Psycho-social sufferings and sexual difficulties among female survivors of child sexual abuse in Pakistan

Abstract

Background

Child sexual abuse is a universal social challenge and the victims of childhood sexual abuse suffer a range of short and long term psychological, social, behavioral and physical problems that vary in different cultures. The study was carried out to explore the perceived impacts of childhood sexual abuse in Pakistan, because no such study was conducted in Pakistan earlier.

Methods

Interpretative phenomenological analysis was used to analyze the data. A snowball sampling technique was used to approach the sample of current study. The sample of the study comprised ten female survivors of childhood sexual abuse of age ranged between 18 and 22 years (M_age= 20.10 years) with the education ranging from matric to BSc. Out of these participants, four were married and six were unmarried and belonged to different cities of Punjab, Pakistan. Data were collected via a semi-structured interview schedule and all interviews were verbatim transcribed.

Results

A rigorous iterative process of data analysis resulted in three super-ordinate themes and ten sub-ordinate themes: Experiencing Abuse (emotional trauma, and physical distress), Psycho-social Distress (low self-esteem, negative self-concept, psychological pain, social suffering, and retaliation vs. forgiveness), and Sexual Difficulties (passive role, emotionally aloof, aversion from hetero-sexuality and avoidance).

Conclusion

It was concluded that childhood sexual abuse is an intense experience that has short- and long-term negative impacts on the lives of female survivors and engulfs their lives as a whole. The study has implications for psychiatrists, psychologists, family counselors, social scientists, educationists, and parents.

Background

Sexual abuse of children (CSA) may commonly include sexual touching, sexual penetration, or noncontact sexual acts such as exposure. Child sexual abuse takes place all over the world, but the exact prevalence cannot be claimed, as the acts of sexual abuse are kept hidden to save the dignity of the victim and family. Shame and stigma compel many survivors to conceal CSA. A very limited set of fragmented data on CSA is available. Police statistics for example, are often inadequate and unreliable because custodians/parents of many female survivors do not report sexual violence to the police for the fear of not being understood and being blamed, abashed, and embarrassed. Incidents of sexual abuse are mostly underreported in Pakistan and the reason might be social costs and stigma attached to victims of sexual abuse. Even with underreported cases, the numbers show that sexual abuse is a prevalent crime across Pakistan [1, 2]. According to a report of ‘The News’: a leading newspaper of Pakistan, 3,832 cases of child sexual abuse were reported in 2018 [2], which is a 33% increase from the preceding year. The annual report published in the year 2019 by ‘Sahil’: an NGO working to safeguard children from abuse, revealed that during the year, a total of 2,846 cases of child sexual abuse were reported in newspapers. The report states that on an average, eight children are abused in Pakistan every day and the children belonging to the age group of six to fifteen years are the most vulnerable [3].

Most of the time, the incident of CSA remains hidden, because children are not in a position to talk about the heinous crime that they have suffered [3]. Qureshi, the author of the book “Mera Jism Mera Hai” on the topic of child sexual abuse in the context of Pakistan, talked about the several obstacles and factors that stop people from talking about their experiences. She states that the first hurdle is the inability to communicate. Even when children realize that the things happening to them are wrong, they lack the vocabulary and a safe space to have those conversations [3]. Moreover, offenders often intimidate or manipulate the victims and pressurize them to stay silent. The survivors often feel embarrassed, humiliated, and guilty about the abuse and blame themselves for letting the incident happen, even though– it is not their fault [3]. Most of the time, the incident of CSA remains hidden. It is the social norms and cultural practices of Pakistan that stop children or their parents from reporting sexual abuse and the legislations that deal with child sexual abuse are very confusing. The problem does not lie with the availability of legal framework but the main concern is lack of interest of the government to take the necessary steps to implement child protection law [4]. The contemporary researchers have displayed an increasing interest in the short-and long-term consequences of CSA. On the basis of those empirical studies that have been undertaken comprising both male and female participants, literature illustrates that the prevalence of reported sexual abuse has been higher among the female survivors than the male survivors [5]. Read et al. as cited in Cavanagh et al. [6], after the review of 40 international studies of adult and adolescent female service users, calculated that as many as 50% of women and 28% of men had experienced childhood sexual abuse. The mainstream knowledge in this area is constructed on cross-sectional studies [7].

