Child Sexual Abuse and Its Implications for Children ’ s Health

The factors that contribute to violent responses – whether they are factors of attitude and behavior or related to larger social, economic, political and cultural conditions – can be changed. In this perspective, understanding the factors that increase the risk of young people being the victims or perpetrators of violence is essential for developing effective policies and programmes to prevent violence. (Krug et al, 2002)


Introduction 1.1 Contextualizing violence and child sexual abuse
The violence is present in the everyday life of citizens all over the world and in national and regional level too, affecting interpersonal relationships and influencing people's way of acting and thinking.
Violence is presented as a complex problem that affects, everybody without distinction, independent of social class, race, religion, sex or age.Today it is more studied, investigated and divulged and because of that it has acquired an important social meaning in the few years.(Moura & Lisboa, 2005) The factors that contribute to violent responses -whether they are factors of attitude and behavior or related to larger social, economic, political and cultural conditions -can be changed.In this perspective, understanding the factors that increase the risk of young people being the victims or perpetrators of violence is essential for developing effective policies and programmes to prevent violence.(Krug et al, 2002) However, we can note that the boundaries between different types of violence aren't well defined, so we must carefully examine all aspects of family violence, and particularly sexual abuse cases, seeking to get a better comprehension about the framework that professional faces.(Ciuffo, 2008) In general, hearing about real cases of sexual abuse cause on people a feeling of malaise.Sexual violence affects many layers of society and people of different ages, including children and adolescents.Reports of such aggression against a child who probably had been induced or coerced and even forced to participate in such an act unfortunately are common.
In this sense, report and prevent child sexual abuse and other crimes against children is a worldwide concern.The cases reported on television and in newspapers of general circulation represent only the tip of the iceberg.If thoroughly investigated, it may be noted that a large number of boys and girls are subjected to violence of all kinds in their daily lives.(Ciuffo, 2008) The interactions that individuals establish in society, economic issues, policies and legal requirements that govern society help us understand more clearly the various forms of violence and, among them, child sexual violence.155 development than the child or adolescent.The abuser or perpetrator has the intention to stimulate a child sexually or use it for sexual satisfaction.These erotic and sexual practices are imposed on children by physical violence, threats or inducements to his will / desire.(Krug et al, 2002).
Child sexual abuse is one of the most perverse forms of abuse that victimizes children and adolescents.The healthy life expectancy is severely threatened by the consequences of this experience.
Sexual violence, among all expressions of violence, brings more consequences for the child's life, considering that besides involving the physical part, it also affects deeply the emotional part, leading to brand that will be taken to adulthood.(Woiski & Rocha, 2010) Analyzing sexual violence, it is worth highlighting the inadequacy of isolating it from the psychological and physical violence.This can be explained because often other types of violence are associated, and the effects sometimes are worse than sexual violence only.
The threat was the most used (41.93%),followed by the use of physical force (29.03%) and seduction (16.12%) and there were no cases of use of a weapon of any kind.The threats often refer to the fact that the aggressor say to the children that they could not tell anything to the parents.In addition, many offenders make the victim feel guilty for the act committed by him (Inoue & Ristum, 2008).
Thinking about threats or physical abuse and their relation to sexual violence is essential and should not be forgotten.Therefore, it is necessary to contextualize the situations in which such act happened.
