Development of a Retrospective Measure of Childhood Sexual Maltreatment in Pakistan

The study was intended to develop a retrospective measure of childhood sexual maltreatment in nonclinical population. Items were developed using existing literature and experts’ suggestions. After preliminary testing, 20 items were administered to a sample of 375 university students including males, females, and participants who kept gender undisclosed. Exploratory factor analysis yielded three factors: Psychological Experience of Childhood Sexual Maltreatment, Physical Experience of Childhood Sexual Maltreatment, and Forced Exposure to Nudity. Final developed scale along subscales showed excellent internal consistency. However, the factor, Forced Exposure to Nudity showed slightly less than satisfactory internal consistency and other psychometric properties. Therefore, it is suggested that the third factor needs to be refined in revisions of the test. The implications and limitations regarding the development of retrospective measure of childhood sexual maltreatment in the context of Pakistan were discussed.

Child sexual maltreatment refers to sexual exploitation, abuse, and manipulation of children and adolescents and it is considered as one of the most serious forms of human rights violation. The range of sexual actions categorized as child sexual maltreatment includes cuddling, tempting a child to touch or to be touched sexually, intercourse, rape, incest, sodomy, immodesty or involving a child in prostitution or pornography (Manay & Collin-Vézina, 2021). Various terms have been used that refer to child sexual maltreatment. These include child sexual abuse (CSA), child sexual assault, child sexual victimization, child sexual exploitation, and adverse sexual experience.

Another definition describes 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, or else that violates the laws or social taboos of society. Children can be sexually abused by both adults and other children who are by virtue of their age or stage of development – in a position of responsibility, trust or power over the victim” (World Health Organization, 2006, p. 10).

CSA has also been defined to be characterized by “any unwanted, non-consensual, or exploitative sexual activity involving a child under 18 years of age, including contact abuse (e.g., kissing; touching of breasts, genitals, or anus; vaginal, anal, or oral penetration) and non-contact abuse (e.g., exhibitionism; use in, or exposure to pornography; observing masturbation or other sex acts”) (Azzopardi et al., 2019,p. 4).
In a review of 28 studies that explored experience of CSA, it was defined as “any act which exposes a child to, or involves a child in, sexual processes beyond his or her understanding or contrary to accepted community standards. Sexually abusive behaviors can include the fondling of genitals, masturbation, oral sex, vaginal or anal penetration by penis, finger or any other object, fondling of breasts, voyeurism, exhibitionism, and exposing the child to or involving the child in pornography. It includes child grooming, which refers to actions deliberately undertaken with the aim of befriending and establishing an emotional connection with a child to lower the child’s inhibitions in preparation for sexual activity with the child” (Royal Commission, as cited in MacGinley et al., 2019, p. 1137).

CSA has also been conceptualized in terms of sexual exploitation. It occurs where, “child sexual exploitation is a form of CSA. It occurs where an individual or group takes advantage of an imbalance of power to coerce, manipulate or deceive a child or young person under the age of 18 into sexual activity (a) in exchange for something the victim needs or wants and/or (b) the financial advantage or increased status of the perpetrator or facilitator. The victim may have been sexually exploited even if sexual activity appears consensual. “Child sexual exploitation does not always involve physical contact; it can also occur through the use of technology” (Working Together, as cited in Beckett et al., 2017, p. 7). It can be observed that the characteristics oincludeven in all the definitions essentially include: Child as a victim, act of sexual nature, absence of consent, and misuse of power.

Another aspect of childhood sexual abuse that has developed since the advent of online social networking sites and smartphones is online sexual abuse. Different forms of online sexual abuse have been reported by children and adolescents, such as through sharing children’s nude/ sexual pictures (Powell et al., 2022), sharing obscene images (Ali et al., 2023), online grooming (Martellozzo, 2019), and sexual soliciting (De Santisteban & Gámez-Guadix, 2018). To current study, however, the term ‘sexual maltreatment’ was chosen because it is more generic term which seems to include multiple aspects of CSA.

