Journal of Child Sexual Abuse

ISSN: 1053-8712 (Print) 1547-0679 (Online) Journal homepage: https://www.tandfonline.com/loi/wcsa20

Exploring Mental Health Adjustment of Children

Post Sexual Assault in South Africa

Shanaaz Mathews , Naeemah Abrahams & Rachel Jewkes

To cite this article: Shanaaz Mathews , Naeemah Abrahams & Rachel Jewkes (2013) Exploring
Mental Health Adjustment of Children Post Sexual Assault in South Africa, Journal of Child Sexual
Abuse, 22:6, 639-657, DOI: 10.1080/10538712.2013.811137

To link to this article: https://doi.org/10.1080/10538712.2013.811137

Published online: 07 Aug 2013.

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Journal of Child Sexual Abuse, 22:639–657, 2013
Copyright © Taylor & Francis Group, LLC
ISSN: 1053-8712 print/1547-0679 online
DOI: 10.1080/10538712.2013.811137

Exploring Mental Health Adjustment

of Children Post Sexual Assault in South Africa

SHANAAZ MATHEWS, NAEEMAH ABRAHAMS, and RACHEL JEWKES

South African Medical Research Council, Cape Town, South Africa

Large numbers of children are affected by child sexual abuse in

South Africa. This study aimed to assess psychological adjustment
of children post sexual assault. In-depth, semistructured interviews
were conducted with caretakers, and structured interviews using
mental health assessment screening tools were given to children
at three intervals over a five-month period after presentation at
a sexual assault center. Almost half of the children met clinical
criteria for anxiety, and two-thirds met criteria for full symptom
post-traumatic stress disorder two to four weeks post disclosure.
With standard care, we observed some recovery; 43.3% of chil-
dren still met full symptom post-traumatic stress disorder nearly six
months postdisclosure. Our findings indicate that current practice
in South Africa does not promote adequate recovery for children.

KEYWORDS child sexual assault, South Africa, post-traumatic

stress disorder (PTSD), anxiety, mental health adjustment,
depression, parental support, psychosocial adjustment

Child sexual abuse (CSA) is a pervasive problem in South Africa, with 44.4%
of all rapes reported to the police involving children 0 to 17 years (Crime
Information Analysis Centre, 2009). The true magnitude of this problem
remains unknown, as children often do not disclose sexual assault or delay
disclosure until adulthood and caretakers do not always act on children’s dis-
closure. Thus, reported cases only constitute the tip of the iceberg (Jewkes

Received 21 October 2011; revised 22 March 2012; accepted 1 May 2012.

This study has been funded by the UK Department for International Development as part
of a research project to support the development of the national curriculum on sexual assault
for health care providers in South Africa.
Address correspondence to Shanaaz Mathews, 46 Sawkins Road, Rondebosch, Cape
Town 7505, South Africa. E-mail: shanaaz.mathews@uct.ac.za

639
640 S. Mathews et al.

& Abrahams, 2002). A study done in the rural Eastern Cape province found
that 39.1% of adult women and 16.7% of adult men disclosed experiencing
sexual abuse before the age of 18 (Jewkes, Dunkle, Nduna, Jama, & Puren,
2010). A community-based survey in urban Gauteng province reported a
lower prevalence of CSA by women (25.3%) but a higher prevalence by
men (20.4%) before the age of 18. Nevertheless, child sexual abuse is still
considered to be highly prevalent (Machisa, Jewkes, Lowe-Morna, & Rama,
2010).
The past two decades have seen a growing body of evidence, particu-
larly from developed settings, on the impact of CSA. The trauma associated
with CSA is predominantly psychological, beginning immediately after the
abuse and often continuing many years into adulthood (Hyman, Gold, &
Cott, 2003). The psychological responses associated with CSA include gen-
eral emotional distress, depression, anxiety including post-traumatic stress
disorder (PTSD), self-harming behaviors, substance abuse, eating disorders,
dissociation, and personality disorders (Maniglio, 2009; Polusny & Follete,
1995). CSA is also associated with an increase in behavioral problems, sexual
risk-taking behavior, and often revictimization of the child (Maniglio, 2009).
A range of psychological and social factors contribute to psychopathology,
particularly family dysfunction, which is associated with negative psycho-
logical outcomes (Briere & Elliott, 1994). Other factors such as gender, age
when abused, type and severity of abuse, cognitive abilities, and relation-
ship to the perpetrator also have an influence on the child’s immediate and
long-term mental health response (Maniglio, 2009). Of significance, expo-
sure to childhood trauma has been shown to have a differential impact
on girls and boys (Schilling, Aseltine, & Gore, 2008). Girls are at increased
risk for internalizing the experience, which results in depression, suicidal-
ity, and revictimization, while boys display externalizing behavior such as
delinquency, aggression, and an increased risk of becoming a perpetrator
of sexual violence (Schilling et al., 2008). Early intervention is thus recom-
mended to reduce the risk of long-term negative outcomes, particularly for
child victims who are symptomatic, as it can prevent long-term sequelae
(Maniglio, 2009).
Responding appropriately is crucial for post-rape recovery, and effective
responses must meet the psychological and social needs of the child (Hunter,
2006). Caregiver support, or having a supportive relationship with a signif-
icant adult, has been associated with less immediate psychological distress
and is important for long-term adjustment (Hyman et al., 2003; Rosenthal,
Feiring, & Taska, 2003). Caregivers’ ability to provide support is in turn influ-
enced by the family environment, which includes factors such as parenting
practices, parental relationship quality, domestic violence, single parenting,
divorce, parental substance abuse, and parent physical and mental health
(Andrews, Corry, Slade, Issakidis, & Swanson, 2004). Furthermore, when chil-
dren are sexually abused, family functioning is often impaired as caregivers
 Mental Health Adjustment Post Sexual Assault 641