The data about this issue is worrying, as evidenced in this study, where the results indicate that children and adolescents victims of sexual abuse were, in most cases, female, 80.9%.The age of onset of abuse has focused on three age groups, with 10.6% of children ranging from 2 to 5 years old, 36.2% of these were between 5 and 10 years old and 19.1% were between 10 and 12 years old.Most children, 26.6% were attending primary school at the beginning of the aggression.(Habigzang et al, 2005) Considering the links between actors of this delicate situation can best direct us to confirm the diagnosis.An important aspect about child sexual abuse is the fact that in most cases the abuser is someone known to the child, so he approaches quiet easily and has great persuasive power.Generally, the main objective is to convince the child to do what they want in secret.(Ciuffo, 2008) Child sexual abuse sets up a phenomenon that affects the entire family, and often exacerbates family disintegration, especially when dealing with sexual abuse that occurs within families.(Carvalho et al, 2009) The perception of victims are related to the abuser shows that the majority of children and adolescents expressed the desire to stay away from the aggressor (41.8%) and were afraid of them (38.2%).Regarding the perception of aggression (31.9%) of the submitted information and documents examined, the children said they would not be conducive to the situation, or haven't consented, trying to avoid it, or expressed their lack of understanding of the abuse experience.(Habigzang et al, 2005) According to the records of the Guardianship Councils, between the years 2003 and 2004, were reported of 1,293 cases of violence, 1,011 (78.1%), originated in the home.The most frequent types of violence were: neglect (727), failure to provide basic care (304) and abandonment (259); physical violence (455), beatings (392) between 2 and 13 years old; psychological violence (374) through threats (219); sexual violence (68) through abuse (58), mainly among adolescents.(Costa et al, 2007) The same authors above clarify that sexual violence reached 68 cases, 58 were cases of abuse and 10 of them were sexual exploitation.The abuse occurred in all age groups, with 20 cases in the range of 10 to 13 years, 12 cases from 14 to 16 years and 9 cases from 6 to 9 years.
In a study which has a sample of 124 cases of suspected sexual abuse was selected, both male and female, aged from 0 to 17 years, the authors reveal that the relationship between victim / perpetrator was the father / stepfather / guardian -a total of 20 cases (16.13%)where 16 cases were female.When the abuser is a relative / acquaintance -the authors found 35 cases (28.23%),where 28 cases were female.When the perpetrator is unknownwas found in 17 cases (13.71%),where 16 cases were female.And finally, also has returned when the offender is not informed -we obtained a total of 38 cases (30.65%), 30 cases were female.(Aded et al, 2007) The prevalence of reported child sexual abuse in the sample studied was 3.9%, higher among girls (5.6%) than boys (1.6%).Over 80% of all reported first sexual abuse episodes took place before reaching 19 years of age; 63% happened before 15 years; 49% before 13 years; 27% before the children were 8 years old; and 6% before reaching 4 years of age.Among the respondents reporting being victims of sexual abuse before 19 years of age, 7.6% reported being less than 4 years old at the time; 37% were less than 8 years; 60% were less than 13 years; and 89% were less than 15 years.(Aded et al, 2007) The prevalence of self-reported sexual abuse before 12 years of age is higher among girls (1.7%) than boys (0.5%) and similarly higher among girls 12 years of age and older (1.5% vs. 0.3%).Girls experienced the majority of the total burden of child sexual abuse reported by the study participants (80% of the child sexual abuse before age 12, and 84.1% of it after age 12).While 53% of all reports of child sexual abuse for boys happened from ages 0 to 7, for girls, 33% of the child sexual abuse happened before age 8 and peaked around ages 8 to 15, when 88% of all reported abuses had already taken place.(Bassani et al , 2009) As a result of their study about the incidence of sexual abuse with children in Rio de Janeiro, found that the abusers had some link with their victims in 55 cases: 20 cases (16.13 %) were assigned to responsible parents or stepparents, and in 35 (28.23%), relatives (uncles, grandfathers, cousins) or acquaintances.(Aded et al 2007) Subsidized by the assertive in the study cited above, we could conclude that although there is a representation of the abusers at all levels of schooling, there is a higher prevalence among those with low education.Therefore, we must give attention to the issue of health education and more specifically for this population group, stimulating abusers a change of attitude towards children by getting them to understand that every child needs to grow and develop healthily, free from violence and surrounded by people who want their welfare.Drezett (2007) states that child sexual abuse is usually committed by people trusted by the child, prevailing parents, stepfathers, uncles and grandfathers as the main aggressors.A study on characterization and analysis of sexual violence cases performed at school revealed to the linkage between aggressor and victim, a higher frequency of domestic violence (56.0%) prevailed.The second most frequent category, this study was entitled "acquaintance" (40.0%) and refers to known offenders, but without any relationship with the victim.(Inoue &, Ristum, 2008) .
