Child Sexual Abuse (CSA) is a pressing human right issue and public health concern. We conducted a systematic review of quantitative and qualitative studies published in the past decade on CSA in India to examine the distribution of the prevalence estimates for both genders, to improve understanding of the determinants and consequences of CSA and identify gaps in the current state of research.
For this systematic review, we searched electronic literature databases (PubMed, POPLINE, and PsycINFO) for articles published in English on Child Sexual Abuse in India between January 1, 2006 and January 1, 2016 using 55 search terms. Data were extracted from published articles only.
Fifty-one studies met inclusion criteria for the review. The review indicates that prevalence rates of CSA is high among both boys and girls in India. Due to heterogeneity of study designs and lack of standardised assessments, reported prevalence estimates varied greatly among both genders in different studies. There is a need to conduct representative studies using a validated instrument to obtain valid epidemiological estimates. Commercial sex workers, men who have sex with men, and women with psychiatric disorders were at higher risks for sexual abuse during childhood. In addition, the synthesis of qualitative data across studies included in the review suggests that exposure and perpetration of CSA is a multifaceted phenomenon grounded in the interplay between individual, family, community, and societal factors. The review indicates poor physical, behavioural, social, and mental health outcomes of CSA in India. We conclude with a research agenda calling for quantitative and qualitative studies to explore the determinants and perpetration of child sexual abuse in India from an ecological lens. This research agenda may be necessary to inform the development of a culturally tailored primary prevention and treatment strategy for CSA victims in India.
Citation: Choudhry V, Dayal R, Pillai D, Kalokhe AS, Beier K, Patel V (2018) Child sexual abuse in India: A systematic review. PLoS ONE 13(10): e0205086. https://doi.org/10.1371/journal.pone.0205086
Editor: Alexander C. Tsai, Massachusetts General Hospital, UNITED STATES
Received: November 12, 2017; Accepted: September 19, 2018; Published: October 9, 2018
Copyright: © 2018 Choudhry et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All relevant data are within the paper and its Supporting Information files.
Funding: The funder (Bayer Crop Science, Mumbai, India) provided support in the form of salaries for authors (RD and DP), but did not have any additional role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. The commercial affiliation (Sambodhi Research and Communications Pvt. Ltd.) of the lead author (VC) had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. The specific roles of these authors are articulated in the ‘author contributions’ section.
Competing interests: The authors declare that there is no conflict of interest financial or non-financial with regard to the study. The interpretation and presentation of the facts and figures given in the paper is not influenced by any personal or financial relationship with any individual or organisation. The funding agency or commercial affiliation (Sambodhi Research and Communications Pvt. Ltd.) of the lead author does not alter our adherence to PLOS ONE policies on sharing data and materials. There are no patents, products in development or marketed products to declare.
The World Health Organization (WHO) defines Child Sexual Abuse (CSA) as “the involvement of a child in sexual activity that he or she does not fully comprehend, is unable to give informed consent to, or for which the child is not developmentally prepared and cannot give consent, or that violates the laws or social taboos of society…”. CSA includes an array of sexual activities like fondling, inviting a child to touch or be touched sexually, intercourse, exhibitionism, involving a child in prostitution or pornography, or online child luring by cyber-predators [2, 3].
CSA is a serious problem of considerable magnitude throughout the world. A recent systematic review of 55 studies from 24 countries found much heterogeneity in studies in terms of definition and measurement of CSA and concluded that rates of CSA ranged from 8 to 31% for females and from 3 to 17% for males . Despite similar methodological challenges, other systematic reviews which included studies conducted worldwide across hundreds of different age-cohort samples have observed alarming rates of CSA, with averages of 18–20% for females and of 8–10% for males, with the lowest rates for both girls (11.3%) and boys (4.1%) found in Asia, and highest rates found for girls in Australia (21.5%) and for boys in Africa (19.3%) [5, 6].
CSA has profound consequences for the child. It is known to interfere with growth and development [7, 8]. CSA has also been linked to numerous maladaptive health behaviors, and poor social, mental and physical health outcomes throughout the lifespan [2, 9–11]. In accordance with that, there is evidence that CSA can affect neuro-biological systems, e.g. the cortical representation of the genital somatosensory field . Other common sequelae for adult survivors of CSA may include relational challenges (e.g., increased risk for domestic violence), violent behaviors, and increased risk of perpetration of CSA as adults [2, 13].
Children, under the age of 18, contribute to 37% of India's population  with large proportions experiencing great deprivations such as lack of access to basic education, nutrition or health care . In addition, they are susceptible to different forms of adverse childhood experiences (ACEs) including various forms of abuse, neglect, and maltreatment with child protection remaining largely unaddressed [16–18]. A large-scale national study conducted in 2007 by Ministry of Women and Child Development (MoWCD), to assess the extent and nature of child abuse in India, uncovered some alarming statistics; that among the 12,447 children interviewed, more than half (53 percent) reported experience of sexual abuse, defined as “sexual assault, making the child fondle private parts, making the child exhibit private body parts and being photographed in the nude” and over 20 percent reported severe sexual abuse . While these statistics need to be interpreted with caution as it was conducted in a convenience rather than nationally representative sample, the numbers speak to the significance of the problem and highlight particularly high-risk groups. Smaller studies from India have also reported very high prevalence of CSA [17, 20, 21].
Increased attention in the public discourse and activism around child protection led to the Government of India passing the, ‘The Protection of Children from Sexual Offences (POCSO)’ law in 2012. This act criminalizes a range of acts including rape, harassment, and exploitation for pornography involving a child below 18 years of age and mandates the setting up of Special Courts to expedite trials of these offences. However, the issue of CSA remains a taboo in India. As around the world, the research findings in India support significant underreporting of CSA to authorities versus reporting in protected research settings [17, 22]. Only 3% of CSA offences uncovered by national level study in 2007 were reported to the authorities. Renuka Chowdhury, the then minister of women and child development, in her introduction to this national survey report of MoWCD referred CSA as “…shrouded in secrecy with a conspiracy of silence around the entire subject” .
A systematic review of prevalence estimates, determinants, and impact of CSA are important for the development of prevention programs and the provision of support. Even though some literature on CSA, from India, has been published as an epidemiological overview and narrative reviews, and some empirical studies have been included in the international literature, there is no systematic review of the literature on CSA in India. This paper presents a systematic review of a wide range of studies, both quantitative and qualitative, conducted over the past decade on CSA in India. It aims to examine the distribution of the prevalence of CSA estimates for both genders, improve understanding of the determinants and consequences of CSA, and identify gaps in the current state of research.