Impact of CSA on mental health can be as serious as its physical impact, and may be equally long lasting [8]. Wagenmans et al. [9] highlighted the occurrence of prolonged and severe psychological disorders among individuals who previously experienced child sexual abuse. Sexual abuse in the middle childhood or adolescence is associated with the symptoms of psychopathologies like; depression, anxiety, and PTSD [10]. A history of childhood abuse is associated with a number of long-term emotional consequences, such as prolonged symptoms of distress [11] and other mental health and behavioral problems in adolescence and adulthood [12] for example; depressive symptoms, sleep problems, somatic complaints, and behavioral problems like, social anxiety, timidity, nervousness, and aggressive behavior. Blanksby and Barber [13] have identified various mental and physical problems that can occur due to childhood sexual abuse as “depression, low self-esteem, anxiety, behavioral problems, social problems, drug use and impaired relationships and a range of sexual relationships” (p. 177). Psychological impact (e.g., poorer emotion regulation, PTSD, depressive symptoms, and problem behavior) are the common consequences of sexual assault among women survivors [13]. Most research suggests that earlier onset of sexual abuse is linked with more severe symptoms of depression, anxiety, and PTSD [14]. Gupta and Garg [15] also noted that child sexual abuse indicates an increased self-harming behavior, fear, depression, impaired brain development, and others that are criteria for developing post-traumatic stress disorder (PTSD). During sexual abuse, victims can feel fear, anxiety, self-blame, guilt, confusion, and anger. They feel self-conscious and humiliated, unable to talk about what happened, which can result in stress and frustration [16]. Younger children are generally unable to defend themselves or receive social support after being the victims of CSA [17], and as a result, they undergo learned helplessness, powerlessness and poor self-efficacy [14]. Empirical studies report an increased suicide ideation among the individuals with the history of childhood sexual abuse and maltreatment [18, 19]. Fear of disclosure is among the frequently narrated psychological symptoms in the survivors of CSA. Research suggests that disclosing and receiving negative responses predict even worse psychological consequences than not disclosing at all [20]. Longitudinal analyses indicated that only negative reactions to disclosure predicted symptoms of post-traumatic stress. Thus, these analyses show that perceived support and negative reactions to disclosure appear to play unique roles in adjustment. Disclosure is often viewed in American culture as an important and beneficial step in trauma recovery [21], whereas studies have elucidated some of the potential social costs and detrimental psychological effects of disclosure, particularly, in case of negative response to disclosure [20]. It might be the reason that most victims report sexual abuse in their later life [22]. Excessive negative perceptions of abuse have been associated with the presentation of more psychological symptoms [17] for example, disbelief was perceived by the survivors, who were abused by relatives compared with those who were victimized by acquaintance and stranger victims. Previous studies have recognized that CSA survivors were more likely to rely on avoiding coping strategies in response to distress [23].

Child sexual abuse also disrupts the social relationships of the survivors. An important factor linking CSA to chaotic social relationships is a family response to sexual abuse that usually induces guilt by putting responsibility on women and exempts men from any punishment, focusing more on regaining “lost” family honor. Literature indicates that sexually abused children scored lower on interpersonal trust in people surrounding them compared to non-abused children [24].

Given that CSA is a high prevalent phenomenon and has prolonged negative impact in adulthood, it plays significant role in sexual development and later sexual functioning of a larger segment of population (i.e., both male and female survivors of CSA). Empirical studies reported a significant relationship between CSA and symptoms of sexual dysfunction and problems [25, 26]. However, the complexities of how and to what extent CSA affects sexual functioning is still not well understood. CSA is associated with an increased risk of a range of sexual health problems, with both immediate and long-term consequences [27]. Literature indicates the likelihood of lower gratification and pleasure in intimate relationships, lower sexual satisfaction and sexual arousal/desire among the female survivors of CSA as compared to women with no history of abuse [7, 28], which is consequently associated with lower satisfaction in marital relationship [29] and higher incidences of divorce [30]. In a study by Najman et al. [31], statistically significant associations between sexual abuse and sexual dysfunction were evident for women only.

Experience of CSA also affects the process and interpretation of sex related information.

Women with CSA histories perceive sexual information as threatening [31], and it is significantly linked to sexual dysfunction in the survivors of CSA [32]. Sexual abuse may create maladaptive beliefs and attitudes towards sexuality, as a consequence, survivors process sex-related information through a threatening lens, and these women experience less pleasure and greater distress when thinking about sex, which leads to lower frequency of and less pleasure during sexual activity, and results in greater sexual dysfunction and lesser sexual satisfaction. Women with the histories of CSA also report lower sexual desire, inhibited sexual arousal and orgasm, and higher sexual pain than women without such histories in both community [31] and clinical samples [33]. There is a need to discuss and raise awareness about child sexual abuse [34].