In a study it was verified that practically all offenders were known to the victim, with only one case of unidentified.The aggressors, all male, numbered a total of 25, since in two cases there was more of an aggressor.There was a predominance of ages "over 40" years (36.36%),followed by ages of 31 to 40 years "(22.72%)and" 20 years "(22.72%),with a variation 15 to 54 years.The forms of coercion or intimidation used by the aggressors were a threat, physical force, seduction and other unidentified.It was observed that in some situations, the aggressor used more than one form of coercion.The threat was the most used (41.93%),followed by the use of physical force (29.03%) and seduction (16.12%).( Inoue & Ristum, 2008) Although people believe that sexual violence is practiced by unknown people, most crimes are actually practiced by someone close to the victim.In this study, regarding age, there was a predominance of attendance for children (42%) and teenagers (36%).Considering separately by sex, was found higher frequency for female adolescents (40%).For males, higher frequency of sexual abuse was among children (79%).About the identification of the aggressor, it was found that 700 (76%) were identified by the victims.Among these, a greater proportion of the category friend / acquaintance (19.2%) was followed by a stepfather (12.4%), father (11.7%), neighbor (11.4%) and uncle (8 3%).(Campos & Schor, 2008) There are common feelings of fear, anger and shame of the victim regarding the abuser, especially in cases of sexual abuse because there is a disruption of the trust and bonding due to violence.(Habigzng et al, 2005) One of the most critical issue of this alarming situation is that in our society, often, the child becomes a victim of this assault for a long time.The attack remains hidden because the prevailing feeling of fear of suffering rebukes by the abuser.(Ciuffo, 2008) However, it is important not to make a pre-judgment of the abuser, but take into account that in some cases, victims didn't resist, others remain passive and others may encourage the abuser, in order to search for love and affection denied by them.But the fact is that most sexual exchanges between adult and child is initiated by the adult.(Ciuffo et al, 2009).

Most frequent forms of sexual abuse
Sexual abuse against children and adolescents can be subdivided, (Magalhães, 2005) The biopsychosocial consequences in situations of abuse are often related to factors such as the conditions in which it occurs, the child's age, degree of intimacy between the child and the abuser and others.So, it is essential that there are measures that seek to protect children and minimize the possibilities of new occurrences.

The nurse's role face child sexual abuse suspicion
Children constitute a group with high vulnerability and exposure to situations of maltreatment, and especially child sexual abuse, which is often imposed to the children by physical violence, threat or inducements to their will.(Ciuffo et al 2009) Obtaining of information and care directed to a sick child requires from the professional, much more than technical care, but subjective care too, since it considers the singularity and individuality of each child and also the expression of their feelings and emotions.It is important to consider the child victim of sexual violence story, in light to know how the child relates to the context in which violence occurred and all the symbols and meanings that this event means to her. (Woiski & Rocha, 2010) It is worth to emphasize that among the professionals involved in this context are the nurses and the nursing staff.These professionals have an important role in the treatment of children with suspected sexual abuse because they can, through care, child support, spread the love and security the child needs to face this situation. .(Woiski & Rocha, 2010) Moreover, nursing, considered as a social practice and committed to emancipation and human development, cannot be performed outside the perspective of the complexity of transformations in the contemporary social context, which includes the integral and multidisciplinary approach of domestic violence against children.(Silva & Ferriani, 2007) It must be considered that nurses can and should have a decisive action when fighting the everyday reality of sexual abuse against children, considering that, besides recognizing and identifying signs of abuse of they should be aware of laws protecting the rights of children's health and attitudes to be taken in these cases.Thus, it enables monitoring the situation of children and their families during and after children care and legal ramifications involved when one considers the suspected sexual abuse.(Ciuffo et al, 2009) It is necessary to understand that nurses must strive themselves working on a service geared to the real needs of the child and his family, seeking health education as a key point in all stages of care.Nurses' role as elements in the health team, imply in a more active attitude, appropriating new knowledge for nursing and practices.(Silva & Ferriani, 2007) Knowing the perception that children who are victims of domestic violence have on family care is crucial to understand their development and relationship with other people.The authors add that this issue is also important to develop more specific and resolutive care strategies.These strategies should be guided the rebuilding of relationships and possibilities preservation of parental bonds and family reintegration.(Gababtz et al, 2010) So, the planning, setting priorities, the survey of available resources are nursing actions that work as a lever to achieve the goals of health care for children and their families.For this, the family's involvement in all stages contributes to the success of care.