experience anxiety and distress themselves, and negative emotional reactions

to the disclosure of child sexual abuse can inhibit their ability to support
the child effectively. Therefore, providing support for both the child and
his or her family is important during the period immediately following the
disclosure of CSA in order to promote recovery and resilience. Likewise,
early identification of dysfunctional families that could benefit from interven-
tions that strengthen their abilities to support their children is recommended
(Hunter, 2006).
In South Africa, there is a considerable mismatch between the scale
of the problem of CSA, anticipated psychological and social consequences,
and the availability of services for children. The Children’s Amendment Act
(Republic of South Africa, 2007) makes it mandatory for all children who
are victims of CSA to receive therapeutic care; however, evidence sug-
gests that very few children have access to such specialized services to
ameliorate the potential negative effects of abuse (Abrahams & Mathews,
2008). A model of post-sexual-assault care in South Africa has been inte-
grated into the public health system with dedicated sexual assault centers
in major urban towns. The model of care is based on the notion of inter-
sectoral collaboration with a partnership between medical staff, police, and
social support services. Currently, standard care at these centers includes
forensic medical examination, HIV testing with pre- and posttest counseling,
pregnancy testing and the provision of emergency contraceptives, treatment
for STDs, provision of HIV post-exposure prophylaxis (PEP), and trauma
debriefing.
However, the needs of adult survivors differ from that of children, and
current integrated services are unable to meet the needs of children. Referral
of children to specialized services is not routine (Christofides et al., 2005).
While the largest metropolitan areas have centers of excellence, they are only
able to accommodate a fraction of the cases presented in their catchment
areas, and services are particularly lacking in the rest of the country (Higson,
Lamprecht, & Jacklin, 2004). South Africa has had a program of post-rape
service strengthening that has spanned most of the past decade. This has
included development of new health sector policies, opening one-stop ser-
vices, and developing a national curriculum for training health professionals
in post-rape care. This process has highlighted particular needs in the area
of mental health responses that still need to be met (Abrahams & Mathews,
2008). In order to contribute to the national policy dialogue and develop-
ment of services, we conducted a small observational study to investigate the
mental health needs of children and their caretakers who are currently using
available services post sexual assault in South Africa. The aim of this study
was to explore the mental health adjustment of the child post sexual assault
through semistructured interviews with the caretaker and the child as well as
to measure three areas of mental health (depression, anxiety, and PTSD) uti-
lizing standardized mental health assessment screening tools. The caretaker
642 S. Mathews et al.

interviews aimed to explore family functioning by focusing on circumstances

of the family and its ability to support the child.

METHOD

This study was conducted from April to December 2008 at two dedicated
sexual assault centers in Cape Town, in the Western Cape province of South
Africa. These centers are both located in an urban metropolitan district where
specialized services for children are available but not attached to the center.
The child survivor and their caretaker were both interviewed three times over
a four to five month period after the sexual assault. In-depth, semistructured
interviews were conducted with caretakers, and structured interviews and
mental health assessment screening tools were used with the children to
assess psychosocial adjustment postassault.