The research questions, inclusion criteria, search strategy, search terms, search engines, and study protocol for the proposed study were developed in consultation with a panel of experts who have been working in the field of sexual violence in India (names included in Acknowledgments) and along the guidelines as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)  (S1 Checklist). We searched electronic literature databases (PubMed, POPLINE, and PsycINFO) to search for articles published on CSA in India. Searches were conducted using both medical subject headings (MeSH) and keywords. An example for the use of search term like sexual assault among 55 other terms (Table 1) that was used is “….(("sexual assault"[MeSH Terms] OR ("sexual"[All Fields] AND "assault"[All Fields]) OR "sexual assault"[All Fields] OR ("india"[MeSH Terms] OR "india"[All Fields])” OR ((“sex offenses"[MeSH Terms] OR ("sex"[All Fields] AND "offenses"[All Fields]) OR "sex offenses"[All Fields]” AND ("india"[MeSH Terms] OR "india"[All Fields]) across the three databases. The same search strategy was used across all three databases.
We included studies that were published in English between January 1, 2006 and January 1, 2016, involved human subjects, and collected primary data on experience, perpetration, or response to CSA in India. Grey literature, reports, studies not collecting or analyzing original CSA data (i.e. epidemiological overview, meta-analyses, systematic reviews), commentaries, and editorials were not included in the study. The study period was chosen to report results from the recent literature on prevalence, correlates, and consequences of CSA in Indian context.
We included observational studies (e.g. cross-sectional studies, cohort studies, and case-control studies) that examined prevalence and incidence of CSA and/or associations of CSA with other independent or dependent variables. The qualitative studies that examined the experiences of respondents that had been victims of CSA were also included. Articles examining sexual abuse experience at ≤ 18 years were included. The review also included 1) articles in which CSA data were collected retrospectively from adults and 2) articles which use age bands which cross the 18-years cut-point (i.e. they collect aggregate sexual violence data for youth aged 10–19, 15–24 etc.). In the latter scenario, authors were contacted for disaggregate data on CSA for ages ≤ 18 years. CSA perpetration studies were also included if they measured perpetration of sexual violence against an individual ≤ 18 year of age (irrespective of the age of the perpetrator). Finally, interventions to prevent and/or treat CSA including randomised control trials were also included in this review.
The peer reviewed articles identified from the electronic databases were transferred and stored in EndNote software X7.5. The relevancy check for all the articles at the step of title and abstract screening was conducted by one of the authors (DP or RD) designated as primary reviewers. In addition, the secondary reviewers (VC or AK) conducted relevancy check for 10% of the randomly selected articles at this step along with relevancy check for all the articles that were deemed as “cannot determine” by the primary reviewers. The primary and secondary reviewers conducted relevancy checks in teams that constituted of one primary and one secondary reviewer for the articles that were selected for full text screening (n = 965). The discrepancies on relevancy of the articles between primary and secondary reviewer were noted and discussed by the entire team in a monthly meeting.
Data extraction and quality assessment
The eligible articles went through a standardized data extraction and quality assessment process. The data extraction form was refined during the extraction of the first few articles to ensure that the forms were comprehensive. The primary reviewers extracted the relevant data in MS Excel for each of the articles that were deemed suitable for inclusion. A few studies were based on same datasets, but we decided to include these studies as different if they assessed different forms of CSA or measured different outcomes associated with CSA. We extracted descriptive characteristics of the sample (e.g. publication date, age of the sample, gender, etc.) from each quantitative (Tables 2–8) and qualitative study (Tables 9 and 10). As contextual moderators, we extracted data on the setting (i.e. schools, colleges, community, shelter homes), and data collection methods (face-to-face interview, focus group discussions or anonymous self-reports). Data on perpetration was also extracted and reported depending on the information available.
Among quantitative studies we extracted three methodological moderators: (a) design of study (primarily cross-sectional, case-control, or otherwise); (b) sampling strategy (random, purposive, or convenience sampling); (c) measurement instrument (name, whether standardised, number of items, etc.). We also extracted the data on the time frame for which CSA was measured (childhood experience or past 12-months experience) for quantitative studies. Three categories of CSA were used: (a) non-contact sexual abuse (e.g., exhibitionism, indecent exposure, sexual harassment or voyeurism); (b) contact sexual abuse without penetration (e.g., non-genital fondling, kissing, or genital touching); and (c) forced intercourse (i.e. anal, oral, or vaginal intercourse), as previously classified in a WHO publication . Depending on the information available for each study, we report prevalence on the total sample or separately on boys and girls.
A synthesis of the qualitative evidence, guided by the review questions, was conducted across the qualitative and mixed-methods studies that are included in the review. The synthesis was performed using an interpretive perspective in which themes were identified in the original papers, compared across studies, and then combined into a whole via a listing of descriptive themes in line with the determinants and perpetration of CSA informed by the socio-ecological framework , and the impact of CSA on the study participants (S1 File). The analysis included coding of text 'line-by-line' as a first step that was conducted by one of the authors (RD). The coding was followed by the development of descriptive themes by two authors (VC and RD) independently, followed by discussions to reach consensus. The categorisation of the respective descriptive themes under the individual, family, community, and societal factors was finalised after discussions among the authors (RD, VC, and AKK). The majority of the qualitative and mixed-methods studies focused on high risk populations such as Men Having Sex with Men (MSMs) and Commercial Sex Workers (CSWs) including assessing the HIV risk among these populations, identifying potential pathways for sex workers or trafficked girls to enter sex work, and experiences of abuse and neglect during childhood among such populations. There were only a few papers that exclusively focused on CSA experiences of the participants. In order to account for this, our study coded the relevant sections of each study that focused on CSA experience of the participants.
A separate quality assessment tool for quantitative and qualitative studies was developed for this review. The quality assessment tool for quantitative studies was adapted from Effective Public Health Practice Project (EPHPP) Quality Assessment Tool . The quality assessment tool for qualitative studies was adopted from Consolidated criteria for Reporting Qualitative Research (COREQ) guidelines . Each article was assessed using the quality assessment tool and then all articles were summarized together (Tables 11–14) to give an impression of the overall quality of the studies included in the review.
Article yield of systematic search
Fig 1 illustrates the flow chart of articles. The initial search of CSA articles published in electronic literature databases (PubMed, POPLINE, and PsycINFO) identified 4,186 potentially eligible studies based on the inclusion criteria. After removal of duplicates, we were left with 3,725 potentially relevant studies that were screened for title and abstract relevancy. After title and abstract screening, 2,760 studies were excluded, leaving 965 for full-text screening applying the same inclusion criteria. Of the 965 articles, 762 articles were excluded because they (1) focused on extraneous topics, (2) lacked Indian context, (3) surveyed a time frame of exposure to sexual abuse for study participants after they attained 18 years of age, or (4) did not collect or analyze original data on CSA. We were unable to retrieve 21 articles through searching our institutional libraries or through contacting the authors (S2 File). Additionally, 131 more articles were excluded from the final analysis, as the articles provided insufficient information to assess eligibility for inclusion and two attempts to contact authors for additional information failed. The final list of included articles consists of 51 studies.
Study designs and study populations
Among the 51 studies included in the review, 35 studies were based purely on quantitative methods, 11 studies were based purely on qualitative methods while five studies utilized mixed-methods. Most quantitative studies were conducted among respondents from general population (Tables 2–5) while a few of them were conducted among populations at risk (Tables 6–8). The majority of quantitative studies utilized a cross-sectional design with only a few using other designs like case-control or utilizing the case records from medical case histories.