The rate of CSA is critically rising in Pakistan [3]. A heinous crime like CSA remains hidden either due to the social stigma or because of the negligence shown by the parents that hampers therapeutic process that is needed to restore the physical health and well-being of the survivors [35]. Sexual abuse is linked to the loss of dignity and honor in the Pakistani society, therefore, any legal and psychological measures to protect the victim and her family from rejection, and social ostracization are kept at bay for the fear that if the identity of the survivor is revealed, the survivor and her family will eventually become a “social outcast whose social-self is torn in the jaws of dishonor and humiliation” [35].

Very few researches on the psychosocial and sexual experiences of female survivors of CSA have been undertaken in Pakistan in contrast to Western societies, due to the fact that CSA is somehow a taboo area in traditional societies like that of Pakistan. Thus, there is a need to spread awareness regarding the gravity of psychosocial problems and sexual difficulties experienced by the survivors of CSA. There is also a need to study the perceived impacts of CSA on female survivors in Pakistan, where girls are kept protected and under the supervision of brothers, mothers and fathers to safeguard their sanctity and to protect the honor of family lineage as well. The present study is important as it focuses on the holistic experiences of female survivors who experienced child sexual abuse in the form of sexual penetration: the worst form of CSA.

Aim

The objective of the study was to explore lived experiences and perception of short-and long-term impacts of childhood sexual abuse to gain a deeper understanding of what is needed for designing counseling programs for the female survivors of CSA.

Research Questions.

• 1. What are the psychosocial experiences of female survivors of CSA in Pakistan?

• 2. How do female survivors of CSA in Pakistan perceive its impact on their sexual orientation and behavior?

Methods

Study design

A retrospective qualitative research design was used to collect data. Identifying and approaching the sample of female CSA survivors was a challenging task, so a snowball sampling technique was used to approach the sample of study. Initially, two participants were approached via personal contacts and through an NGO (anonymous) and rest eight were indicated by the participants.

Sample

The sample of the study comprised ten female survivors of CSA at the age between 9 and 12 years i.e., middle childhood [36]. In IPA studies, the less sample size is considered more, and small sample sizes are common due to the emphasis on understanding the lived experience of each participant [37, 38]. The age range of the participants was between 18 and 22 years (M_age= 20.10 years) with education ranging from matric to BSc. Out of ten participants, four were married and six were unmarried. Four participants were abused by relatives and six were either abused by acquaintances or strangers. All participants belonged to middle income families of different cities of Punjab, Pakistan.

Inclusion/Exclusion criteria. The women who experienced abuse in the form of sexual penetration were included in the study, while other forms of sexual abuse were excluded. The women who were confident that they remembered every detail of the sexual assault were included in the study. Women, who were abused in middle childhood/preadolescence were included in the study, because ages 6–12 are the most crucial years of a child’s life [36]. Those women who were abused after middle childhood i.e., 13years and onwards [39] were not included to maintain the homogeneity of the sample, as recommended by Pietkiewicz. & Smith, for IPA studies [40], sample should be preferably homogeneous. The women who were under any psychiatric treatment, and those in their late adulthood were also excluded from the sample.

Table 1 Demographic characteristics of the sample (N = 10)

Table 1 shows the demographic characteristics of the sample, where four participants completed matric level education, four did F.A. and two completed BSc degrees. Four participants were married and six unmarried. Perpetrators of four participant were relatives and six were strangers or acquaintances. Five participants belonged to Lahore, two Multan, one from Gujrat, one from Kasur and one from Sahiwal.

Instrument

Data for the current study were collected via a semi-structured interview schedule, prepared by the authors for this study (attached as a supplementary file). The interview schedule covered CSA related emotional, psychological, social and sexual experiences of the participants. First, third and fourth authors developed interview questions independently and finalized the schedule of semi-structured interview collectively. Then a professor of social work, who had experience of working with the victims of child sexual abuse was requested to critically read and give suggestions. After incorporating her feedback, interview schedule was ready to be used for conducting interviews. Interview questions were carefully worded, so that it might not trigger the emotional outburst. For example; Would you like to share any childhood incident that has strong impact on your life? What was the first thing that came into your mind at that time? How did you react during that assault? How did your parents/family come to know? Their reaction? Could you please share the kind of changes you felt in your personality, identity and relationships after this incidence? etc.

Ethical consideration

The study was approved by the Department of Psychology of GC University Lahore and Bioethics Committee of the University issued clearance certificate (No. GCU/IIIB/138). Written informed consent was taken from the participants. Written permission to audio record the interview was taken in the consent form. There was no harm involved in the study. To uphold the promise of confidentiality, pseudo names were used to hide the identity of the participants during the interviews. In order to safeguard their identity, even participant number has not been mentioned in the verbatim on the request of participants. Participants were informed that they had a right to withdraw their participation at any point. A trained clinical psychologist remained present during all the interviews, so that during and post interviews, counseling could be provided to the participant in case of emotional disturbance. APA ethical guideline was followed in the study.