Study Sample
Children ages 8 to 17 and their caregivers were identified and enrolled in the
study by fieldworkers at the two centers from April to June 2008. Although
child sexual abuse is a problem affecting both genders, we decided to focus
only on girls, as this was a small exploratory study. We selected a lower age
limit of 8 years old in order to enable us to include data collection from the
children themselves. Children’s and caretakers’ level of distress was assessed
prior to enrollment using a set of questions, and severely traumatized chil-
dren or caretakers were not included in the study. Children with learning
difficulties were also excluded based on their school performance, as they
would not be able to meaningfully participate in the study. Further exclu-
sions included children whose parents had filed a charge of statutory rape
and where the child disclosed a consensual intimate relationship with the
perpetrator. These cases were excluded as the child did not experience the
sexual incident as abusive, and thus her response and the family’s response
to the incident differed. In addition, cases of incest and where children were
removed from their parents’ care as a result of the sexual assault were also
excluded, as participation in the study might not have been in the best
interest of the children psychologically.
Overall, 50 children were recruited for the study. Seventeen children
were not enrolled because either the children or caretakers were too trau-
matized based on a consultation prior to enrollment or caretakers felt
participation in the study might impact the child’s recovery. Of the 33 chil-
dren and caretakers enrolled in the study, two children disclosed that the
sexual incident was consensual as they were in an intimate relationship
with the perpetrator, and one child completed the first interview only, as
she subsequently moved to the Eastern Cape and the second and third
 Mental Health Adjustment Post Sexual Assault 643

interview could not be conducted. Thus, complete data was collected with
both children and their caretakers for 30 cases. The sample was 80% African,
speaking Xhosa, and 20% of mixed origin, English and Afrikaans speak-
ing, which is representative of the region the study was conducted in.
Caretaker interviews were mainly conducted with mothers (n = 24), three
were conducted with grandmothers, while only one father, one sister, and
one aunt participated in the study. Children included in the study were
mainly sexually assaulted by a known perpetrator (n = 22) ranging from
an acquaintance (n = 16), relative (n = 3), ex-boyfriend (n = 2), and
one landlord, with eight sexually assaulted by a stranger. The majority of
the sexual assaults were single incidents (n = 26) rather than repeated
(n = 4).

Procedure and Instrument

Ethical approval for the study was obtained from the Medical Research
Council’s Ethics Committee. Study participants were identified and recruited
by field-workers at two sexual assault centers, mostly when presenting soon
after the sexual assault. At recruitment, the parents or caregivers of chil-
dren aged 8 to 17 years were approached at the end of their first visit to
the center. The caretaker was provided with information about the study,
and written permission was obtained for the researchers to contact care-
takers later. Care was taken to ensure that caretakers did not feel coerced
to participate in the study; thus, field-workers stressed that treatment was
not dependent on their participation in the study. Formal enrollment into
the study took place on a subsequent occasion, when written informed
consent with the caretaker and assent from the children were obtained.
This typically happened at another meeting 1 to 2 weeks following the ini-
tial visit to the sexual assault center, before the first interview. Interviews
with the caregiver and child were set up once they were enrolled into the
study.

MEASURING CHILDREN ’ S MENTAL HEALTH ADJUSTMENT

To assess children’s adjustment, structured interviews were conducted using

activity-based worksheets. These worksheets allowed for discussion on top-
ics such as the children’s home environment, people they lived with, the
sexual assault experience either through drawing and talking about their
drawing or through storytelling, important people in their life, and look-
ing at themselves in the future through play or storytelling. This was used
in conjunction with mental health screening tools administered at each
interview to measure psychological adjustment. This was a format that
children had some familiarity with from school. Worksheets were adapted
from standardized scales used in other South African studies (Cluver &
644 S. Mathews et al.