A quarter (13/51) of studies that were included were based in educational institutions. A fifth of the studies (10/51) included community samples of young men and girls while a few other studies (5/51) included women or young adolescents attending gynecology, mental health facilities, or health camps organized by non-governmental organizations (NGOs). Approximately half of the other studies (24/51) were conducted in specific populations such as commercial sex workers, children in shelter homes, sex-trafficked young girls in observational homes, adolescent street boys, runaway children, men who have sex with men (MSM) and children in conflict with law. Most qualitative studies were conducted with specific populations as discussed above.
Almost half the studies included in this review evaluated CSA through interviews with children below 18 years of age (25/51) while the rest of the studies evaluated retrospective recall of CSA experiences among adults. Twenty-one studies were exclusive with girls or women with 17 of these studies among female sex workers and trafficked girls. Nine studies were conducted exclusively with boys including runaway or adolescent boys living on the streets and MSMs. The rest of the studies (20/51) included both boys and girls either from the educational institutions, community samples, health camps, or children in conflict with law.
CSA definitions and measurement
Around 50% of the studies that utilized purely quantitative methodology, assessed all forms of CSA (forced intercourse, contact, and non-contact). Most of these studies were conducted among students in educational institutions or community populations. All the studies that utilized mixed-methods approach and seven studies among purely quantitative studies used a narrower definition (forced intercourse or rape) of CSA and majority of these studies were conducted among female sex workers. While most of these studies (36/40) evaluated childhood experience of CSA while four studies included the question on experience of CSA in the past year.
Among the 37 studies using quantitative methods, only 16 studies reported use of standardized tools. The various tools that were used were 1. ISPCAN Child Abuse Screening Tool (ICSAT)–C and ICSAT- R, 2. Childhood Trauma Questionnaire, 4. Adapted Questionnaire from MoWCD study, 5. Finkelhor’s Sexual Abuse Scale (used in community studies), and 6. Sexual Abuse Screening Tool. Two studies were based on validation of ICSAT-C and ICSAT-R for measurement of CSA in six countries including India [28, 29].
The prevalence of CSA ranged from 4%- 41% in studies conducted exclusively among young women below 18 years of age and who are current students while the studies reported a lifetime CSA prevalence of 3–39% among women above 18 years of age. There was a much wider range of CSA prevalence (4%- 57%) reported among boys in educational institutions. One third of the study sample of adolescent street boys reported forced intercourse , while almost a quarter of the study sample of men who have sex with men (MSMs) reported experiencing contact sexual abuse with or without forced penetration during childhood . The studies also reported variations in prevalence estimates when they included all forms of CSA (contact, non-contact, and forced intercourse). For example, 35% prevalence of any form of CSA was reported in the age group 15–19 in one study  as opposed to 4% among young girls in age range 12 years to 16 years when CSA was specified as “sexual abuse” in general . The prevalence estimates of CSA experiences reported among select populations like sex trafficked girls and women ranged from 4% to 66%.
Determinants of CSA
The social-ecological model guided the emergence of determinants of CSA as one of the themes in the synthesis of qualitative data across studies included in this review as shown in Fig 2. The synthesis suggests that CSA is a multifaceted phenomenon grounded in the interplay between individual, family, community, and societal factors. The patriarchal societal norms and power differentials in such societies based on class, gender, and sexual preferences emerged as common descriptive themes that increased the risks of CSA across the qualitative studies on CSWs and MSMs [31, 34, 35]. Individual factors like poor socio-economic status, death of a parent or husband, and being born to a commercial sex worker were descriptive themes that emerged as pathways to be initiated in commercial sex work and resultant CSA experiences for minor girls that had been trafficked. Early childhood experience of CSA was also documented as a risk factor for re-victimization as well as initiation into commercial sex work. Lack of proper family support, family and personal history of mental health pathology, and pathological family exposures to sexual images were some of the other potential risk factors, that emerged in the review  [37–43]. Lack of sanitation and poor safety of women were also found to be community level factors that increased the risks for CSA from the review of qualitative studies . There were conflicting results in the review of quantitative studies regarding age, gender, family structure (joint vs. nuclear family), and monthly family income as covariates of CSA [30, 45–49]. However negative perception about parents, lower education of mother, and perceived congeniality of family were found to be significantly associated with CSA experience . Domestic child laborers were also found to be at higher risk of all forms of abuse including CSA in one study .
Perpetration of CSA
Few studies (11/51) among the quantitative and mixed-methods studies included in the review reported about the characteristics of the CSA perpetrators [31, 49, 52–61]. The studies conducted among the community sample indicated that perpetrators of CSA in India are known to the abused children, and many of them are family members [49, 58, 59, 62]. The qualitative synthesis of studies that included perpetration as a sphere of enquiry suggests that multiple factors at individual, family, and societal levels play a significant role in perpetration of CSA. The offenders, often known to the victims, take advantage of their accessibility to potential victims and with lack of severe punishment by family members and protective nature of the family members towards the abuser, often leads to the incident getting unreported [58, 59, 62]. However, studies that included adolescent boys as samples reported higher percentage of perpetration by strangers as compared to adolescent girls . The synthesis of data from qualitative studies conducted among MSMs indicated that these perpetrators may be older boys or other men in power like police [31, 57, 63]. A qualitative study among adolescents in our review indicates pathological family atmosphere with precocious exposures to sexual behaviors and sexual acts, traumatic sexual experiences in childhood, sexual interests and exploration, deprivation and failure in romantic relationships, and young boys who have been coerced into homosexual acts are at increased risk of becoming young sexual offenders . Gender inequitable norms were found to be significantly associated with CSA perpetration in a study on evaluation of an intervention to promote gender equality among adolescent boys . However, we need to exercise caution with drawing conclusions about the determinants of perpetration considering the limited number of studies that evaluated the associations, cross-sectional and qualitative study designs, and small sample size of these studies.
Health outcomes of CSA in India
The health outcomes of CSA can be grouped into mental health, physical health, behavioral and interpersonal (Fig 2). The studies, both quantitative and qualitative, reported high risks for psychiatric disorders  including obsessive compulsive disorders , suicidal behaviors  and depression . The victims of CSA were also found to have increased risks for temperamental problems, poor social adjustment, lack of trust, and insecure relations with parents [48, 55, 65–68]. Lower academic performance was also associated with reporting CSA in one study . Only one quantitative study evaluated the associations between increased risk of Sexually Transmitted Infections (STI) and CSA . The studies suggest that sexually trafficked women and MSMs involved in commercial sex work and had experienced CSA also report high prevalence and risk behaviors for HIV infection [31, 34, 37–39, 45, 70–74]. However, their HIV status in this study could be an outcome of sex work rather than the experience of CSA itself.