Procedure

The survivors of CSA who gave consent were very committed, but they were very conscious about the confidentiality and disclosure of their experience. They were assured that their identity would not be disclosed in any form. Interviews were conducted at the preferred places and time of the participants (authors’ home, office and participants’ own home). The interviewers had formal training (in MPhil and Post doctorate) in conducting semi-structured interviews and interpretative phenomenological analysis (IPA). Two meetings were arranged with every participant: In the first meeting, consent for interview was taken and in the second meeting interviews were conducted. Two participants (participant 5 and 10) did not allow audio recording of their interviews, so the 3rd author took detailed notes during interviews that were conducted by the first author. Initially, 14 female CSA survivors were contacted, but only 10 agreed to appear for the interview. Interviews took 50 to 70 min. The interviewers asked all the questions from the semi-structured interview schedule with prompts and probes and stopped with the last question (viz., Anything else that you want to share related to your experience of sexual abuse and life after that, you can please share? ). No emotional outburst was observed during the interviews.

Interviews were conducted and transcribed in Urdu and the selected verbatim to be included in the manuscript was translated in English by the first and second authors and validated by the third and fourth authors, and finalized by a professor of English.

Results

Interpretative phenomenological analysis (IPA) was used to analyze the data. IPA allows for the exploration of lived experiences. It helps us to explore how people make sense of their personal and social world, and aims at generating rich and detailed descriptions of how individuals are experiencing a phenomenon under investigation rather than by assessing pre-existing relationships among variables [37]. After conducting interviews of ten participants, audio-recorded interviews were first transcribed, and each transcript was closely read by the authors afterwards. Interpretative phenomenological analysis (IPA) was used to identify themes within the transcribed data that reflected participants’ lived experiences [38]. Initial themes were converted into emergent themes, then emergent themes were clustered together by following guidelines given by smith et al. [38] to construct sub-ordinate and super-ordinate themes. Even the pseudonyms for the participants in the results section have not been used because of the sensitivity of the phenomenon of CSA. To promote rigor and consistency in analysis, a selection of interviews was independently coded by the first author. The first author did primary coding and regular discussion of the analytic process was conducted the second and third authors to develop an agreed-upon set of emergent themes. The themes were further re-examined by two independent qualitative researchers to validate the process of analysis. Like other qualitative analyses, assessment of reliability of analysis is not structured or quantified in IPA, but is instead an iterative process in which all interpretation must be clearly grounded in the raw data.

Table 2 Master table of themes (N = 10)

Table 2 illustrates the superordinate themes and subordinate themes derived from interviews of all the study participant.

Experiencing abuse

The participants of the study reported to experience childhood sexual abuse as an emotional trauma and physical distress. The participants stated that initially, they were confused during sexual assault. They shared how dreadful the experience was. They showed physical resistance to protect themselves from the untoward situation that they were facing, but ultimately gave up when they realized that it was of no use and no one would come to rescue them. The participants found themselves all alone facing the abuse and they all reported to have surrendered them at the mercy of the perpetrator and endured both emotional and physical torture. Participants shared:

The situation was chaotic and I was unable to understand why my brother like cousin was doing this all with me. When I said, I would complain to my mom and dad while I was screaming, he said “I will kill you if you open your mouth”, I became silent and he did this all to me two-three more times.

I was traumatized and trembling. The situation was novel for me and I was unable to understand why he was treating me like that. It was a dark room and the only thing that I could feel was the brutality with which he was treating my body.

He took me to an unknown deserted place. When he started his malicious action, I started screaming for help, he further squeezed my body and said that there was no one to rescue me. I was at the mercy of that wicked rickshaw driver.

“In the beginning, I showed resistance, tried to rescue myself and begged him to leave me, I requested for his mercy to stop that brutal act and told him that it was very painful for me- He was laughing and enjoying doing all that. He was playing with my body parts and doing all against my will. He was pressing and clutching my breast and treating me like a corpse, whom he was using to gratify his lust. It was a doom’s day”.

“I had to bear that pain for many months. I could not even tell my mother what happened to me because, my step father used to do it when my mother was out of town for her job assignments. I had pain in my abdomen for many months that doctors could not treat, so I left school for one year because I couldn’t stay at school due to pain. I still feel that physical agony”.

