Sexual Abuse

As part of a study designed to better understand the impact of forced migration on fertility, mortality, violence and traumatic stress among Sudanese nationals living in southern Sudan and Ugandan nationals and Sudanese refugees living in northern Uganda, we interviewed 3371 individuals from 1842 households in the Ugandan and Sudanese populations in the West Nile. Interviews were structured and were administered in the native languages of Lugbara or Juba Arabic. The study's design involved a multi-stage sampling design.
The full training of the interviewers took two months. The project objectives and the rationale behind the structure of the survey instrument as well as that of each question in the questionnaire were discussed in detail. Great attention was also paid to issues such as initial contacts, maintaining a professional attitude while in the field, avoiding influencing the respondent, and reducing interviewer and courtesy biases. The importance of collecting information by means of standardized questions so that the same question was asked to all respondents is stressed and questioning and probing skills were developed. Supervisors were instructed separately on data collection guidelines, their roles and their responsibility to ensure data quality. Keeping in mind the sensitive nature of some of the questions regarding violence and trauma and the fact that the team members were from the study population and probably had experiences similar to the respondents, a workshop on sexual and gender-based-violence was conducted by a consultant to the UNICEF office in Kampala, before the survey. The aim of this workshop was to increase awareness and sensitivity of the team towards respondents and their experiences. Another consultant to the project reviewed the team's interviewing skills and the project's data quality control measures just before the start of the survey. Problem areas were identified and remedied.
Data were complete and analyzed for N = 3179 respondents: 2,540 (75 %) of the respondents were women (15–50 years of age) and 831 (25%) were men (20–55 years of age). Details of the sampling, translation and assessment procedures, as well as the socio-demographic characteristics of the populations, have been described elsewhere [15 (link)].
Traumatic events were assessed using a checklist consisting of possible war and non-war related traumatic event types (i.e. witnessing or experiencing injury by a weapon or gun, beatings/torture, harassment by armed personnel, robbery/extortion, imprisonment, poisoning, rape or sexual abuse, beatings, abduction, child marriage, forced prostitution/sexual slavery, forced circumcision, etc.). The checklist was compiled after interviews with key informants (security personnel, doctors, community leaders, women's representatives) and 30 respondents from all three populations about their personal history of stressful events. Following these interviews, the single events obtained in these studies were rated as being potentially traumatic by experts. The following pilot checklist was pre-tested among further 44 Ugandans and Sudanese in areas not selected for the survey and modified according to the suggestions of the respondents. A primary item analysis based on inter-item correlations led to the exclusion of some events that were obviously not directly related to traumatic histories, e.g. the experiencing of witchcraft. Events included 19 experienced events and 12 witnessed events. Respondents were asked for each event type if they had experienced or witnessed such an event ever (i.e., lifetime experience) and if it happened in the past year. PTSD in respondents was assessed using the Posttraumatic Stress Diagnostic Scale (PDS), modified for assessment by trained lay interviewers [16 ]. The PDS is a self-report measure widely-used in industrialized countries as a screening instrument for the diagnosis and severity of PTSD based on DSM-IV Criteria.
Confidentiality was assured and it was explained that researchers were not working for any UN or Ugandan government organization. Informed consent was obtained using a standardized form explaining the potential risks of participation and explaining that no compensation would be provided. Informed consent forms were signed by the respondent and a witness; fingerprints were taken from illiterate respondents. No financial incentives were provided and respondents were informed that no improvements in living conditions were to be expected as a result of participating in the survey. Respondents were provided with referrals to counseling services provided by NGOs where available.