Interventions for CSA in India
Our review found only five intervention studies [54, 57, 65, 66, 75]. One study examined the 12-month efficacy of Parivartan (English: transformation), a primary prevention program for young boys that aims to prevent perpetration of gender-based violence through promotion of gender equitable norms . The program resulted in statistically significant increase in gender-equitable attitudes but no change in sexual abuse perpetration among the boys who participated in the intervention. Two studies based on the same dataset that included 120 abused girls as cases and 120 non-abused girls as matched comparisons focused primarily on positive effects of general counseling on symptom reduction for CSA survivors in rehabilitation homes set up by the government or an NGO [65, 66]. An exploratory controlled evaluation of a multi component intervention, Yuva Mitr (friend of youth), involving educational institution-based peer and teacher training, and information material to the youth led to decrease in prevalence of sexual abuse among urban youth at end of 18 months as compared to baseline data .
Quality assessment of the published studies
Of all included quantitative studies, approximately half the studies had high risks of selection bias with poor sampling strategy or sample sizes (Tables 11–13). Half of the quantitative studies rated poorly for representativeness of the sample, whereas the same number of studies did not use an acceptable case definition. Among all quantitative studies only ten studies reported risk of any other bias including bias due to social desirability responses, observer bias, or recall bias. Only a quarter of the included studies used a validated tool for measurement of CSA. Majority of studies rated poorly on data analytical techniques while none of the studies met all criteria of quality assessment. Limited information on prevalence estimates for each type of sexual abuse, and heterogeneity of study designs and CSV measures precluded conduct of a meta-analysis.
Among qualitative studies none of the studies included a description of the moderator or the interviewer´s characteristics while half the included studies did not report any theoretical framework in the study design (Table 14). In addition, majority of the studies did not describe the recruitment process for the study participants and their relationships with the research staff. Most of the included studies rated poorly on qualitative data analysis and reporting.
Our systematic review summarizes what is known about the characteristics of CSA and the status of the research on CSA in India during the last decade. It adds to the scant knowledge of CSA and draws attention to the magnitude and severity of the ongoing epidemic in India. The reviewed literature estimates that 4–41% of the girls and 10–55% of the boys in school and college samples have experienced one form (contact, non-contact, forced) of CSA in India. The prevalence figures are much higher among commercial sex workers, street adolescents and children, children working as domestic laborers, MSMs, and women with mental health problems. In addition to highlighting the high frequency of occurrence, the studies in this review begin to highlight the ecological determinants of CSA experience and perpetration along with adverse impact of CSA on social functioning, behavioral issues, mental health, and physical health.
The review highlights the heterogeneity of the methodologies utilized between the included studies. It is difficult to generalize the estimates of CSA in India noted in this review because of the small sample sizes and non-random samples. Further, the different sampling strategies, varying operational definitions of CSA, different study populations (child, adolescent or adult; vulnerable populations, e.g.- street children, children with mental health difficulties etc.), different study settings (in school, colleges, shelter homes, health clinics, or community based), and various instruments for measurement of CSA add to the practical, methodological, and statistical challenges of presenting pooled prevalence estimates, inter-study comparisons, and cross-population comparisons. Our review suggests that the studies that included standardized instruments and comprehensive definitions of CSA (contact, non-contact, and forced intercourse), reported higher prevalence of CSA. A currently available standardized instrument, like ICSAT- C and R, used globally and validated in Indian context could be a tool for methodologically robust measurement across studies for national and international comparisons.
As per the NCRB statistics for 2015, the legislative framework in India- The POCSO Act, 2012 has resulted in increased reporting of CSA . However, the issues related to mandatory reporting of the CSA incidents, lack of clarity of legislation among professionals (medical officers and police), and general lack of professional support for victims of CSA create potential problems for implementation in the Indian context . The socio- cultural beliefs and practices suggested in our qualitative synthesis and others pertaining to parental rights and styles in a closely-knit patriarchal family system, as existing in India, often do not acknowledge that children are individuals with their own rights and often neglect the sexual and other forms of abuse that the child may report [17, 22]. The underreporting of CSA in India can be attributed to the fear of indignity, guilt, denial from the community, associated socio-cultural stigma (especially if the abuse is in the context of the family), not being able to trust government bodies, and a gap in communication between parents and children about this issue [16, 17, 19, 20, 78]. An upcoming paper, based on data extracted for this review, highlights the ethical and measurement issues with respect to training of interviewers on data collection in addition to non-standardized tools for data collection can result in underreporting of CSA in research studies . Another major concern in India is dearth of good monitoring of various juvenile residential institutes. In addition, majority of the healthcare professionals do not have the abilities and are not trained to examine and manage cases of CSA. Hence the few cases that reach these institutions also often go unreported .
Our review also exposed gaps in the current understanding of CSA in some populations in India. The findings suggest that young boys in India have similar and sometimes higher prevalence of CSA as girls. This is in accordance with current understanding of CSA in India [16, 17, 19, 20, 80] but the high prevalence of CSA among boys is in contrast with the majority of global trends [4, 6, 81] However, patriarchal society and existing social norms around masculinity and focus on young girls as primary targets for CSA programs leave vulnerabilities of young boys largely unexplored .
The studies with at risk populations for CSA, like trafficked girls, also reported substantial variations with higher estimates from studies where the respondents were below 18 years of age and study included all forms of CSA. The few qualitative studies among MSMs and trafficked girls for commercial sex work included in the review suggest early childhood sexual abuse experiences that often reflect power differences between the child and the perpetrator are pathways that lead the victims into commercial sex work. In addition, our review points to increased risks of CSA among certain populations that include children of commercial sex workers, young girls with mental health issues, and adolescent boys and girls out of schools and in labor force (like domestic laborers etc.)
Evidence suggests deviant sexual interests are a major risk factor for CSA . According to research sexual offenders against children can be distinguished into two groups. The first group account for about 60% of officially known offenders and show no sexual preference disorder, but who, for different reasons, sexually abuse children (e.g., sexually inexperienced adolescents seeking a surrogate; persons with poor mental health, or those with antisocial personality disorders, or from traumatizing family constellations). The other groups are those showing a sexual preference disorder, namely pedophilia (erotic preference for prepubescent children) or hebephilia (erotic preference for early pubescent children) who account for about 40% of officially known offenders [83, 84]. A study included in our review that focused on sexual preferences, estimated sexual preferences for children among 3.3% of the respondents (majority of married and women respondents) . We need to exercise caution with drawing conclusions from a single study that was based on small sample size and poor methodology. However, keeping in mind that the prevalence of paedophilia is at least 1% in the male population [85, 86], it is obviously important to do more research in this direction in India, because there are indicators that many paedophiles are reachable before acting out their impulses [87, 88].
