CSA is grossly under-reported offence in our country [3,5]. Literature on the burden and pattern of sexual abuse among children in India is scanty. We studied the prevalence and spectrum of self-reported childhood sexual abuse in a sample of college students at a medical college in Southern India. An additional objective was to study the psychological problems associated with CSA.

This descriptive study was conducted at the Department of Forensic Medicine, Indira Gandhi Medical College, Puducherry in July-September, 2018. The study population consisted of undergraduate medical students (MBBS) studying in the institution. At the time of study there were five batches of medical students, with 150 students. (total 700-750 students). All these students formed the study population. Those students who could not be contacted despite three attempts were excluded.

A pretested, structured, anonymous, self-administered English language questionnaire served as the study tool. The questionnaire was prepared using core components of child sexual study by Halpérin, et al. [6] and in consultation with the subject experts. It was pretested in a small group of students and modified accordingly. Questions were framed in various sections regarding loss of parents, parental care, abuse physical and/or sexual and support. Term sexual abuse was defined as a variety of acts like fondling genitals of a child, making the child fondle genitals of an adult, exhibitionism, pornography and sexual assult like inter-course, incest, rape and sodomy etc [7]. For the purpose of this study, lifetime experience of sexual abuse was considered if any subject has experienced of any kind of sexual abuse in his/her life till date.

The students were briefed about the study objectives and assured of complete confidentiality and privacy. Written informed consent was obtained. Consent forms were kept separate from the questionnaires to maintain anonymity. Questionnaires were handed out to the students just after completion of classes and ensuring privacy at all times.

Study subjects were explained and informed about not writing their names or put any mark that can help in their identification neither on the questionnaires nor on the envelopes. Students were instructed to fill the questionnaire and leave it in the prepared collecting box. Of them, boys and girls were 15 each. On an average, it took 30-45 minutes to conduct interview with one subject. Permissions were obtained from the institutional ethics committee, respective colleges, and Child Welfare Committee of Puducherry.

Qualitative data collection was done by in depth interview with respondents willing to talk freely till point of exhaustion. The semi-structured interviews (n=30) were conducted by a trained interviewer.

Statistical analysis: All the questionnaires were manually checked for completeness and were then coded for computer entry. The collected data was entered in Excel and analyzed using SPSS version 22 (IBM). Chi square test was used to test statistical significance, wherever applicable.

Of the 452 respondents (57% girls), 148 (32.7%) reported experiencing one or other form of sexual abuse; 84 (56.8%) of these were girls.

Most instances of CSA occurred either at own house (n=50, 33.8%), a neighbour’s house (n=34, 22.9%) or at any other unknown place (n=30, 20.3%). Sexual abuser was someone from friend (n=39, 26.4%), some unknown person (n=32, 21.6%), uncle (n=15, 10.1%), neighbor and some known person (n=14, 9.5% each) followed by cousin brother (n=10, 6.8%). Most (n=126, 85.1%) of the times the sexual abuser was male. As per respondants, abuser was below twenty years in 80 (54.1%) such instances whereas 21-30 years in 48 (32.4%) cases. Majority of sufferers (n=89, 60.1%) did not inform or share the instance of CSA to anyone. Fear of negative consequences (n=64, 43.2%), feelings of guilt (n=45, 30.4%), fear of not being believed by family (n=17, 11.5%), loyalty to the perpetrator (n=15, 10.1%) were few factots that made them not to inform such abuse to their family members. Most (n=41, 69.5%) of the times, instances of CSA was revealed to the friends followed by mother and sisters (n=7, 11.9% each).

Fondling (44.6%), making him/her look at pornographic pictures, films, videotapes or magazines (29.7%), and looking at his/her genitals (22.3%) were the three most common types of sexual abuse (Table I).

Psychological problems like sense of insecurity at home, suicidal thoughts, of being disliked by parents, sense of depression and anxiety were significantly more in subjects who had experienced CSA (Table II).

The current study among medical college students in Puducherry found that overall, 32.7% of them had a history of sexual abuse, and it was similar between the sexes. These results are in consonance with previous reports [8,9]. A meta-analysis of more than fifty studies across various countries reported that the burden of CSA was 8-31% among girls and 3-17% among boys aged less than eighteen years of age [8]. Another meta-analysis concluded that 7.9% of males and 19.7% of females experienced one or other form of sexual abuse before attaining the age of 18 years [9].

Another study from Southern India on childhood sexual abuse conducted among a sample of college students reported the prevalence of CSA as 2.6–14.3% [10]. Similar prevalence among boys and girls has also been reported previously [11]. As per UNICEF (2005–2013) report, 42% of Indian girls have faced trauma of sexual violence in their teenage life [12]. Another study from Kerala [13] on burden of sexual abuse among adolescents, reported that 36% boys and 35% girls suffered from one or more incidents of sexual abuse at least once.

In this study we observed that most instances of CSA occurred either at home or in the neighbourhood, in contrast to the study by Krishnakumar, et al. [13], that reported majority of such incidents took place while travelling in bus or train [13]. The commonest type of CSA acts in our study were similar to previous reports [10,13].

Not surprisingly our study shows that majority (60.1%) did not inform or share the instance of CSA to anyone. Probably it could be due to conservative nature of Indian society where conversation and discussion on topics related to sex and sexuality is considered a taboo.

We also observed that the psychological problems like sense of insecurity at home, suicidal thoughts, of being not liked by parents, sense of depression and anxiety were clearly more in subjects experiencing the CSA. Clear evidance is available in literature about a link between CSA and psychiatric symptoms [14-16].

We chose medical students for the purpose of this study as openness to talk on such issues and better recollection of past incidents were required. Children may not recognize the diverse aspects of CSA. This aspect motivated us to fetch the desired information from a sample of medical students, thus adding strength to the study. Regarding limitations, possibility of recall bias is definitely an evident limitation. The results of this investigation are from a single tertiary care centre which limits the generaliability of the findings. Multicentric studies with bigger sample size are warranted.

Approximately one-third of medical students reported an incident of sexual abuse at least once in his/her life in Puducherry thus roots of CSA are deep in the society in which we live. In contrast to the socially prevalent belief that girls are more sexually abused compared to boys, this investigation interestingly highlights that even boys are equally facing the burnt of this issue. Discussion on topics related to sex and sexuality is still considered a taboo. Therefore this is need of an hour to evolve methods of protecting our childen from CSA and it should cater need of both boys and girls.

Ethics clearance: Institutional ethics committee of Indira Gandhi Medical College and Research Institute; No. 17/IEC/IGMC/F-7/2017 dated 21 November, 2017.

Contributors: RDM: Conception and design, AS: Analysis and interpretation of the data, MC: Drafting of the article, Manuscript preparation, MB: Manuscript editing, Final approval of the article, PM: Literature search, YB: Statistical analysis, RR: Collection and assembly of data.

Funding: None; Competing interest: None stated.