The characteristics of the children are shown in Table1. The characteristics of the mothers were displayed in Table 2. The characteristics of the fathers are shown in Table3. Two fathers in the IFSA group, two fathers in the EFSA group, and three fathers in the control group were not included in this analysis since they died during the study period.
The data revealed by CTQ are displayed. Their comparative analysis revealed significant differences between the three groups in terms of the presence of emotional neglect, emotional abuse, physical neglect, and abuse and sexual abuse(p≤0,001). However, there were no significant differences between IFSA and EFSA mothers regarding all domains(Table4). The assessment of mean FAD scores elucidated significant differences between all groups regarding all subscales(p≤0,001). Mean FAD scores of IFSA and EFSA groups were significantly higher than controls (p≤0,001). However, there were no significant differences between IFSA and EFSA. A comparison of the mean PBI scores of the mothers between the groups revealed a significant difference (p<0,001). However, there was no significant difference between IFSA and EFSA mothers(Table6). Comparative analysis of the groups in terms of mean PAS scores revealed a significant difference between the groups (p≤0,001); however, but the difference between IFSA and EFSA groups was not significant(Table7).
Logistic regression analysis was used to determine the best predictors for sexual abuse of children. The logistic model conducted with the factors that were found significantly associated with sexual abuse. The model fit was good(Hosmer-Lemeshow test, p:0,938) and the created model explained 87% of the variance(Nagelkerke R square). This analysis showed that maternal marriage at a young age, low PBI scores, history of maternal psychiatric disease are the best predictors for sexual abuse in children(Table8).
Discussion: In this study, our findings indicated that IFSA mothers got married before the age of 18 more frequently than EFSA. In terms of all variables, the significant differences are revealed between the groups. IFSA mothers and fathers were younger than EFSA(p:0,001 and 0,003 respectively). However, there were no significant differences in terms of variables except mentioned previously variables between IFSA and EFSA. According to attachment theory, the relationship with the primary caregiver, especially with mother gives shape to some beliefs in later close relationships. These beliefs are encoded as internal working model. Internal working model is associated with emotions, defenses and relational behavior in close relationships [36]. It could be said that attachment security is associated with later close relationships with partners and so children [37, 38]. Hence, the women with insecure attachment are more likely to have difficulties in romantic relationships, have chaotic family relationships. Childhood attachment relationship impact also parenting [39]. Children who grow up in these chaotic families are vulnerable to sexual abuse. Based on the attachment theory framework, the maternal-child relationship could be an essential risk factor for examining the sexual abuse risk of children [40]. In our study, we found that mothers of the children in the IFSA group mothers more frequently got married before 18. In Turkey, marriage under 18 requires a court order in addition to parental consent.
Several studies reported that the mean age of IFSA children was lower than EFSA children according to judicial records [8, 41]. There was no significant difference between the mean patient ages of IFSA and EFSA groups in our study. This finding was not consistent with those reported in the literature. However, the fact that we did not include the patients younger than 10 in our study cohort needs to be considered.
A meta-analysis showed that mothers of IFSA children were significantly younger than those of EFSA children [42]. Our findings were in line with this study. It was reported that mothers of sexually abused children had a lower education level [7, 43]. Our findings support these reports. Our study showed that the rate of marriage before the age of 18 was significantly higher in IFSA mothers than EFSA mothers. However, a comparison of the IFSA and EFSA groups in terms of maternal marriage age revealed no significant difference. Although studies investigating the maternal marriage age of the sexually abused children are scarce, it was reported that maternal marriage age was inversely correlated with the risk of CSA[26]. As such, a maternal marriage earlier amplifies this risk.
Our analysis regarding the paternal features of CSA victims demonstrated that IFSA fathers were younger than EFSA fathers and fathers of healthy controls. Also, the education level of the fathers of sexually abused children was lower than that of healthy controls, but there was no significant difference between IFSA and EFSA groups in this regard. These findings are consistent with the literature[7].
CSA leads to adverse emotional and behavioral effects during childhood and adulthood[44]. It is also known that the history of CSA increases the prevalence of psychiatric disorders during adulthood[45, 46]. The most common psychiatric disorders diagnosed in these patients are PTSD, MDD, adjustment disorder, anxiety disorders, and acute stress disorder [47-49]. The K-SADS-PL diagnosis rates of our study were similar to the rates previously reported in the literature. However, the rate of being diagnosed with at least one psychiatric disorder was higher than the previously published reports in our series. This difference may be because our study population consisted of children who presented to the child psychiatry clinics. However, frequency of IFSA and EFSA diagnoses were not differentiated from each other. It was thought that these findings are significant. Previous studies reported frequencies of diagnoses of sexually abuse children in forensic evaluation. Hence; it was the first study in the literature to compare the diagnoses of patients followed in a psychiatry outpatient clinic.
Previous studies reported that mothers of sexually abused children had higher rates of CSA than the mothers of healthy controls[50, 51]. Baril et al. proposed the intergenerational cycle hypothesis in sexual abuse [52]. Our findings support this hypothesis.
It was reported that physically or sexually abused female adolescents perceive their family environments more conflicting than others[53]. It is known that parents' age and childhood experiences influence their parenting style[54, 55]. Parenting style and parental attitudes affect children's relationships with other people, and these effects may extend to adulthood[56]. Attachment security and quality are essential determinants of relationships with other people, response to stress, and hopelessness feelings[57].
To the best of our knowledge, our study was the first to compare the mothers of IFSA and EFSA children regarding CSA. However, it has some limitations which need to be considered while evaluating its findings. First, we did not include the details of the sexual abuse experience and the elapsed time between the incident and psychiatric assessment. Second, our analysis also did not include follow-up data such as follow-up duration. Third, we have not collected any data about CSA of mothers whether it is IFSA or EFSA. The data regarding about that could give us more information about which of them is more transmitted. The other limitation is that considering previous studies, we did focus on childhood maltreatment history of mothers, not focus on the maltreatment history of fathers. On the other hand, it should be considered that we focused on the childhood traumas of the mothers of sexually abused children. It should also be noted that our study considered family functioning, parental attitudes, and parental bonding while making this comparison. This comparison revealed significant differences between sexually abused children and healthy controls in terms of family functioning, parental attitudes, and parental bonding. However, there were hardly any significant differences between IFSA and EFSA groups concerning these parameters. One reason of that might be that IFSA was kept secret due to threats. The other reason might be accommodation syndrome. According to accomodation syndrome; children are not ready to be abused. It is implied that abuser is a trusted person and more robust than victim. For children, the fear of losing the abuser's affection and being ostracized by family members might be more frightening than any threat or violence. Therefore, children prefer to believe that the abuser is a good person to accomodate the new chaotic situation[58, 59]. Hence, more well-designed studies are needed to determine the differences in intergenerational transmission of IFSA and EFSA. So, differentiated intervention and treatment options for children and their mothers might protect next generations from neglect and abuse. Therefore, we conclude that protecting a child from sexual abuse or optimal follow-up of SAC will also help protect the next generations.