Subscales that contained 5 or more items were scored for severity of exposure to the latent category by determining the number of items with positive endorsements and model parameters. These scores typically fell between values of-4 and +4 and represent mean-centered logit scores. They were recalibrated to range from 0–10, so that total exposure severity levels across the 10 subscales could range from 0–100. Subscales with 4 items could not be scored in this manner due to insufficient item parameters. Instead, they were scored 0, 3, 5, 8 and 10 based on a linear interpolation of number of items positively endorsed.
MACE criterion scores for indicating above threshold exposure within each MACE category were established by comparing MACE severity scores to cut scores of other instruments. Criterion scores were designed to be similar to the ACE (comparator) for the six overlapping categories (sexual abuse, physical maltreatment, emotional neglect, physical neglect, emotional abuse, and witnessing interparental violence). The parental and peer verbal abuse category of the MACE was compared to the Verbal Abuse Questionnaire [46 (link)], that provides separate measures of maternal and paternal verbal abuse, as well as of female and male peer verbal abuse. Maternal and paternal verbal abuse score were averaged and a cut score (>40) was used for comparison. Female and male peer verbal abuse scores were combined and a maximum (male or female) score of 30 (significant level of verbal aggression) and 40 (substantial level of verbal aggression) were used as comparison cut scores [25 (link)].
The Abuse and Trauma Questionnaire that we created and used in previous studies [25 (link),26 (link),46 (link)], provided additional data on 766 of the subjects for establishing criterion scores for exposure to parental physical abuse, peer physical bullying, sexual abuse, witnessing interparental violence and witnessing violence to siblings. This instrument assessed exposure to physical abuse by the question: ‘‘Have you ever been physically hurt or attacked by someone such as a parent, another family member or friend (for example have you ever been struck, kicked, bitten, pushed or otherwise physically hurt)?” If so, they were asked to provide information on their relationship to this individual, the number of times they were hurt, age of initiation and termination of these episodes, whether the abuse received, or should have received medical attention, and whether the abuse resulted in permanent injuries or scars. Similarly, sexual abuse was assessed by response to the question: ‘‘Have you ever been forced into doing more sexually than you wanted to do or were too young to understand? (By ‘‘sexually” we mean being forced against your will into contact with the sexual parts of your body or his/her body)”. Witnessing violence was assessed using the question, “Has an adult member of your family ever purposefully attacked another family member (i.e., struck, kicked, bitten, pushed, hit)?” Followup questions identified the individuals involved, number of times observed, ages of initiation and termination and severity.

Fragmented, often abusive early settings characterised by poor relationships with one or both parents characterised participants sense of their place in the world. The family home was frequently associated with experiences of physical, emotional and sexual abuse. With the disruption of formative networks and bonds with caregivers, this culminated for many within institutional care or the care of relatives. Reported experiences of care were mixed, with many women describing “getting in with the wrong crowd” and taking drugs for the first time but also feelings of relief during a respite from abuse at home:

Me mam was a severe alcoholic. I used to get beat up daily. The school didn’t do anything until I was 12-year old, after me nanna died. And basically, I got put with the person who was actually raping me. So I was there for 3 months and the trauma of that, I just couldn’t cope with. So I rebelled at school, and that’s when I got put into […] children’s home. Things started to calm down a little bit there, but I just wanted to be – it sounds stupid – but I wanted to be where my safety net was, where my mam was (Rosie).

Women described the home environment being one where substance misuse and interpersonal conflict were normalized. Trauma was widely experienced, with multiple adverse experiences throughout the life course. Leaving home often occurred as a result of crisis, either the death of a main caregiver or family breakdown. Women described getting into relationships with older men, which provided both a means of escape and in many cases a trap. For Michelle, a relationship initially provided a refuge from her homelife and though the relationship quickly turned sour her mother did not allow her to return home: “I moved out when I was 15 year old I rang me mam crying cos I was miles away from [home …] and she went “you’ve made your bed you lie in it” (Michelle).
Early experiences of abusive family life set future expectations of relationships, where physical violence was normalized and associated with love. Tracy described how unremarkable experiences of violence were, which foreshadowed later relationships:

I was beaten as a child by my father. My mother beat my sister. Never ever hit me. Sides get picked, you get her I get her. And I thought it was how someone showed that they loved you, you know? … I had my nose broken. First my dad. And then boyfriends. There was a competition going on. It becomes a way of life I guess (Tracy).

Early experiences of lack of informal support of parents and extended family; resources that are normative and critical to healthy child development and achievement even into early adulthood [64 (link)] impact these women throughout their lives. Experiencing early trauma, including emotional, physical, and sexual abuse, neglect, parental mental ill-health and/or substance abuse, are all particular risk factors associated with unresolved trauma and long-term homelessness in adulthood [65 (link)].

Child abuse was defined as any of the following acts being committed by a caretaker (parent or guardian) on a person younger than 18 years: physical abuse, neglect, sexual abuse, and psychological abuse.³ Details on the reporting of abuse under the Japanese system are given in eMethods in Supplement 1. Hokkaido University deemed this cross-sectional study exempt from ethics review and waived the informed consent requirement because publicly available aggregated and anonymized data were used. We followed the STROBE reporting guideline.
We obtained the publicly available 2019 to 2021 monthly number of child abuse consultations and estimated the child abuse consultation rates in 47 prefectures from the Ministry of Health, Labour and Welfare in Japan.³ The pandemic binary term was encoded with 0 for 2019 (prepandemic period) and 1 for 2020 to 2021 (pandemic period). We used an interrupted time series method to estimate the association of the pandemic with consultation rates for the first-stage, prefecture-level analysis. Subsequently, the first-stage analysis estimates were pooled using a random-effects meta-analysis model to generate the nationwide association. Parameterization of methods is described in the eMethods in Supplement 1. Analyses were performed using R, version 4.2.0 (R Core Team).