The accounts of participant reveal that they were initially confused and shocked and when they felt that something wrong was happening to them, they showed resistance through both verbal and physical means and begged the mercy of perpetrators, but the offenders used their power and made them realize that they were alone and no one was around to rescue them. The perpetrator chose a safe time and place for the crime. Eventually, the survivor gave up and endured the emotional pain and physical agony. The use of a word ‘corpse’ indicates that the participant seems to perceive that assault as a death of her emotions and sanctity.

Psycho-social distress

The incidence of sexual abuse had wide-ranging impacts on the personal, psychological and social domains of the participants’ lives that include low self-esteem, negative self-concept, psychological pain, social suffering, and retaliation vs. forgiveness. While talking about the impact on their self, the participants shared that it induced the feelings of worthlessness and lowered their self-esteem.

Participants narrated their perception of the impact of sexual abuse on their self as:

“I am rubbish, because he treated me like this…He brutally used my body to satisfy his lust and threw me in a dumpster in a state of unconsciousness. I am a broken girl…He not only tore my body but also my personality and identity as a woman as well. I cannot assure the blamers that I am innocent…I feel guilty for not been able to rescue myself”.

I feel myself like a garbage, used by a wicked man and has no place in the society. A girl is sacred because she is untouched and I could not protect my honor and sanctity…I can never regain my lost dignity. I am a smudge on the dignity of my parents and my family name. I do not like to beautify my body, because this abuse has given me an ugly face.

I am a broken girl, my trust in relationships, my dignity, my future plans, my dreams…everything has been shattered. I don’t even find any reason to live. I am a girl who deserves to be disgusted. If people come to know about this abuse, they will hate me.

The narration of participants illustrates that the incident of sexual abuse has smashed their self-worth and identity as a woman. One of the participants used the analogy of ‘rubbish’ as a metaphor that seems true to its literal meaning, because she was thrown in a dumpster that made her think of herself as a part of garbage. The other participant used the metaphor ‘garbage’ because she perceives herself as a useless girl, who lost her honor and dignity due to that incident. She seems to feel that she has lost a respectable place in the society and this incident has diminished her status as a woman. The word ‘garbage’ also signifies giving bad name to the family due to the incidence of sexual abuse. One of the participants has used the word ‘broken girl’ because of the physical cruelty that she endured during the sexual abuse and also because the incident has torn her apart- she now has question marks on her future, relationships and trust in people. CSA has shattered social respect of those whose secret of abuse had become public and many of the participants blamed themselves and felt shame upon them.

Turning towards the emotional and psychological impact shared by the Participants:

“If people come to know, they will reject me, blame me, and hate me. I never shared this incident with my friends to protect my dignity and good name of my family. Only my parents know this. I have left my friends for the fear of disclosure… stopped talking to people. I became silent because my mother said, ‘seal your lips’, my only friend who referred me to you, she knows about this”.

“I am a sinner… Allah will not forgive me. I feel myself bad in the eyes of people, because I know I am not sacred like other girls. My mother knows about this incident and she has asked me to seal my lips…I cannot forgive myself”.

If people come to know about this abuse, they will spit on my face and degrade my parents. It is a sort of cancer for my social and personal life. My relatives call me a smudged girl, and do not allow their daughters to sit near me. I have lost my friends and social status. Nothing can bring my dignity back.

I feel feeble and powerless, because I could not protect my sanctity and I cannot regain what I have lost. I often cry on my helplessness and loss of my sanctity as a woman.

I have lost interest in everything. I cannot sleep properly for the fear of re-experiencing the same situation in dream. I still feel the pain and agony when I have recollections of this event for example, knowing about the rape of any innocent girl. Sometimes I think to kill myself to get rid of this torture.

Participants’ words truly reflect the fear of disclosure of identity that has engulfed them. They report a sense of insecurity, guilt, fear of rejection, blame and social hatred and loss of family dignity on the disclosure of this abuse. These incidents have developed feelings of unworthiness and social damage in the minds of the survivors. Many participants had disturbed sleep at night due to the flashbacks of the horrid incidents they faced. They feel helplessness and powerlessness for not being able to protect themselves. They have lost meaning and purpose in life and some of them want to end their lives.

“I don’t trust my father and any male relatives, my uncles and male cousins. All men are lustful and untrustworthy. I hate my brothers and father too. My brother like cousin robbed my honor. He seems to me a wolf”.

The victims have developed hatred for men in general, and perceive them as lustful, selfish and untrustworthy, and have lost trust even in their blood relations. The stigma that they bear has led to social inhibition, which has detached them from their family members. Due to this mistrust, they cannot share their pain with even the most significant people in their lives. They are called by different names, like ‘smudged girl’, ‘bad character girl’, which makes them angry and frustrated. They are unable to make friends because the girls of other families are instructed to keep a safe distance from them. They shared that they had lost their social respect and were being degraded by public. Most of the participant perceived the incidents as a complete destruction of life.