Gardner, 2006) to measure depression, anxiety, and PTSD symptomatol-

ogy.
Depressive symptomatology was measured by the Child Depression
Inventory (CDI short form; Kovacs, 1992), which has been used in South
Africa and shows good psychometric properties (Flisher, 2007). Each item
of the 10-item scale has three responses with scores of 0–20, for a total
composite score of 0 (not depressed) to 20 (very high risk of depres-
sion). A cutoff of 8 was used for this study, as this is equivalent to a
standardized t-score of 62–66, which corresponds to the upper 10% of the
distribution in a nonclinical sample (Cluver & Gardner, 2006). Anxiety was
measured by the Children’s Manifest Anxiety Scale (Wild, Flisher, Bhana,
& Lombard, 2004). This 28-item scale has also been used before in South
Africa with good psychometric properties. Items were dichotomized as 1
= yes and 0 = no with a cutoff score of 18 used to predict clinically sig-
nificant levels of anxiety (Cluver & Gardner, 2006). PTSD symptomatology
was measured using the Child PTSD Checklist (Amaya-Jackson, Newman,
& Lipschitz, 2000). The Child PTSD Checklist rates the degree to which
each of the 17 symptoms of PTSD has been present over the past month.
The scale has been derived from the Diagnostic and Statistical Manual
of Mental Disorders, 4th Edition (DSM-IV) criteria, uses a 4-point Likert
severity scale, which has been used in Cape Town (Cluver & Gardner,
2006; Seedat, Nyamai, Njenga, Vythilingum, & Stein, 2004), and has been
found to be diagnostically useful. The scale shows test-retest reliability
(r =.91) and internal consistency; Cronbach’s α ranges from .82 to .95
(Cluver, Fincham, & Seedat, 2009). Using the DSM-IV criteria for PTSD,
the symptom clusters and their clinical cutoffs (1 = reexperiencing, 3 =
avoidance, and 2 = hyperarousal) are reported. A conservative symptom
threshold of most of the time (measured as 3) was used for determining
symptom presence; 1 = symptom not present, 2 = present sometimes,
and 4 = most severe. These standardized instruments were used in all
three interviews with the children to assess psychological adjustment over
time.

INTERVIEWS WITH CAREGIVERS

Semistructured, in-depth interviews with caregivers were conducted with the

aid of a scope of inquiry, which differed for each of the three interviews.
The first caregiver interview focused on the circumstances of the assault,
care-seeking, responses from the police, and how caretakers felt. The sec-
ond interview asked about the child’s adjustment and how or whether the
child had changed after the rape. Each follow-up interview asked about
progress with the legal case, changes in adult and child feelings, changes in
social circumstances as a result of rape, the use of counseling services, and
perceptions of responses from these services.
 Mental Health Adjustment Post Sexual Assault 645

DATA HANDLING AND ANALYSIS

All interviews were tape-recorded, transcribed, and translated into English.

The analysis was ongoing, as the first interviews of the caregivers and
children were analyzed before the follow-up interviews were conducted.
Open code software was used to manage the data and assist in thematic
content analysis of interviews. Transcripts of the interviews were analyzed
inductively using a grounded theory approach. Grounded theory analysis
is based on the notion that the theory emerges and is grounded in the
data as the researcher seeks to understand the social process (Strauss &
Corbin, 1998). The first stage of coding, or open coding, attempts to iden-
tify the important emerging themes in an unstructured manner and broadly
corresponds to the scope of inquiry (Charmaz, 2009). Hypotheses were
developed, tested, and modified through a process of coding, subcoding,
and continual interpretation with reference to the data (Silverman, 2001).
Once broad codes were established, thematic categories were refined, with
subcategories being formed and relationships between these elucidated. The
quantitative data from the worksheets were entered using Excel. The STATA
Version 10 statistical package was used in the analysis. Demographic char-
acteristics were assessed using frequency and descriptive statistics. T-tests
for correlated samples used to explore the changes in mental health symp-
tomatology at the different assessment intervals were significant, with the
significance level set at p < .05.

RESULTS

The mean age of children was 13.5 years, with 80% of the sample 12 years
and older (see Table 1). All but one of the children were still in school.
Although the majority of children reported that someone within their house-
hold was working, 39% of families lived in an informal dwelling (normally
a shack made out of metal sheets). The qualitative interviews showed
that although families were not entirely destitute, most were impoverished.
Families mainly had meager incomes, with only one employed family mem-
ber supporting the rest. This is a fairly common occurrence given the high
unemployment rates in South Africa. Nearly 75% (n = 23) of perpetrators
were known to the children, ranging from an acquaintance (n = 17), rel-
ative (n = 3), ex-boyfriend (n = 2), and one landlord, with eight sexually
assaulted by a stranger. All of the younger children were abused by a person
known to them.
Table 2 shows the mental health assessments at three intervals.
Depressive symptomatology with a score of 8 or above on the inventory
was found to be present in just over a third of children during the first inter-
view. The level of symptomatology decreased significantly (p < .001) to 13%
4 to 8 weeks later and remained at that level at the assessment 4 to 5 months
646 S. Mathews et al.