The singularity, habits, family dynamics, culture and social and financial situation of the family should be studied carefully so that the inclusion of nursing and health team for children and their caregivers are in line with the reality in which they live.
It is also important to emphasize that understanding an in-depth study of this phenomenon, taking into account its specificity, help nurses to think and act in a timely and proper posture in front of the child.(Ciuffo, 2008) In this perspective, one aspect of great importance regarding the nurse's role when treating a child with suspected sexual abuse is the "care from the perspective of another."The authors noted that preserving patient avoiding them to be exposed in the ward, in order to minimize the trauma suffered with a sensitive and a special look that includes the family, is part of nursing care.(Ciuffo et al, 2009) The nursing care has a broader significance for the human beings because it involves the relationship and interaction between people.When a nurse or any other professional is willing to help others to grow, to feel better, teaching them to become more independent they are taking care of them.
During the assistance of children with sexual abuse suspicion, the nurse has a valuable role and should seek to apply their scientific and technical knowledge to perform global care.So, it requires a deep study about this major public health problem in order to better direct nursing actions, making them more effective and focusing mainly on early detection and reducing the consequences.
Furhermore, research in the field of nursing focused on care for the child victim of sexual violence is of great importance, because it allows, not only to understand better experience of caring a child that lived such impacting phenomenon, but also to think about nurse's performance in this cases in order to improve it.(Voiski & Rocha, 2010) We believe that listening carefully to the reports, explaining the consequences of sexual abuse in child health for the family are fundamental steps.In addition, using an appropriate vocabulary respecting the social and cultural context and beliefs is an interesting posture to be adopted by the nurse in their daily practice.
It is clear for us that if nurses act this way they will have more possibilities to increase the chances of making a follow-up with the child, ensuring continuity and systematization of nursing care.
Professional role is to guide families to other ways to educate and communicate with their children, and accompany them with respect and attention.However, there are aspects of social and economic context that transcend individual or family behavior.The community or social group where the children and adolescents live with their families affects directly their behavior.In this reasoning line it is essential to think about the role of social networks support as important fronts for work and interaction with family from the perspective of protection, defense and guarantee the rights of children and adolescents.(Brasil, 2010) The professional intervention promotes physical and emotional health of children and adolescents in their process of growth and development, especially during times of major changes.So in the course of professional assistance, it is useful to highlight that the speech, the look, gestures, the information communicated in simple and accessible language can make a huge difference in building raport with the child.(Brasil, 2010) Sexual violence must also be worked preventively, together with the family and their children.It is possible to make an approachment, using language that is appropriate to their ages and explaining the issue of sexuality and also the body touches socially appropriate and inappropriate between a child and someone older or adult.(Brasil, 2010)

The interdisciplinarity in the performance of health professionals in relation to suspected or confirmed cases of child sexual abuse
The detection sexual violence cases is a very important step, however, the institutions where children are assisted have to prepare and train professionals to offer an appropriate care for the child and his family.To help unravel the principle that the data are hidden in the cases treated, it is missing the vision of multiple causes of such violence.(Ciuffo, 2008) Nursing actions can be thought as a driving force that propels nurses to develop researches in child health field.These researches may influence in a healthy growth and development in childhood.So, we agree that group actions with other professionals who work in the health care team are very important, because the chances of identifying health problems and needs related to them increases a lot.
Promoting interdisciplinary actions is vital to delivering an appropriate support, whose efforts should focus not only on physical examination and diagnosis, but also emotional and psychological support for the well-being of the individual, and in particular child who suffered domestic violence.The victimized child is very vulnerable because childhood is a stage of life where the greatest changes occur physically and psychologically.By these cahnges need to be followed in order to promote and maintain health, as well as the intervention on factors that could compromise it.( Grüdtner, 2005) Nurses and others health professionals must understand that children may be brought to professional attention because of physical or behavioural concerns that, on further investigation, turn out to result from sexual abuse.(Krug et al, 2002) In addiction, the authors above also affirm that to be able to detect child sexual abuse requires a high index of suspicion and familiarity with the verbal, behavioural and physical indicators of abuse.It is possible that many children will disclose abuse to caregivers or others spontaneously, though there may also be indirect physical or behavioural signs.