Global Prevalence of Childhood Sexual Maltreatment

Studies show that a large part of population in various regions has been found to have experienced at least some form of childhood sexual maltreatment. In a global meta-analysis of 48 publications on prevalence of childhood sexual abuse, the rate of CSA was estimated to be 24% (Pan et al., 2021). In another study, conducted in Cyprus to assess the prevalence, context, and correlates of CSA, evidence was found supporting the previous findings regarding prevalence of child sexual maltreatment in Europe, that one out of five children have experienced sexual abuse (Karayianni et al., 2017).

In China, the prevalence of CSA among men was found to be 9.1% and for women it was 8.9% (Ma, 2018).  In Scandinavian countries, the percentage of CSA was found to range from 3 to 23% in males and from 11 to 36% in females (Kloppen et al., 2016).  Japan was found to have 4.1% rate of incidence of reported contact CSA cases for males and up to 60.7% for females (Tanaka et al., 2017). In Saudia Arabia the percentage of reported CSA cases regardless of gender was 14% (Al-Eissa et al., 2015) and in Tanzania it was found to be 13% for males and 28% for females as victims (Abeid et al., 2015). In India, among females under eighteen years, the rate of CSA was 4 to 41%, in males of almost similar age it was 4 to 57% and in females over eighteen years, the prevalence was reported to be 3 to 39% (Choudhry et al., 2018). In a recent survey in Australia, the percentage of childhood sexual abuse was found to range from 24 to 27% (Mathews et al., 2023).  The percentage of childhood sexual abuse in the US was found to be 14.1% with varying rates for males and females (Henkhaus, 2022). Moreover, a considerable percentage of people (15.6%) was found to report various kinds of online sexual abuse before the age of eighteen years in the US (Finkelhor et al., 2022).

Prevalence of Childhood Sexual Maltreatment in Pakistan

In Pakistan, any kind of discussion on sexual abuse is considered a taboo, which probably is one of the reasons that the cases of sexual abuse also remain under-reported. The issue of CSA, therefore, is even more deliberately swept under the carpet as children being dependent on their adult immediate family members, need their support for such disclosure, and they hardly get it. Adults themselves usually are incapacitated because of lack of trust in institutional practices as well as due to societal norms of maintaining the ‘silence’ (Back et al., 2003; Hyder & Malik, 2007; Rahim et al., 2021). This cultural and societal norm is so deep rooted that even in Pakistani community living in Britain, the rate of reporting CSA is extremely low (Harrison & Gill, 2018).

A few studies do provide data on the prevalence of CSA in Pakistan. For example, a study showed that reported CSA cases in schools in 2018 were 3832, the number of these cases was found to be 11% more in comparison with reported cases in 2017 (Rahim et al., 2021). In terms of gender, boys between 6 to 15 years of age have been found to be more at risk of sexual abuse and in girls, those up to five years of age and those between16–18 years were found to be more at risk (Sahil, 2018). Another study showed a huge number of adolescents of both genders to have experiences childhood trauma including sexual trauma, with males scoring higher than females on trauma measures (Fatima et al., 2024). Abbas (2021) discovered prevalence of various forms of CSA in retrospective accounts of the incident among university students in Pakistan.

Physical molestation was the most common type of CSA (31% in females and 27% in males) and after that staring at intimate areas of body was the most frequently reported type among both males and females (25% females and 27% among males). Penetrative sex was also reported by almost eight percent of the participants including males and females, with males having higher incidence of this kind of abuse. Bari et al. (2024) also found that 45% of the university students in their sample had experienced sexual abuse before the age of 18 years.  Another study on CSA in Pakistan by Alam et al. (2018) conducted in Peshawar revealed that most vulnerable age group for sexual abuse was 11 to 30 years, which is consistent with findings in other cultures (Cybulska, 2007; Lal et al., 2014; Rawat & Masthanaiah, 2015). This was probably because this is the age range when children are either going to colleges or as adults enter their first job and thus start going to an unfamiliar environment of their new workplace.