TABLE 1 Social and Demographic Characteristics of Children

N = 31

Age (Years)
< 12 6 (19.4%)
12–14 14 (45.1%)
15–17 11 (35.5%)
Primary Caregiver(s)
Mother or Father 10 (32.2%)
Both Parents 15 (48.5%)
Relative 6 (19.3%)
Type of Dwelling
Formal 19 (61.3%)
Informal 12 (38.7%)
Perpetrator
Known Person 23 (74.2%)
Stranger 8 (25.8%)

TABLE 2 Self-Reported Mental Health Assessment of Children

Interview 1 Interview 2 Interview 3

4 weeks post 8–12 weeks post 16–20 weeks post
(N = 31) (N = 30) (N = 30)

Depression Inventory
<8 20 (64.5%) 26 (86.7%) 26 (86.7%)
≥8 11 (35.5%) 4 (13.3%) 4 (13.3%)
Manifest Anxiety Scale
< 18 17 (54.8%) 22 (73.3%) 23 (76.6%)
≥ 18 14 (45.2%) 8 (26.7%) 7 (23.3%)
PTSD
Mean Symptom Scores:
Reexperiencing (5) 3 2.6 1.7
Avoidance (7) 3.7 3.7 3.1
Hyperarousal (5) 2.7 2.2 1.6
PTSD Diagnosis
Full Symptom 21 (67.7%) 14 (46.7%) 13 (43.3%)
Partial Symptom 9 (29.3%) 13 (43.3%) 9 (30.0%)

post-presentation. At the first interview, nearly half (45.2%) of the children

were identified as experiencing clinically significant levels of anxiety, with a
significant decrease (p < .001) in anxiety for 26.7% of children at the second
interview (scoring 18 or over), and remaining at a similar level (23.3%) at the
third interview.
At the first interview, just over two-thirds of children had symptoms
indicative of full symptom PTSD, with an additional 29.3% of children having
partial symptoms. Indeed, only one child (15 years old) was asymptomatic
in the period immediately after disclosure. The second interviews were con-
ducted on average 5.7 weeks (range of 4 to 8 weeks) after the first interview.
Although PTSD symptoms had decreased over that period, the change in
 Mental Health Adjustment Post Sexual Assault 647

the proportion of children assessed as having full symptoms was not sig-
nificant (p = 0.07), and 90% of children still met combined full and partial
symptom criteria. At the third interview, the proportion of children with
full symptom PTSD remained virtually unchanged, but there was a decrease
in the proportion meeting the partial symptom criteria. Nevertheless, over
70% of children still displayed symptoms at a clinically significant level
4 to 5 months post sexual assault, suggesting that long-term psychological
adjustment was of concern.

Psychosocial Adjustment of the Caregiver

The accounts of caretakers showed that the post-rape period was char-
acterized by intense emotional distress. Caretakers described how they
were initially feeling “hurt,” “shock,” and “anger,” and this was the state
they were in when initiating services. It impacted their interactions while
receiving services and on their memory of the care received. As one mother
explained, “This is the time I was really stressed. . . . This makes me feel
as I cannot talk. Then the doctor comes and I can’t even talk to the doctor.”
Most parents’ emotional distress was heightened as they had not received
trauma counseling or attention to their needs at the center, as the focus was
on the child.
Three mothers had a history of sexual assault that impacted their ability
to support their daughters emotionally. For one of these mothers, the rape
of her teenage daughter provided her with the first chance she had ever
had to disclose her own rape as a teenager. Her prior concealment had a
major impact on her response to her daughter. She was unable to support
her child emotionally and denied the magnitude of the impact of the rape,
which negatively affected her daughter’s recovery.
In the initial interview, caretakers were generally very supportive of their
children and were concerned about changes they saw in them, such as loss
of appetite, not socializing with friends, lethargy and/or an increase in sleep-
ing, and sleep pattern disturbances. They were concerned that these signified
problems with coping. By the third interview, most caretakers reported that
things were back to normal, but many of them indicated that their rela-
tionship with their children had become fraught. Most caretakers were very
concerned about their child’s general behavior, but they did not attribute
behavioral changes to the sexual assault; thus, in many cases, it led to with-
drawing support from their child. This may have reflected their own needs
to move on and put the rape behind them, which they projected onto their
children, expecting them to “forget.” One mother asserted that “we got used
to it.” As a consequence, the lingering psychological distress from the sex-
ual assault greatly impacted children’s lives but was unrecognized and not
dealt with.
648 S. Mathews et al.