As a result of the study on nursing care of children with suspected sexual abuse, one of the categories that emerged from interviewees' speech was entitled "interact with other professionals in child care," where many subjects emphasized in their speeches that a step of great importance in the care of children who suffered sexual abuse lies in interdisciplinarity. (Ciuffo, 2008) Joining forces with other professionals to provide a better service that is comprehensive, focused on the social, emotional and psychological aspects.In this perspective, it is possible to characterize the contribution of professionals of many different formations in attendance.(Ciuffo, 2008) It is of great importance that the team of professionals from different fields comply with the trauma and pain produced by violence, considering that this phenomenon goes beyond the socio-cultural factors and also the legal, since violence interferes in the victim's psychological field and also in their family structure.(Carvalho et al 2009) In the study on labor relations in interdisciplinary teams, the authors emphasize that the contribution of new forms of work organization in health.As a result of their study it was found that there are several factors that influence in improving the relationship between professionals and clients, some of them include: bonding, acceptance and quality care.(Matos et al 2009) In this sense, it is possible to say that the routine of health professionals should include recognition of signs of various forms of violence against children.They also need to be aware that the approach of these situations involves the complexity .So, when suspecting or confirming the existence of ill treatment, try to keep in mind that not only skill is necessary, but also sensitivity and commitment to this cause.(Voiski & Rocha, 2010).
Undoubtedly, the above mentioned factors are of great importance in assisting interdisciplinary teams in health practice and also in attention to child and family.We would also add empathy, willingness to help, to hear and a comprehensive view at the problems of others.(Ciuffo, 2008) The interdisciplinary team should seek to achieve weekly meetings in order to discuss the cases treated to facilitate and ensure the timing in attendance, allowing an integral and homogeneous comprehension by all professionals on every patient seen.Also according to these authors, "this work dynamic enables an actual vision of each work on violence, while ensuring higher quality of care to victims.( Mattar et al 2007) Nurses should understand and prioritize the need of interaction with other professionals in attendance, seeking to find better solutions for their actions.Thus, it is also an opportunity to gain more support and acquire new knowledge from this interaction with other professionals.( Ciuffo, 2008) There are many socio-cultural contradictions, family conflicts and professional dilemmas involved in violence situations.Exploring these interfaces represent that the professional has a commitment with the family, the aggressor and the child that experience violence in everyday life (Pierantoni, 2007).Thus, the task of monitoring the situations of violence requires the nurse and the interdisciplinary team to work in health education and skill development to each case of violence, the use of group discussions and a deep study to apply prevention and intervention of this issue towards a more effective approachment.
Every health professional has special moments of contact with children, adolescents and their families.For example: receipt, vaccines, bandages, health education and medical, dental, nursing or psychological care, home visits, among others.
The moments described above are appropriate and create favorable conditions to observe the existence of signs and symptoms that may be resultant of a violent situation.Also they promote the required care for the protection and welfare of the child and it is an opportunity to give orientation to families about prevention and how to overcome the violence.(Brasil, 2010) It is necessary to develop reflections about the needs of studies that seek understand more clearly the complexity of different realities where violence occurs.However, there is a difficulty in understanding violence in different contexts, because each professional has a point of view of someone who has experienced it.But we also must expand our knowledge and also see the violence as a consequence of a complex relational dynamic.(Nunes et al 2008)

Conclusion
Through the present study, we could conclude that nursing staff and the multidicisciplinar team must be motivated by this problematic, directing the service for the necessities of the child who suffered violence.It is important to adopt a posture that enables the professional to give specialized attention, to listen and to agree on possible solutions for the problem, building an assistance with better quality.
Furthermore, we believe that extensive research in this area provides a broader perspective, which not only addresses to the symptoms and signs, but also searches tools to identify the clinical features and history of violence.
Nurses should contribute with the nursing staff guiding their care.It is primordial exercise an especially attentive listening and careful observation for the child who suffered sexual violence.It is also important to be available to understand the attitudes, postures, verbal and non verbal expressions of children and their families, which might have significant meanings.