However, the available information regarding prevalence of child sexual maltreatment can hardly be considered to accurately represent the actual number of cases. We can speculate that in Pakistan too this can be attributed to similar reasons as found in other cultures, that is low rate of reporting on part of victims, differences in approaches employed for identification of such cases, lack of well-organized systems for ensuring safety of children (Beckett et al., 2017; Lal et al., 2014), and societal values and practices that discourage such kind of reporting as it is assumed to bring disgrace to the victim and to the family (Tener et al., 2020 ).

Psychological Correlates

Literature on psychological disorders and CSA indicates that childhood sexual maltreatment can lead to various psychological issues in childhood as well as in adult life. Pérez-Fuentes et al. (2013) found that the people who experience childhood sexual maltreatment had more chances to develop depression in adulthood as compared with people without any history of it. Another study from Austria by Kisely et al. (2018) showed that people with the history of child sexual maltreatment have higher rate of depression than the rest of the sample. These findings are supported by evidence provided by some other studies as well (Gardner et al., 2019; Kamiya et al., 2016). Similar evidence was found regarding association of CSA with depression, anxiety, and psychiatric disorders among people with varying religious affiliations in the Jewish community as well (Rosmarin et al., 2018). Moreover, CSA has also been found to predict suicidal ideation in adult survivors (Bahk et al., 2017).

There is also ample research evidence on the association of CSA with substance misuse and abuse. For example, one study showed CSA to be related with anxiety and alcohol use (Villalba et al., 2020).  In a meta-analysis of forty studies Fletcher (2021) also found substance abuse in adolescence and adulthood to be associated with CSA. Hailes et al. (2019) also found association of CSA with various psychological problems and the strongest association found was with PTSD, schizophrenia, and substance misuse. Studies have also found CSA to be related to PTSD and brain damage due to trauma (Edwards, 2018; Sheffield, 2013). A systematic review of 24 studies on childhood sexual abuse reported by adult survivors of South Asian origin, revealed that adult survivors, even if they are not clinically diagnosed with some psychological illness, go through relationship related difficulties, risk of self-harm and other cognitive and emotional problems (Talwar et al., 2024).

Existing Scales on Childhood Sexual Maltreatment

Over the past two decades, number of measures have been developed to measure childhood sexual abuse. Notable among these are Adverse Childhood Experience Scale (Felitti et al., 1998), Childhood Trauma Questionnaire (Bernstein & Fink, 1998), and Childhood Experience of Care and Abuse Questionnaire (Smith et al., 2002). All these measures include subscales of sexual abuse comprising four to five items each. Although the psychometric properties of these scales are satisfactory and they can be used as reliable screening instruments, however, the number of items does not seem to cover the range of behaviors that can be categorized as sexual abuse or sexual maltreatment which may specially include online sexual maltreatment.

In the context of Pakistan, the scales that have been developed to measure childhood sexual maltreatment are intended for use with children aged 8-12 years (Malik & Saeed, 2022), while some other studies on childhood sexual abuse that have been conducted in Pakistan employed qualitative methods (Qureshi, 2024). Rest of the studies have used instruments either not exclusively developed in Pakistan or if developed in Pakistan, they are intended for use up to 19 years of age and do not focus exclusively on CSA but measure adverse experiences in terms of different dimensions of adverse experiences, such as Adverse Childhood Experiences (Riaz & Bano, 2020). Such scales can be used for screening purposes regarding childhood sexual abuse, but they may not encompass the various kinds of sexual maltreatment.

Rationale of the Study

The current study intended to develop a retrospective scale measuring childhood sexual maltreatment that could be used not only for screening purposes, but also for identifying the intensity of childhood sexual maltreatment experience and its impact on the individual particularly in nonclinical populations. No such measure exists that has been developed in the cultural context of Pakistan measuring the intensity in terms of various dimensions of experiencing childhood sexual maltreatment retrospectively (to be used with adults) yet. Moreover, another reason to develop this scale is that the existing measures do not investigate abuse committed through use of gadgets like android phones, social media platforms and internet in general.