The participant had the urge to retaliate and take revenge from those who abused them. Their tone was very aggressive while talking about their feelings for the offenders. The participants said:

“I will never forgive that rascal. I want to kill him. When my brother-in-law comes to our home, I cannot sleep for next many nights. I want to give him poison so that I can get rid of the memories of this abuse… he is a devil who shook my trust in relationships”.

“It is a complete disaster. A girl has only one precious thing that she is supposed to protect and that is a sanctity of her body. He used my body for the satisfaction of his lust. I want to kill that dog…I cannot forget the way I was treated and the agony through which my family is suffering is a continuous torture for me”.

How can I forgive a person, who destroyed my life. forgiveness becomes meaningless in such cases… for the havoc he brought in my life is an unforgiveable act.

The participants shared hostile feelings for the offenders. None of them was ready to forgive the offenders. The participant believed that the action of offenders is beyond the sphere of forgiveness.

Sexual difficulties

The brutal incident of CSA appears to shatter the sexual life and behavior of the participants that include passive role, emotionally aloof, aversion from hetero-sexuality and avoidance, as they shared:

I am very passive in my sexual relationship. My husband uses me the way he wants to. He sometime mistreats me during this relationship, but I have never shown resistance. I feel myself like a cold meat during sexual relationship with my husband, I become overwhelmed by the powerlessness that I experienced in the sexual assault.

“I don’t see any pleasure in sexual relationship…some time I feel good in this relationship, but suddenly the offender replaces my husband and I feel repugnance for him and become irritable. Once I started biting my husband. I have a sort of mechanical relationship with him”.

“When my fiancé starts romantic/sexual talk, I become aggressive. I hate marriage because I hate physical relationship”.

“As you know, sex is a primary drive, sometimes, I satisfy myself through masturbation, which is harmless and nonviolent, but one can seek pleasure. I will never marry… if my husband comes to know about my dark past, marriage will bring havoc in my life,”.

The sexual abuse appears to have a substantial impact on the sexual behavior of both married and unmarried participants. The married participants shared that at times they used to remain passive during sexual intercourse, because it reminded them of the powerlessness they felt during CSA. One of the participants has used the analogy of ‘cold meat’, which signifies that she feels herself a dead body, who has no emotions. The other participants shared that they remained emotionally cold during sexual relationship. One of the participants has shared that at times she became aggressive during intercourse because of the ambivalent feelings towards her husband.

In the excerpts given above, one of the participants shares that she hates the topic of sexual intercourse and discourages her fiancé to talk on this topic. Participants seem to avoid any topic of sexual nature and even refuse to engage in the sexual activity, which shows their sexual inhibitions. The participants appear to overcome their feelings of feebleness and helplessness, which they felt when they were sexually assaulted by controlling the sexual demands of their husband or fiancé.

The participants who were unmarried appear to be rigid and conceive marriage as ‘devastation’ and have certain fears regarding their sexual relationship after marriage. Some of them prefer masturbation as a means to avoid the heterosexual relationship and male dominance in sexual relationship.

Discussion

The study was carried out to explore the experiences of female survivors of CSA in Pakistan. Ten young female survivors were interviewed to study the perceived short-and long- term impacts and reflections of CSA. While sharing their experiences of abuse, almost all the participants shared that they were initially confused and were not able to understand the situation, but when the perpetrators started maltreating their body, they realized that something wrong was going to happen. They showed physical resistance and requested the offenders for mercy, but all in vain. The participants reported the incident as emotionally traumatic and physically painful. They reported that they continued living with that emotional burden.

The participants perceived long term impact of CSA on their personal, psychological and social well-being. They reported feelings of worthlessness, shame, self-blaming and lower self-esteem and experienced bouts of guilt for bringing disgrace to the family. The results are in line with the literature that survivors often feel embarrassed, humiliated, and guilty about the abuse and blame themselves for letting the incident happen, even though– it is not their fault [3]. Some of the participant believed that their physical beauty could not compensate the ugliness of body caused by sexual abuse, so they were least concerned to enhance their beauty and physical appearance. Though the authors did not find any empirical evidence on the perception of body as filthy and self-negligence among CSA survivors, the reason of these feelings might be the belief of study participants that they had lost the sanctity and holiness of their body due to CSA. They seemed to believe that apparent beauty of their face could not compensate the ugliness that the incident of CSA brought for their identity.