Nursing is considered as a social practice which is committed to emancipation and human development.In this thought line, it cannot be performed outside the perspective of the complexity of transformations in the contemporary social context.So, it must include the integral and multidisciplinary approach of domestic violence against children.(Silva & Ferriani, 2007) In this sense, studies are necessary for establishing national and international parameters and more precise drawings about the risk factors and prevention.We believe that still exist a gap in nursing actions.So, the studies in this area are very important, since every time the nurses can't detect a sexual abuse suspicion, they are colluding with the possible recurrences.It is important to remember that other types of violence may also be present in that child's life.
In addition, we believe it is essential to rethink public health policies in order to develop new actions that would not only prevent the phenomenon, but also protect the victims, avoiding the appearance of new recurrences and promoting the health of children and their families.
The situation of child sexual abuse is undoubtedly a great challenge today.If society isn't interest in understanding violence, its magnitude and its density, there will never be appropriate tools to fight it, or care for its victims.(Carvalho et al, 2009) It can be reaffirmed that domestic violence against children and its nuances impose themselves as an exercise to understand the current dynamics of the family and society.The theme is complex and, given its complexity, knowledge about it is still under construction.(Silva & Ferriani, 2007) The study above aimed at assessing information systems to accompany the magnitude of the problem, that attempt to improve a theoretical-analytic reference framework that is capable of permitting an understanding of the specific nature of this phenomenon today, the vulnerability and protection factors which different cultures and societies have in common.
The restitution of the child's self-esteem, reframing the moral values of children and family and a deep reflection on the training of individuals in society are points to be observed, studied and analyzed by all of us as human beings.
It is necessary trained professionals who can investigate and take appropriate tools to apply in resolving this type of violence, we must take the allegations seriously.We believe it is substantial special units in police departments, special public prosecutor to alert the school professionals to be vigilant to signs of identification of cases.
Cases of violence are increasingly closer to the daily lives of people.Every day appears stories of violence in media and this phenomenon has assumed a social problem.Thus, health professionals can not be indifferent to this situation and should position itself as a facilitator and organizer in the network of support and protection for victims.(Luna et al, 2010) We understand that child sexual abuse and various types of family violence can be avoided if health professionals, with the support of education professionals, police, government officials know how to recognize suggestive signs in these situations.
The development of multisectoral and multidisciplinary actions in order to have a closer look into the risk factors of sexual violence in childhood allied to prevention of recurrence of the cases can be a feasible path to help solve this collective problem.
Governments have an important role to play in public education efforts, national and also international campaigns carrying the message that abused children have rights and that there are ways to prevent and avoid not only sexual abuse but all aspects expressed by violence.
From the statement above is interesting to reflect on possibilities to act in advance.We must think about prevention, the way is by investigating profiles and main characteristics of violence.Moreover, understanding the context and the circumstances in which the violence occurs facilitates the intervention's planning.
In this perspective, we must pay attention to the risk factors above when we are in nursing assistance.It is also of great importance hearing the victim's story and try to contextualize the problem, seeking the most appropriate solutions.
Challenging violence requires an effective integration of different sectors such as health, security, justice and education, as well as the involvement of civil society organizations.(Inoue & Ristum, 2008) As conclusion it was point out the relevance of this theme.Everyone can exercise their coparticipation in the protection of children, who are in the phase of growth and development.
This study also suggests new researches to supplement gaps in knowledge and improve children's quality of life.(Martins, 2010) Professionals who deal with children need to be engaged in various everyday issues that affect the lives and health of human beings.F o r t h a t t o h a p p e n , t h e r e m u s t b e a n "awakening of consciousness" through studies, training and practice that every day throws us new challenges to overcome.We think that life itself invites us to learn new lessons every obstacle, thus enabling the reflection, a rethinking of old concepts no longer apply to the practice, and the need to be guided by the construction of new knowledges considering the inexorable changes in society and science advances.
Verbal sexual abuse can be characterized by the conversations about sexual activities with the aim of arousing the interest of the child and adolescent and shocking them; -Sexual harassment is configured in the proposals of sexual contact, which in most cases the victim is blackmailed by the position of power occupied by the aggressor; :www.intechopen.com-Pornography refers to the use of children and adolescents as actors or models in obscene pictures and videos, usually for economic purposes, and -Prostitution concerns the participation of children and adolescents in sexual acts with adults or other minors, where there is not necessarily physical strength, but in this kind of situation there might be coercion.