While our review yielded a combination of cross-sectional and qualitative studies that provides an insight into the linkages between a few psychological, physical, and behavioral health outcomes and CSA, it also reveals some knowledge gaps and potential research agenda. There is extensive research literature from high-income countries that links any Adverse Childhood Experiences (ACE) like CSA, abuse, neglect, parental violence etc. with poor psychological, social, and physiological outcomes across the lifespan . All ACEs including CSA tend to have a dose-response relationship with many unwanted health and social outcomes including perpetration and victimization of intimate partner violence, sexual re-victimisation, depression, drug abuse, and even mortality [89–92]. Amongst the significant challenges to addressing ACEs including CSA, other forms of abuse, maltreatment, and neglect in India are its huge population of children, poor child welfare service coverage, poverty, gender inequality, and illiteracy. The limited literature in India suggests that CSA does not necessarily occur in isolation and may co-occur with other forms of ACEs in the same child [16, 17, 93]. There is a need to assess the associations between CSA and physical health outcomes like menstrual irregularities; behavioral issues that persist in adult life of CSA survivors including increased risk of perpetration of CSA, increased participation in sex work, re-victimization as adults, high risk sexual behaviors and psychosexual dysfunctions; and delays in developmental milestones leading to deficits in motor, emotional, behavioural, language, psychosocial, social, and cognitive skills among children in Indian context as has been indicated in global literature on consequences of CSA [11, 81]. The qualitative literature [58, 59, 62], included in the review, based on the experiences of sexually abused girls indicated that the reactions of the families to the discovery of CSA often caused re-traumatization and hindered the healing process. More research is needed to understand the complex familial and social factors that influence the wellbeing among victims of CSA to inform programs and policies for prevention and treatment of CSA victims.
The review also highlights the need for research aimed at designing and evaluating programs for primary prevention and treatment of CSA victims. The high prevalence of CSA in India calls for a multi-faceted ecological approach that also includes strategies for impacting policies, laws, and social and cultural norms of patriarchy and gender inequality that surround CSA [16, 17, 94]. There may be potential value in primary prevention approaches, such as adopted in Yuva Mitr (friend of the youth), through multiple components like information dissemination to young people and universal educational programs that could be delivered in schools and aimed at potential victims of all genders, their parents, professionals, and the general public about CSA . In addition, a culturally tailored intervention module with specific adaptation of trauma and abuse-focused Cognitive Behavior Therapy (CBT) could also be developed for an Indian context for victims of CSA .
In addition to the limited causal inferences that can be drawn due to near exclusive cross-sectional study designs of most studies, this systematic review suffers some further limitations. Publication bias is a common and well-documented problem in systematic reviews. Despite comprehensive efforts to retrieve all the available data on CSA prevalence rates in India, we might still have failed to identify some non-referenced publications such as reports from civil society organizations that work in the field of CSA in India, other grey literature and literature such as journalistic articles, commentaries, and other reports available in local languages of India. Furthermore, it is likely that the results of this review are biased because not all unpublished data could be accessed. Furthermore, methodological weaknesses of studies limit the reliability and validity of the results. In addition, we included studies whose main aim was to evaluate the CSA experience among Indian children along with studies whose primary objectives may not have been CSA but included CSA as a covariate. However, our goal was not to critically evaluate each individual study, but to comprehensively review the information currently provided in the literature. Despite its limitations, this systematic review makes a significant contribution to research on CSA in India, since it systematically and comprehensively reviewed, structured, and summarized previous research on the prevalence of CSA, and in doing so, provides a future research agenda.
CSA is a dark reality that is highly prevalent in India and adversely impacts health. Our literature review underscores the need for the development of a standardized definition of CSA and a validated tool for accurate measurement of CSA across India. Moreover, additional in-depth studies of CSA among the general and specific populations like commercial sex workers and MSMs are needed to develop effective ecological models for prevention and treatment of CSA that are sensitive to the diversity of vulnerabilities of children and adolescents in the Indian context. Furthermore, there is definitely a great need for more research concerning the perpetrators of child sexual abuse, including gathering more knowledge about paedophilia in India, in order to enhance primary preventive strategies.
S1 Checklist. PRISMA 2009 checklist for systematic reviews.
S1 File. Coding sheet for synthesis of qualitative data.
We would like to thank the advisory board members and experts for their constructive feedback on the study protocol: Dr. Ravi Verma (International Center for Research on Women, New Delhi); Dr. Vidya Reddy (Tulir, Chennai); Dr. Bela Ganatra and Dr. Avni Amin (World Health Organization, Geneva), Dr. KG Santhya (Population Council, New Delhi) and Geetha Nambiar (Public Health Foundation of India, Gurgaon). We would also like to acknowledge FIC (grant K01 TW009664) for supporting Dr. Ameeta Kalokhe’s contribution to this study.
- 1. World Health Organisation. Report of the consultation on child abuse prevention (WHO/HSC/PVI/99.1). Geneva(Switzerland): World Health Organisation, 1999.
- 2. Putnam FW. Ten-year research update review: child sexual abuse. Journal of the American Academy of Child and Adolescent Psychiatry. 2003;42(3):269–78. Epub 2003/02/22. pmid:12595779.
- 3. Wolak J, Finkelhor D, Mitchell KJ, Ybarra ML. Online "predators" and their victims: myths, realities, and implications for prevention and treatment. The American psychologist. 2008;63(2):111–28. Epub 2008/02/21. pmid:18284279.
- 4. Barth J, Bermetz L, Heim E, Trelle S, Tonia T. The current prevalence of child sexual abuse worldwide: a systematic review and meta-analysis. International Journal of Public Health. 2013;58(3):469–83. pmid:23178922
- 5. Pereda N, Guilera G, Forns M, Gómez-Benito J. The international epidemiology of child sexual abuse: A continuation of Finkelhor (1994). Child Abuse & Neglect. 2009;33(6):331–42. http://dx.doi.org/10.1016/j.chiabu.2008.07.007.
- 6. Stoltenborgh M, van Ijzendoorn MH, Euser EM, Bakermans-Kranenburg MJ. A global perspective on child sexual abuse: meta-analysis of prevalence around the world. Child maltreatment. 2011;16(2):79–101. Epub 2011/04/23. pmid:21511741.
- 7. Foster JM, Carson DK. Child sexual abuse in the United States: Perspectives on assessment and intervention. American Journal of Humanities and Social Sciences. 2013;1(3):97–108.
- 8. Goodman GS, Quas JA, Ogle CM. Child maltreatment and memory. Annual review of psychology. 2010;61:325–51. Epub 2009/07/07. pmid:19575622.
- 9. Irish L, Kobayashi I, Delahanty DL. Long-term Physical Health Consequences of Childhood Sexual Abuse: A Meta-Analytic Review. Journal of Pediatric Psychology. 2010;35(5):450–61. PubMed PMID: PMC2910944. pmid:20022919
- 10. Luo Y, Parish WL, Laumann EO. A Population-Based Study of Childhood Sexual Contact in China: Prevalence and Long-Term Consequences. Child abuse & neglect. 2008;32(7):721–31. PubMed PMID: PMC2582752. pmid:18614231
- 11. Maniglio R. The impact of child sexual abuse on health: a systematic review of reviews. Clinical psychology review. 2009;29(7):647–57. Epub 2009/09/08. pmid:19733950
- 12. Shrivastava AK, Karia SB, Sonavane SS, De Sousa AA. Child sexual abuse and the development of psychiatric disorders: a neurobiological trajectory of pathogenesis. Industrial Psychiatry Journal. 2017;26(1):4–12. PubMed PMID: PMC5810166. pmid:29456314
- 13. Davidson G, Shannon C, Mulholland C, Campbell J. A longitudinal study of the effects of childhood trauma on symptoms and functioning of people with severe mental health problems. Journal of trauma & dissociation: the official journal of the International Society for the Study of Dissociation (ISSD). 2009;10(1):57–68. Epub 2009/02/07. pmid:19197712
- 14. Registrar General & Census Commissioner of India. Census of India New Delhi2011 [cited 2017]. Available from: http://www.censusindia.gov.in.