Also, most of the existing scales require responses in yes/no format, which does not provide information regarding the intensity of the impact childhood sexual maltreatment can have. Another reason to develop a retrospective measure was that in Pakistani culture people are usually not very eloquent before the age of 18 to 20 years about reporting their experiences that involve sexuality of any kind. Therefore, despite the suspected loss of detailed information due to time lapse, the reports of adults aged 18 to 25 years regarding their CSA experiences can be more representative of what they experienced and what they went through emotionally afterwards.

Method

The study was conducted in two phases including item generation and validation in Main Study.

Phase 1 - Item Generation

Items were generated with the help of existing literature, and guidance of experts; psychologists, psychiatrists from Bolan Medical College, Quetta; a lawyer; and a judge from High Court Balochistan; educationists and counseling psychologists from Balochistan University of Information Technology and Engineering and Management Sciences; Quetta. After identifying the possible factors comprising the construct of childhood sexual maltreatment, 40 items were generated.

Pre-Testing

The pre-testing of 40 items was conducted with five-point rating scale. The items covered different dimensions of the construct like physical, psychological, and abuse using social media. The items started with the statement: Mention the degree of agreement or disagreement with the statements based on your experiences you had before the age of eighteen years. Data were collected from 40 university students. All the participants were asked for feedback on the scale to identify and eliminate any confusion. Based on participants’ feedback regarding clarity of items and suggestion from experts regarding the content coverage and structure of items, 20 items were selected for final administration.

Phase 2- Main Study

Sample

The scale was administered to a convenience sample of 375 undergraduate students with the age range of 18-24 years. The sample comprised 200 females and 175 males.

Tools

Pretested 20 items for the intended retrospective measure of childhood sexual maltreatment were administered with five response categories, Strongly Disagree (1) to Strongly Agree (5).

Procedure

After approval from the departmental research ethics committee, students were approached on campus for data collection. They were informed about the purpose of the study; written informed consent was taken. On average they took 15 minutes to complete the questionnaire.

Results                                                                                             

The scale was found to have excellent internal consistency reliability (20 items; α = .93). Exploratory factor analysis was used to identify the latent factors. The sample size for the analysis was 375.  Principal component analysis with Promax rotation was used.

Table 1: Factor Loadings and Communalities for 20 Items of the Retrospective Measure of Childhood Sexual Maltreatment (N = 375)

Note. Boldface factor loadings show retention in respective factors.

Oblique rotation is used because the variables are expected to correlate with one another. Kaiser-Meyer-Olkin value is .90 and Bartlett’s sphericity test is significant, which shows that data is suitable for exploratory factor analysis. Based on Eigenvalues, three components are extracted with eigenvalues of 8.9, 2, and 1.3. The three factors accounted for 61.7 % of the total variance with Factor 1 accounting for 44.7% of total variance, Factor 2 accounting for 10.5%, and Factor 3 accounting for 6.5%.  The factors are identified to be 1. Psychological Experience of Childhood Sexual Maltreatment, 2. Physical Experience of Childhood Sexual Maltreatment, and 3. Forced Exposure to Nudity.  

Table 2: Descriptive Statistics and Correlations of Retrospective Measure of Childhood Sexual Maltreatment and Subscales (N = 375)

**p < .01.

The skewness and kurtosis values for the full scale as well as for all three subscales are found to fall in acceptable range keeping in view the large sample size (Hair et al., 2018).  Cronbach alphas are satisfactory. The correlations among subscales are significant and the correlation of subscales with total scale score are moderate to high and significant (see Table 2).