As the psychological well-being of the survivors’ concerns, the survivors whose abuse was not disclosed in public were engulfed by the fear of disclosure because of the anxiety that people would hate them and disrespect their family if they came to know about this. The results are consistent with the studies that elucidate some of the potential social costs and detrimental psychological effects of disclosure, particularly regarding the impact of negative social response to disclosure [20]. Disclosure of CSA in the cultural context of Pakistan is deemed as havoc for the survivor and the family, because living in a society dominated by a religious value system, people think that only a virgin woman is worthy to be married. People blame the victim and the family for this disaster. Results showed that women in our study perceived them as losers, because they had lost their ‘sanctity’ and ‘dignity’ of their family. Some of the participants believed that death was better than living because they were constantly living with the burden of guilt and they often had suicidal thoughts. The participants had difficulties in sleeping, because they would often wake up thinking of the crime committed on them. They still had crying spells over their powerlessness and damage caused by sexual abuse. As the study participants experienced CSA in middle childhood and literature indicates that younger children are generally unable to defend themselves or recruit social support after being the victim of CSA [17], and as a result, they suffer feelings of learned helplessness and poor self-efficacy [14]. Our results are partially consistent with the work of Anteghini et al. [12] that reports depressive symptoms, sleep problems, somatic complaints, social anxiety timidity, nervousness, and aggressive behavior. Literature also illustrates that survivors of childhood abuse exhibit long term emotional and psychological consequences, such as prolonged symptoms of distress [8, 11]. Results are also consistent with the previous studies that report suicide ideation among the individual with the history of childhood sexual abuse [18,19], and a study by Lopez-Castroman et al. [14] that women who experience sexual assault in childhood are more likely to attempt suicide than other women.

Experiencing CSA impaired the social relationships of the survivors of CSA and they lost trust in men believing that men ignore all ethics and moral values just to satisfy their lust. The theme is consistent with the results of a study by Ullman [17] that found perceived disbelief among the survivors who were abused by relatives. Those whose abuse was not still disclosed in public had detached themselves from people, because they lost trust in people after the incident and did not share it even with the closer people due to the negativity attached to disclosure [41]. This result is in line with the studies that sexually abused children scored lower on interpersonal trust in people surrounding them compared to non-abused children [24].

The results showed that CSA had profound impact on the sexual health of the both married and unmarried female survivors in this study. The participants reported four types of sexual difficulties: passivity in sexual relationship, emotional aloofness, aversion from hetero-sexual relationship, and avoidance of sex related conversation. Most of the participants shared that their incapacity and helplessness at the time of sexual abuse used to dominate them during sexual intercourse with their husbands and they felt like a dead body that had no emotional involvement and did not feel any pleasure out of the sexual relationship. Results are consistent with the previous work that CSA survivors do not feel gratification and pleasure in intimate relationships, noticeably feel lower satisfaction with their sexuality. The results are in line with the studies indicating that sexual function and sexual satisfaction are impaired among victims of CSA [7]. The results are also in agreement with Rellini [26] that sexual problems in women with a history of CSA were relatively common. Some of the participants shared that their husband used to dominate them during this relationship and this was painful because it was a constant reminder for the abuse that they had suffered. The results support traumatic sexualization hypothesis as a result of CSA that is based on Finkelhor and Browne’s trauma genic dynamics model [41]. Traumatic sexualization indicates that powerlessness experienced during the abuse may lead women to feel that they are unable to control sexual situations, which lead to submissive role of women in their sexual relationship. Traumatic sexualization may also induce feelings of being betrayed by the abuser, or by others.

Those who were unmarried, they showed abhorrence towards marriage because they could not imagine to have a physical relationship and closeness of men. Moreover, they had a fear that the knowledge of their past, would destroy their marital life. For the fear of heterosexual relationships and in order to stay away from men, some participants reported to find safe haven in masturbation to satisfy their sexual impulse. They believed that in this way, they could save their body from maltreatment by the nasty men. Literature shows that women with CSA histories perceive sexual information as threatening [32]. The avoidant attitude of the participants towards marriage is in line with previous studies that recognized the tendency and reliance on avoidant coping strategies in response to distress among CSA survivors [23].

The results have shown that the experiences of CSA female survivors in our study are to a great extent similar to the Western literature. However, some themes are unique and pertinent to Pakistani culture. Women in the present study perceived their body as unclean and ugly due to CSA and this ugliness had undermined the apparent beauty and attraction of their body. This feeling reflects perceived descriptive norms of Pakistani society where honor and value of a woman is conditioned to her piety and sanctity and strength of character of an unmarried woman is measured via her virtue of being virgin. A Muslim woman’s virtue is measured and prized by her not being sexually intimate outside of marriage. If it is proved that she had, she is considered stained for the rest of her life. A substantial proportion of female value is based upon virginity and the fact that her sexual honor remained intact [42]. Sexual abuse is a question mark on the piety of a woman in Pakistani society, which seems to damage their physical self-concept.