Children’s Psychosocial Adjustment

Most children experienced disclosure and the period immediately thereafter
as a time of heightened anxiety due to the caretaker’s response, the need for
medical examinations, having contact with police, and often experiencing
the perpetrator as being “still around.” For example, one child saw the per-
petrator at her school. A number of older children had begun to display
acting out behaviors by the second interview. All 16 of the older girls were
described by their caretakers as having behavioral problems. They were said
to be mixing with the wrong friends, not returning home after a night out,
using drugs and alcohol, being truant, engaging in sexually risky behavior,
and becoming aggressive and moody (Briere & Elliot, 1994). A sister who
was the primary caregiver reported, “T_ started taking money after this thing
. . . if I ask her, she says, ‘It was here I lost it’” (15-year-old).
In another example, a 12-year-old started skipping school and taking
drugs (in the form of dagga [cannabis] muffins). One of the other girls (age
17) had been previously very brutally raped by an uncle when she was
10. After the second rape, she began to engage in risky sexual behavior,
partied with an older group of peers, and drank heavily over the weekends.
She also lost interest in school, as she had difficulty coping with the school
work. This problem was compounded by a developmental delay consequent
to her initial rape trauma.
The changes in children’s behavior had multiple implications for them
and often meant losing the initial support they had from their caretakers
after the rape. One child’s mother planned to send her away to live with
an aunt in the Eastern Cape to continue schooling in a different environ-
ment. Caretakers did not understand the behavior as a consequence of the
rape, and it often caused further conflict and tension in the family. A few of
the parents interviewed said that they now felt it was the child’s behavior
that “caused” the rape. Thus, they began to disbelieve and blame the child.
A mother of a 12-year-old who had been raped by two older boys explained:

I thought that she was telling the truth when she said that this thing hap-
pened like the way she explained it, not that Lwando was her boyfriend
. . . when this thing came out . . . she was not afraid to say “it was you,
you did this to me.” At that time she was saying it, I thought that she was
telling the truth . . . but only to find out that it’s not the truth.

Similarly, an aunt who fostered her 17-year-old niece who had previously
been raped (described previously) doubted whether her niece was raped
the second time, because she had heard that her niece was promiscuous:

A: What I picked up from her is that any guy [outjie] is actually her
boyfriend.
I: Mm.
 Mental Health Adjustment Post Sexual Assault 649

A: That I picked up, because it looks as if she is quite easy, but I now
don’t know how far it goes . . . I think there were two of who I know
about, that I heard she also just quick, quick, two in one night ne.

This aunt attributed her niece’s promiscuous behavior to the previous rape
but still provided limited support for the child. The aunt felt she could
not “control” her and acknowledged the need for counseling, yet did not
prioritize it, and the child had not received any counseling by the third
interview.
In two cases, fathers blamed the children and constantly told them that
the rape was their fault. Fathers also particularly blamed mothers, which was
described as causing further conflict and stress at home. The mother of a
14-year-old who was lured into a car and raped by a community worker in
their area explained: “If N does something wrong, to her father . . . it will
be because of what happened. He says this is because she wanted what
happened to her [the rape] by getting in that car. Everything that happened
to N, he says she called it upon herself.”
This child felt that the counseling sessions she was attending helped
her cope, saying it made her “feel better,” yet she was unable to under-
stand her father’s anger. Making sense of parents’ feelings was very difficult
for children, and parental distress projected into anger toward the children
intensified their feelings of hopelessness and self-blame.

Family Support
Many of the children were raised in families with multiple problems and
had experienced poor parenting practices such as unsupervised care, incon-
sistent rules, use of physical punishment, and lack of recognition of the
children’s emotional needs, all of which appear to have increased their vul-
nerability. While nearly half of the children were living with both parents
at the time of the sexual assault, most families were riddled with problems,
including unemployment, substance abuse, parental separation, death, and
domestic violence. Exposure to domestic violence was particularly common,
with more than half of the intact families experiencing some form of domestic
violence. Levels of family dysfunction were illustrated by one of the children,
who was raped with her 5-year-old sibling (not part of this study), came from
a large family of seven children, lived in abject poverty with a father who
had been recently released from prison and was violent toward their mother,
who herself had signs of depression.
Family support is vital for recovery, but it was often lacking due to
the emotional unavailability of caretakers. When not blamed, some of the
children were simply not supported. One example was the child whose
mother had disclosed her own rape and expected her daughter to cope as
she herself had done. Another was the previous example of a dysfunctional
650 S. Mathews et al.

family in which both children, ages 8 and 5, had been sexually abused by
an uncle. The mother showed empathy toward the younger child but had
difficulty recognizing the impact on the older child to the extent that only the
younger child was taken for counseling initially. She appeared to be unable
to respond appropriately to the older child’s needs, saying:

R: No I feel very sad about these things [the rape of the two children].
I: Mm.
R: Very, very, very sad.
I: Mm.
R: Especially, it’s my baby girl, my baby girl.