Discussion

Childhood sexual maltreatment affects a large percentage of population in most parts of the world. In Pakistan too, it affects a lot of people in various ways, regardless of gender and into their adulthood. Despite its prevalence, it remains under reported due to taboo nature of the topic. Moreover, the available assessment techniques of childhood sexual maltreatment assess its occurrence mostly as a categorical variable. Whereas, in a society where sexual maltreatment is vastly prevalent and has various facets and manifestations, it seems justified to treat it as a continuous variable and assessed in terms of varying intensity as well.

The scale development was done in three steps: Item generation, theoretical analysis, and psychometric analysis. The scale showed over all excellent internal consistency reliability. Factor analysis yielded three factors. The first factor is Psychological Experience of Childhood Sexual Maltreatment; this factor encompasses the emotional and psychological harm that the experience of sexual maltreatment in childhood entails. What makes this factor more relevant psychologically is that it focuses more on intensity of the emotional and psychological harm due to childhood sexual maltreatment irrespective of nature and frequency of experiencing childhood sexual maltreatment.
The second factor is Physical Experience of Childhood Sexual Maltreatment; this involves the ways a person is sexually maltreated physically. This factor describes the different direct ways in which a child experienced sexual advances involving physical closeness. This factor, however, does not include detailed description of different modes of physical sexual maltreatment such as touching intimate body parts, attempted penetration, and kissing to name a few. These items were although included in the pretesting stage, the feedback from the participants and experts suggested that the content of these items was too explicit to be included in a questionnaire developed in Pakistan, where talking about sexual experiences is not considered appropriate. And these items may discourage respondents from giving true response.  Therefore, it was deemed reasonable only to include items that ask about physical sexual maltreatment in a more generic way.

The third factor is Forced Exposure to Nudity. This factor includes the items that involve situations when a child is made to witness nudity and explicit sexual content under pressure. This factor has three items that constitute the experience of nudity in a way that includes the involvement of internet or usage of gadgets to send such pornographic material and soliciting or pressurizing the victim to reveal their body in inappropriate ways online. The psychometric properties of this factor, particularly internal consistency and kurtosis despite falling within acceptable range, probably due to large sample size (Hair et al., 2018), suggest that this factor needs to be refined. Therefore, future research on the scale would intend to add more items and improve this factor.

Overall, what makes Retrospective Measure of Childhood Sexual Maltreatment relevant and more meaningful in the context of Pakistan is that it comprises three factors of sexual maltreatment with more items for each subscale, especially emphasizing the psychological impact of childhood sexual maltreatment in a more detailed manner which is the aspect of this experience that may eventually have long term effects lasting through the adulthood.

The Scale can be used with nonclinical population between 18 and 25 years of age, which is an extremely pivotal period of a person’s life for establishing a stable career and family. Moreover, keeping in view the context of Pakistan this might be the age range in which people become more assertive and expressive regarding their experiences, due to newly acquired self-confidence owing to exposure in higher education and work settings. This self-confidence may also help them talk about the experiences they did not talk about in their adolescence.

Limitations

Scales measuring childhood sexual maltreatment as a continuous variable are hard to find. Therefore, no such measure of childhood sexual maltreatment was available that could be used as a standard for validation purposes.  Moreover, due to immoral notions of discussing such experiences, some of the sexual maltreatment acts could not be included in the questionnaire. Hopefully, future versions of the scale will include more details to make it more representative of the sexual maltreatment experience.

Implications

A retrospective self-report measure of sexual maltreatment would not only encourage adults to share their experience of sexual maltreatment as a child but as opposed to case study method that has its own benefits, the scale could help in conducting prevalence surveys on this topic with larger samples.

Another aspect of the development of Retrospective Measure of Childhood Sexual Maltreatment, is that such scales can develop acceptance for bringing issues regarding sexual abuse to the fore and thus could help diminish the taboo status of this topic in Pakistani society. Moreover, the scale could also help sensitize parents and caregivers on what the symptoms look like in order to identify if a child is experiencing childhood sexual maltreatment.

Conflict of interest statement

On behalf of all authors, the corresponding author states that there is no conflict of interest among the authors.

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Received 13 December 2023
Revision received 14 April 2025