Most of the participants in the study considered themselves as undignified because of symbolic interaction as people around them had inculcated in them the cognition that they were smudge on the honor of their parents. It shows that CSA is not experienced in isolation in Pakistani society but experience is built by taking into account the public attitude and reaction.

Feelings of retaliation and taking revenge from the offenders is unique to the present study that shows the severity of aggression towards the offender, reflection of helplessness during sexual abuse and perception of CSA as a total destruction and end of life. This unfinished business seems to be the result of suppression of incident of abuse that needs to be addressed via psychotherapy.

Indulging themselves in masturbation to satisfy sexual impulse safely is also a unique theme in our study. The female survivors were determined to avoid hetero-sexual intercourse to protect their body from maltreatment and dominance of men after marriage.

Implications

The study has psychological, social and research implications. Pediatric nurse practitioners (PNPs), Psychiatrists and psychologists can develop therapeutic interventions for early management of survivors of CSA to evade its long-term negative impacts. The findings will help the child psychiatrists/psychologists and school counselors to ponder upon undisclosed cases of child sexual abuse while dealing with psychosocial and sexual issues of young adults. This study can be used for creating awareness among parents, so that they should not leave their daughters unattended and keep an eye on the male employees, male relatives, and mobility of their children. Children should be educated right from the early years regarding bad touch and self-defense, so that they become able to protect them from evil beings. The results are useful in guiding both researchers and clinicians working to support survivors of CSA to recover. The study offers insight into a multitude of complex and understudied phenomena that relate to the disclosure of sexual trauma and disclosure processes themselves. Conducting research on issues of child sexual abuse in Pakistan is a real challenge as people think it better to hide the matter as much as it can be, so not only most of the victims live without psychological help, but seal their lips on this issue. The study will encourage the female survivors of CSA to talk about their unfinished business and bottled-up aggression and seek help for their issues and challenges related to childhood sexual abuse.

Limitations and suggestions

The sample size was small due to unapproachability or reluctance of female survivors to share their experiences of CSA. As study used retrospective design, false memories or recovered memories might have interrupted the data. Only female survivors were included in the study, impact of CSA on male survivors can be explored in future studies. Parents and siblings, who play important role in consequence and experiences of CSA should be also be interviewed in future studies for the holistic understanding of the phenomenon of CSA.

Conclusions

The results of the study have revealed that there were short-and long-term consequences of child sexual abuse, and different dimensions of victim’s life undergo transformation due to CSA. Sexual abuse is linked to the loss of dignity and honor in Pakistani society and thus, is most likely to have detrimental effects on self-concept, social cognition and interaction, and leads to interpersonal difficulties, emotional disturbances, psychological problems and sexual difficulties. The adults often try to shield the incident for the fear of societal response. Sexual abuse is followed by various traumas faced all along the course of life involving social, developmental, and psychological problems. This is the main reason that people show reluctance to seek psychological help for CSA victims in Pakistan. Results indicate that a victim’s life with an untold story of abuse deteriorates her subjective wellbeing and mental health. Factors leading to underreporting of CSA include child’s own fears and guilt associated with abuse, child’s failure to recognize such activity as abusive especially, if offender is close relative or friend, suppression of incident for the fear of negative response on disclosure and stigma.

In Pakistan, there is a need to work in this area. The adverse impacts of CSA on the personal, psychological, social and sexual life of the survivor are often ignored in Pakistan. Legal and special psychological measures should be considered important in alleviating the trauma through which the victims suffer. Therapeutic interventions should be devised in Pakistan for the survivors of sexual abuse. It is important to be aware that sexual abuse can result in serious sequelae, especially if unrecognized and untreated. The capacity building to prevent child sexual abuse must start with the family. There is need to spread awareness in families on how CSA can affect a child’s life.

One operational initial point to manage and prevent CSA is home: a lot depends on how parents raise their children, and teach to refuse being touched in a manner which makes them uneasy and uncomfortable. Next comes schools, where children can be taught the same thing in a formal setting. Media can also play a significant role in it. Governments alone cannot be blamed for the occurrence of CSA, because it is parents who should take care of their children. Governments must be held answerable when police fail to take appropriate and necessary action and when proper laws do not exist. Societies must take action and stand up when victims of abuse are ridiculed and when and where no legal or judicial mechanism exists to handle such cases sensitively.