- 15. International Institute of Population Sciences. National Family Health Survey- 4. India: International Institute of Population Sciences, 2015–16.
- 16. Carson DK, Foster JM, Chowdhury A. Sexual Abuse of Children and Youth in India: An Anthropological Perspective. The Oriental Anthropologist. 2014;14(2):343.
- 17. Carson DK, Foster JM, Tripathi N. Child Sexual Abuse in India: Current Issues and Research. Psychological Studies. 2013;58(3):318–25.
- 18. Singhi P, Saini AG, Malhi P. Child maltreatment in India. Paediatrics and International Child Health. 2013;33(4):292–300. pmid:24070123
- 19. Kacker Loveleen, Vardan Srinivas, Kumar P. Study on Child Abuse: India 2007. Ministry of Women and Child Development, Government of India, 2007.
- 20. Human Rights Watch. Breaking The Silence: Child Sexual Abuse in India. 2013.
- 21. RAHI Foundation. Voices from the Silent Zone:Women´s experiences of Incest and Childhood Sexual Abuse:The RAHI Findings. New Delhi: 1998.
- 22. Singh MM, Parsekar SS, Nair SN. An Epidemiological Overview of Child Sexual Abuse. Journal of Family Medicine and Primary Care. 2014;3(4):430–5. PubMed PMID: PMC4311357. pmid:25657958
- 23. Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche PC, Ioannidis JPA, et al. The PRISMA Statement for Reporting Systematic Reviews and Meta-Analyses of Studies That Evaluate Health Care Interventions: Explanation and Elaboration. PLOS Medicine. 2009;6(7):e1000100. pmid:19621070
- 24. Andrews G, Corry J, Slade T, Issakidis C, Swanston H. Child Sexual Abuse. Ezzati M LA, Rodgers A, et al., editor. Geneva (Switzerland): World Health Organisation; 2004. 1851–940 p.
- 25. Alaggia R. An Ecological Analysis of Child Sexual Abuse Disclosure: Considerations for Child and Adolescent Mental Health. Journal of the Canadian Academy of Child and Adolescent Psychiatry. 2010;19(1):32–9. PubMed PMID: PMC2809444. pmid:20119565
- 26. Armijo-Olivo S, Stiles CR, Hagen NA, Biondo PD, Cummings GG. Assessment of study quality for systematic reviews: a comparison of the Cochrane Collaboration Risk of Bias Tool and the Effective Public Health Practice Project Quality Assessment Tool: methodological research. Journal of evaluation in clinical practice. 2012;18(1):12–8. Epub 2010/08/12. pmid:20698919.
- 27. Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. International journal for quality in health care: journal of the International Society for Quality in Health Care. 2007;19(6):349–57. Epub 2007/09/18. pmid:17872937.
- 28. Dunne MP, Zolotor AJ, Runyan DK, Andreva-Miller I, Choo WY, Dunne SK, et al. ISPCAN Child Abuse Screening Tools Retrospective version (ICAST-R): Delphi study and field testing in seven countries. Child Abuse Negl. 2009;33(11):815–25. Epub 2009/10/27. pmid:19853301.
- 29. Zolotor AJ, Runyan DK, Dunne MP, Jain D, Peturs HR, Ramirez C, et al. ISPCAN Child Abuse Screening Tool Children's Version (ICAST-C): Instrument development and multi-national pilot testing. Child Abuse Negl. 2009;33(11):833–41. Epub 2009/10/28. pmid:19857897.
- 30. Gaidhane AM, Syed Zahiruddin Q, Waghmare L, Shanbhag S, Zodpey S, Joharapurkar SR. Substance abuse among street children in Mumbai. Vulnerable Children and Youth Studies. 2008;3(1):42–51.
- 31. Tomori C, McFall AM, Srikrishnan AK, Mehta SH, Nimmagadda N, Anand S, et al. The prevalence and impact of childhood sexual abuse on HIV-risk behaviors among men who have sex with men (MSM) in India. BMC public health. 2016;16:784. Epub 2016/08/16. pmid:27520978; PubMed Central PMCID: PMCPMC4983056.
- 32. Krishnakumar P, Satheesan K, Geeta MG, Sureshkumar K. Prevalence and spectrum of sexual abuse among adolescents in Kerala, South India. Indian journal of pediatrics. 2014;81(8):770–4. Epub 2013/10/25. pmid:24154965.
- 33. Pillai A, Patel V, Cardozo P, Goodman R, Weiss HA, Andrew G. Non-traditional lifestyles and prevalence of mental disorders in adolescents in Goa, India. The British Journal of Psychiatry. 2008;192(1):45–51. pmid:18174509
- 34. Chakrapani V, Newman PA, Shunmugam M. Secondary HIV prevention among kothi-identified MSM in Chennai, India. Culture, health & sexuality. 2008;10(4):313–27. Epub 2008/05/20. pmid:18484376.
- 35. Mimiaga MJ, Closson EF, Thomas B, Mayer KH, Betancourt T, Menon S, et al. Garnering an in-depth understanding of men who have sex with men in Chennai, India: a qualitative analysis of sexual minority status and psychological distress. Archives of sexual behavior. 2015;44(7):2077–86. Epub 2014/11/02. pmid:25358949; PubMed Central PMCID: PMCPMC4441605.
- 36. Jangam K, Muralidharan K, Tansa KA, Aravind Raj E, Bhowmick P. Incidence of childhood abuse among women with psychiatric disorders compared with healthy women: Data from a tertiary care centre in India. Child Abuse Negl. 2015;50:67–75. Epub 2015/06/30. pmid:26118353.
- 37. Basu A. Communicating Health as an Impossibility: Sex Work, HIV/AIDS, and the Dance of Hope and Hopelessness. Southern Communication Journal. 2010;75(4):413–32.
- 38. Devine A, Bowen K, Dzuvichu B, Rungsung R, Kermode M. Pathways to sex-work in Nagaland, India: implications for HIV prevention and community mobilisation. AIDS care. 2010;22(2):228–37. Epub 2010/04/15. pmid:20390501.
- 39. Gupta J, Raj A, Decker MR, Reed E, Silverman JG. HIV vulnerabilities of sex-trafficked Indian women and girls. International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics. 2009;107(1):30–4. Epub 2009/07/25. pmid:19625022; PubMed Central PMCID: PMCPMC3071755.
- 40. Karandikar S, Gezinski L, C. A. Meshelemiah J. A qualitative examination of women involved in prostitution in Mumbai, India: The role of family and acquaintances2013. 496–515 p.
