao C, Chandra G. Barriers and challenges in seeking psychiatric intervention in a general hospital, by the collaborative child response unit, (a multidisciplinary team approach to handling child abuse) A qualitative analysis. Indian J Psychol Med 2017;39:12-20.  Back to cited text no. 5
[PUBMED]  [Full text]  
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Gerda Lerner. The creation of Patriarchy. Oxford university press. London 1986. Available from: https://global.oup.com/academic/product/the-creation-of-patriarchy-9780195051858.  Back to cited text no. 8
    
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Heywood A. Political Ideologies: An Introduction. New Hampshire, United Kingdom: Palgrave Macmillan; 2012. Available from: https://www.he.palgrave.com/page/detail/political-ideologies-andrew-heywood/?sf1.st1.  Back to cited text no. 9
    
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Correspondence Address:
Vyjayanthi Kanugodu Srinivasa Subramaniyan
Department of Psychiatry, M.S. Ramaiah Medical College, Bengaluru, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/psychiatry.IndianJPsychiatry_195_17

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