Two families were so dysfunctional that it was clear during the research
that the young children were at further risk, so the team initiated a process
to get them placed in alternate care. One child’s mother was a drug addict
who regularly left the child unattended. Another 8-year-old child was living
in a home where the adults regularly abused alcohol during the weekends,
and she had been left unsupervised over a weekend that resulted in her
being raped by a group of older boys. She presented with old vaginal scar-
ring that suggested previous sexual abuse, and in the third interview, her
mother maintained that the father had alleged their son was having sex with
her. Although these cases showed grossly neglectful parenting, inadequate
parenting practices were evident in accounts of home life from most parents.

Support Services
Although all the children were referred for support services, only 12 of the
31 children accessed and received counseling, with the longest attendance
being 10 weeks and the shortest being one visit. Counseling was offered
by two organizations, but one saw children only 14 years and older. The
therapeutic approach of the organization focusing on younger children was
biblio play, which is a method of play therapy utilizing journals as well as
creative and dramatic play to enable children to release their emotions in
a nonthreatening environment. The counselors were predominantly trained
social workers who also assessed the child’s safety in the home. The organi-
zation who worked with the older girls is said to utilize a feminist approach
with a focus on empowering children to be an active participant in their own
healing. Counselors were mainly volunteer counselors who had undergone
a 6-week trauma counseling training and were supervised by social workers.
Experiences of the counseling were variable, but a few felt positive about it,
as a mother of a 16-year-old asserted, “In counseling many things that you
didn’t know becomes clear. I mean you can understand better than what you
knew. I mean now I am coping and she is coping.” A child expressed the
following:
 Mental Health Adjustment Post Sexual Assault 651

C: It’s helping me but it’s taking me back.

I: When you say it’s taking you back, what do you mean?
C: Like when I try not to think about this thing and then they ask me
about it there, you see.

This sense of counseling “taking you back” was common for many children
and parents, which suggested a resistance to the therapeutic process. Most
parents said that talking about the feelings made them feel better, but they
wanted to “forget,” and counseling meant revisiting and discussing issues and
experiences that made them feel uneasy. This resulted in some expressed
ambivalence around the counseling process.
Similarly, a 17-year-old who had severe psychosomatic symptoms
and was abusing substances was very angry at her mother for involv-
ing their priest, as she felt coerced to continue with counseling. Talking
about her reasons for not wanting to go to counseling, she asserted the
following:

R: I don’t think I need counseling, I do think I need somebody once in

a while to speak to.
I: Mm, but that is basically the same, I mean counseling is basically
speaking to someone.
R: I know man but I don’t want to have to go for counseling like,
counseling is sort of like a routine, you go every week or every
month until the counselor thinks no but you are done now. That
is just reminding me, giving me unnecessary memories of taking me
back the whole time, stuff like that. I don’t want that to happen, if I
do feel like emotional once in a while. That’s like going to be once
in every third month maybe that I really break down and cry, I don’t
cry often then, then I need somebody to speak to, then I will phone
my friend. Why should I have to go back to that every week when
it’s not even necessary I feel I should go when I think, no I don’t feel
right and so on and I need somebody to speak to.

The limitations of the therapeutic approaches available to support

children after rape were highlighted by a 17-year-old who had severe
psychological symptomatology after being raped by a police officer and con-
cealing it for months before disclosure. She did not find her counseling
sessions useful, as she had persistent nightmares about being murdered
by a drug dealer and was preoccupied by the idea that “I’m not going to
live long.”
Although most caretakers raised the structural and institutional barri-
ers to help-seeking, it appears that psychological barriers to help-seeking
were most prevalent. Most caretakers wanted the child to forget about the
rape and move on, and thus most families did not talk about the rape to
others. In some instances, parents encouraged the child not to disclose the
652 S. Mathews et al.

rape to schoolmates and friends. These psychological barriers hold long-term

implications for the psychological adjustment of the child.