- 41. Karandikar S, Gezinski LB. Intimate Partner Violence and HIV Risks among Female Sex Workers of Mumbai, India. Journal of Ethnic & Cultural Diversity in Social Work. 2013;22(2):112–28.
- 42. Rescue Magar V. and Rehabilitation: A Critical Analysis of Sex Workers’ Antitrafficking Response in India. Signs: Journal of Women in Culture and Society. 2012;37(3):619–44.
- 43. Sinha S. Reasons for Women’s Entry into Sex Work: A Case Study of Kolkata, India. Sexuality & Culture. 2015;19(1):216–35.
- 44. Sahoo KC, Hulland KR, Caruso BA, Swain R, Freeman MC, Panigrahi P, et al. Sanitation-related psychosocial stress: A grounded theory study of women across the life-course in Odisha, India. Social science & medicine (1982). 2015;139:80–9. Epub 2015/07/15. pmid:26164119
- 45. Bal B, Mitra R, Mallick AH, Chakraborti S, Sarkar K. Nontobacco substance use, sexual abuse, HIV, and sexually transmitted infection among street children in Kolkata, India. Substance use & misuse. 2010;45(10):1668–82. Epub 2010/07/02. pmid:20590379
- 46. Bhilwar M, Upadhyay RP, Rajavel S, Singh SK, Vasudevan K, Chinnakali P. Childhood Experiences of Physical, Emotional and Sexual Abuse among College Students in South India. Journal of tropical pediatrics. 2015;61(5):329–38. Epub 2015/07/02. pmid:26130618
- 47. Charak R, Koot HM. Abuse and neglect in adolescents of Jammu, India: the role of gender, family structure, and parental education. Journal of anxiety disorders. 2014;28(6):590–8. Epub 2014/07/10. pmid:25004808
- 48. Deb S, Walsh K. Impact of physical, psychological, and sexual violence on social adjustment of school children in India. School Psychology International. 2012;33(4):391–415.
- 49. Jaya J, Hindin MJ. Nonconsensual sexual experiences of adolescents in urban India. The Journal of adolescent health: official publication of the Society for Adolescent Medicine. 2007;40(6):573 e7-14. Epub 2007/05/29. pmid:17531768
- 50. Deb S, Modak S. Prevalence of Violence against Children in Families in Tripura and Its Relationship with Socio-economic Factors. Journal of Injury and Violence Research. 2010;2(1):5–18. PubMed PMID: PMC3134897. pmid:21483193
- 51. Banerjee SR, Bharati P, Vasulu TS, Chakrabarty S, Banerjee P. Whole time domestic child labor in metropolitan city of Kolkata. Indian pediatrics. 2008;45(7):579–82. Epub 2008/08/13. pmid:18695278
- 52. Bhat DP, Singh M, Meena GS. Screening for abuse and mental health problems among illiterate runaway adolescents in an Indian metropolis. Archives of Disease in Childhood. 2012;97(11):947–51. pmid:22904267
- 53. Bhattacharyya SK, Saha SP, Pal R. Rape among women and girls presenting at a gynecological emergency department, North Bengal Medical College, Darjeeling, India. International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics. 2012;117(2):186–7. Epub 2012/03/01. pmid:22374108
- 54. Das M, Ghosh S, Verma R, O'Connor B, Fewer S, Virata MC, et al. Gender attitudes and violence among urban adolescent boys in India. International Journal of Adolescence and Youth. 2014;19(1):99–112.
- 55. Deb S, Mukherjee A. Impact of Sexual Abuse on Personality Disposition of Girl Children. Journal of the Indian Academy of Applied Psychology. 2009;35(1):113–20.
- 56. Kar N, Koola MM. A pilot survey of sexual functioning and preferences in a sample of English-speaking adults from a small South Indian town. The journal of sexual medicine. 2007;4(5):1254–61. Epub 2007/08/04. pmid:17672829
- 57. Miller E, Das M, Tancredi DJ, McCauley HL, Virata MC, Nettiksimmons J, et al. Evaluation of a gender-based violence prevention program for student athletes in Mumbai, India. Journal of interpersonal violence. 2014;29(4):758–78. Epub 2013/10/22. pmid:24142444
- 58. Sahay S. Socio-Cultural Factors and Young Sexual Offenders: A Case Study of Western Madhya Pradesh (India). International Journal of Adolescence and Youth. 2008;14(2):113–34.
- 59. Sahay S. Making of Victim a Patient: Sexually Abused Children and the Consequences of Unprofessional Help. Psychological Studies. 2013;58(2):153–63.
- 60. Silverman JG, Decker MR, Gupta J, Maheshwari A, Patel V, Willis BM, et al. Experiences of sex trafficking victims in Mumbai, India. International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics. 2007;97(3):221–6. Epub 2007/02/27. pmid:17320087
- 61. Silverman JG, Raj A, Cheng DM, Decker MR, Coleman S, Bridden C, et al. Sex Trafficking and Initiation-Related Violence, Alcohol Use, and HIV Risk Among HIV-Infected Female Sex Workers in Mumbai, India. The Journal of Infectious Diseases. 2011;204(Suppl 5):S1229–S34. PubMed PMID: PMC3247788. pmid:22043037
- 62. Sahay S. Compelled Subjugation and Forced Silence: Sexually Abused Girls and their Family Members: A Case Study of Western Madhya Pradesh (India). International Journal of Adolescence and Youth. 2010;15(4):343–64.
- 63. Rashid J. An analysis of self-accounts of children-in-conflict- with-law in Kashmir concerning the impact of torture and detention on their lives. International Social Work. 2012;55(5):629–44.
- 64. Pillai A, Andrews T, Patel V. Violence, psychological distress and the risk of suicidal behaviour in young people in India. International journal of epidemiology. 2009;38(2):459–69. Epub 2008/08/30. pmid:18725364
- 65. Deb S, Mukherjee A. Background and Adjustment Capacity of Sexually Abused Girls and their Perceptions of Intervention. Child Abuse Review. 2011;20(3):213–30.
- 66. Deb S, Mukherjee A, Mathews B. Aggression in Sexually Abused Trafficked Girls and Efficacy of Intervention. Journal of interpersonal violence. 2011;26(4):745–68. pmid:20587459
- 67. Jaisoorya TS, Janardhan Reddy YC, Thennarasu K, Beena KV, Beena M, Jose DC. An epidemological study of obsessive compulsive disorder in adolescents from India. Comprehensive psychiatry. 2015;61:106–14. Epub 2015/06/04. pmid:26038283
- 68. Shahmanesh M, Wayal S, Cowan F, Mabey D, Copas A, Patel V. Suicidal behavior among female sex workers in Goa, India: the silent epidemic. American journal of public health. 2009;99(7):1239–46. Epub 2009/05/16. PubMed Central PMCID: PMCPMC2696657. pmid:19443819
- 69. Shahmanesh M, Cowan F, Wayal S, Copas A, Patel V, Mabey D. The burden and determinants of HIV and sexually transmitted infections in a population-based sample of female sex workers in Goa, India. Sexually transmitted infections. 2009;85(1):50–9. Epub 2008/08/08. pmid:18684856
- 70. Charak R, Koot HM. Severity of maltreatment and personality pathology in adolescents of Jammu, India: A latent class approach. Child Abuse Negl. 2015;50:56–66. Epub 2015/06/10. pmid:26056057
- 71. Nayak MB, Korcha RA, Benegal V. Alcohol use, mental health, and HIV-related risk behaviors among adult men in Karnataka. AIDS and behavior. 2010;14 Suppl 1:S61-73. Epub 2010/06/23. PubMed Central PMCID: PMCPMC2905508. pmid:20567896
- 72. Silverman JG, Decker MR, Gupta J, Maheshwari A, Patel V, Raj A. HIV prevalence and predictors among rescued sex-trafficked women and girls in Mumbai, India. Journal of acquired immune deficiency syndromes (1999). 2006;43(5):588–93. Epub 2006/10/05. pmid:17019369
- 73. Silverman JG, Saggurti N, Cheng DM, Decker MR, Coleman SM, Bridden C, et al. Associations of sex trafficking history with recent sexual risk among HIV-infected FSWs in India. AIDS and behavior. 2014;18(3):555–61. Epub 2013/08/21. PubMed Central PMCID: PMCPMC4111225. pmid:23955657
- 74. Deb S. Mental disposition of commercial sex workers (CSWs) with HIV/AIDS. Journal of the Indian Academy of Applied Psychology. 2008;34:90–100.
- 75. Balaji M, Andrews T, Andrew G, Patel V. The acceptability, feasibility, and effectiveness of a population-based intervention to promote youth health: an exploratory study in Goa, India. The Journal of adolescent health: official publication of the Society for Adolescent Medicine. 2011;48(5):453–60. Epub 2011/04/20. PubMed Central PMCID: PMCPMC4991743. pmid:21501803
- 76. National Crime Record Bureau, Ministry of Home Affairs. Crime in India 2015.
- 77. Belur J, Singh BB. Child sexual abuse and the law in India: a commentary. Crime Science. 2015;4(1):26.
- 78. Choudhury R. Understanding family life in India. In: Chowdhury A, Carson DK, Carson CK, editors. Family life education in India: perspectives, challenges, and applications. Jaipur: Rawat Publications; 2006.
- 79. Dayal R, Kalokhe AS, Pillai D, Choudhry V, Beier KM, Patel V. Ethical and Measurement Issues in Research on Child Sexual Abuse. 2018.
- 80. Kumar MT, Kumar S, Singh SP, Kar N. Prevalence of child abuse in school environment in Kerala, India: An ICAST-CI based survey. Child Abuse & Neglect. 2017;70:356–63.
- 81. Collin-Vézina D, Daigneault I, Hébert M. Lessons learned from child sexual abuse research: prevalence, outcomes, and preventive strategies. Child and Adolescent Psychiatry and Mental Health. 2013;7(1):22. pmid:23866106
- 82. Mann RE, Hanson RK, Thornton D. Assessing Risk for Sexual Recidivism: Some Proposals on the Nature of Psychologically Meaningful Risk Factors. Sexual Abuse. 2010;22(2):191–217. pmid:20363981
- 83. Beier KM. Differential typology and prognosis for dissexual behavior—a follow-up study of previously expert-appraised child molesters. International journal of legal medicine. 1998;111(3):133–41. Epub 1998/05/20. pmid:9587795
- 84. Seto MC, Cantor JM, Blanchard R. Child pornography offenses are a valid diagnostic indicator of pedophilia. Journal of abnormal psychology. 2006;115(3):610–5. Epub 2006/07/27. pmid:16866601
- 85. Ahlers CJ, Schaefer GA, Mundt IA, Roll S, Englert H, Willich SN, et al. How unusual are the contents of paraphilias? Paraphilia-associated sexual arousal patterns in a community-based sample of men. The journal of sexual medicine. 2011;8(5):1362–70. Epub 2009/11/26. pmid:19929918
- 86. Joyal CC, Carpentier J. The Prevalence of Paraphilic Interests and Behaviors in the General Population: A Provincial Survey. Journal of sex research. 2017;54(2):161–71. Epub 2016/03/05. pmid:26941021
- 87. Beier KM, Ahlers CJ, Goecker D, Neutze J, Mundt IA, Hupp E, et al. Can pedophiles be reached for primary prevention of child sexual abuse? First results of the Berlin Prevention Project Dunkelfeld (PPD). The Journal of Forensic Psychiatry & Psychology. 2009;20(6):851–67.
- 88. Beier KM, Grundmann D, Kuhle LF, Scherner G, Konrad A, Amelung T. The German Dunkelfeld project: a pilot study to prevent child sexual abuse and the use of child abusive images. The journal of sexual medicine. 2015;12(2):529–42. Epub 2014/12/05. pmid:25471337
- 89. Dube SR, Anda RF, Whitfield CL, Brown DW, Felitti VJ, Dong M, et al. Long-term consequences of childhood sexual abuse by gender of victim. American journal of preventive medicine. 2005;28(5):430–8. Epub 2005/05/17. pmid:15894146
- 90. Easton SD. Understanding adverse childhood experiences (ACE) and their relationship to adult stress among male survivors of childhood sexual abuse. Journal of prevention & intervention in the community. 2012;40(4):291–303. Epub 2012/09/14. pmid:22970782
- 91. Felitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, Edwards V, et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. American journal of preventive medicine. 1998;14(4):245–58. Epub 1998/06/23. pmid:9635069
- 92. Ports KA, Ford DC, Merrick MT. Adverse childhood experiences and sexual victimization in adulthood(). Child abuse & neglect. 2016;51:313–22. PubMed PMID: PMC4713310. pmid:26386753
- 93. Deb S. Children in agony: A source book: Concept Publishing Company; 2006.
- 94. Kenny MC, Wurtele SK. Preventing childhood sexual abuse: an ecological approach. Journal of child sexual abuse. 2012;21(4):361–7. Epub 2012/07/20. pmid:22809043
- 95. Choudhary V, Satapathy S, Sagar R. Review of randomized controlled trials on psychological interventions in child sexual abuse: Current status and emerging needs in the Indian context. Indian Journal of Psychological Medicine. 2016;38(4):279–84. pmid:27570336
- 96. Sahay S, Nirmalkar A, Sane S, Verma A, Reddy S, Mehendale S. Correlates of sex initiation among school going adolescents in Pune, India. Indian journal of pediatrics. 2013;80(10):814–20. Epub 2013/04/23. pmid:23604612
- 97. Hasnain N, Kumar D. Psychological well-being of women reporting sexual abuse in childhood. Journal of the Indian Academy of Applied Psychology. 2006;32(1):16–20.
- 98. Reed E, Silverman JG, Stein B, Erausquin JT, Biradavolu M, Rosenberg A, et al. Motherhood and HIV risk among female sex workers in Andhra Pradesh, India: the need to consider women's life contexts. AIDS and behavior. 2013;17(2):543–50. Epub 2012/07/12. pmid:22782790