DISCUSSION

This study found high levels of mental health symptomatology, with nearly
half of all the children meeting the clinical diagnostic criteria for anxiety,
and just over two-thirds of children meeting the criteria for full symptom
PTSD. With the standard care children received from support services, we
observed some recovery over time, particularly for depression, but one in
four children still showed clinically significant levels of anxiety nearly six
months after disclosure. Of concern are the persistent high rates of PTSD
symptomatology, with 43.3% of children still meeting the criteria for full diag-
nosis of PTSD, and a further 30% meeting the partial PTSD criteria nearly six
months post-disclosure. These rates are similar to reported rates in the United
States for PTSD symptomatology in a nonclinical group of children post sex-
ual assault (McLeer et al., 1998; Putnam, 2003), as the risk of developing
PTSD following a sexual assault incident is known to be greater than fol-
lowing other traumatic experiences (Copeland, Keeler, Angold, & Costello,
2007; Seedat et al., 2004). Nevertheless, current care practices where only
debriefing of the child is provided at sexual assault centers and children
are referred on for specialized services appear to be inadequate, as most
children do not access counseling due to structural and institutional barriers.
Most children are therefore left with high levels of mental health distress post
sexual assault. Important, it has also been shown that PTSD symptoms are
more likely a response to trauma where children come from adverse fam-
ily circumstances (Copeland et al., 2007). It is thus important that recovery
after rape is conceptualized within the context of families and how they can
promote resilience and reduce long-term psychopathology post child sexual
assault.
Emotional support from a parent or significant adult has been found to
be important in recovery post sexual assault, as it has been shown to assist
in the prevention of maladjustment and to facilitate resiliency (Hyman et al.,
2003; Rosenthal et al., 2003). We found that caregivers’ ability to support the
child was compromised by their own experiences of trauma combined with
their emotional responses to the disclosure of the child’s rape. Mothers who
themselves had experienced sexual abuse or domestic violence not only had
difficulty supporting the child but were emotionally unavailable to the child,
and their ability to adequately parent was compromised (Banyard, 1997;
Polusnny & Follette, 1995). Notably, low levels of parental support have
been found to be associated with elevated psychological distress (Meyerson,
Long, Miranda, & Marx, 2002), which is a possible explanation for the contin-
ued high levels of distress in this group of children. The difficulty caregivers
 Mental Health Adjustment Post Sexual Assault 653

experience in supporting children was evident, as most felt children were

“coping” by the last interview even though a number of children were dis-
playing acting out behaviors. Rape survivors are often thought to engage
in substance abuse to numb painful memories, particularly when the family
is unable to provide them with a buffer to ease such pain. The current
approach to care, which is referral-based and provides counseling to the
child alone, appears to be inadequate in facilitating recovery given the resid-
ual high levels of mental distress. A therapeutic process that includes both
the child and the caregiver and is more accessible is thus a critical part of
the child’s recovery.
Problems within the family are commonly found when children expe-
rience sexual abuse (Briere & Elliott, 1994). Adverse family circumstances
were found to be common among these families, which not only impacts
the child’s vulnerability to be abused but also appears to impact post sexual
assault adjustment. Difficulties in recovery were particularly pronounced in
families where mothers were absent, mothers had themselves been raped,
parents had conflict between them, or substance abuse was prevalent.
However, current standard care practices expect caretakers to provide the
child with day-to-day support without providing them with the necessary
psychosocial support to deal with their own responses related to the trauma
of having a child raped or preexisting needs related to their own experience
of trauma. In addition, studies on psychological adjustment of children post-
CSA found that disclosure of abuse may also lead to an environment that
is conflictual and unsupportive to the child victim (Meyerson et al., 2002).
Unconditional support from the caretaker is vital, as it enhances recovery
of the child. This was difficult as parents did not understand changes in
the child’s behavior post-rape, which caused them to place blame on the
child. Thus, the initial support parents provided to the child was withdrawn,
as they lacked the necessary support that would enable them to deal with
the difficulties the child presented with. Providing appropriate and adequate
support to caretakers after child sexual assault to help them understand the
impact of rape on their children and on them as parents is thus critical in
assisting children in their recovery.
This study has some limitations. Using a convenience sample of only
girls at two metropolitan sexual assault centers in the Western Cape Province
limits the generalizability of findings. Yet the study provides us with valu-
able insight with regard to mental health adjustment in a community-based,
nonclinical group of children, as there is limited information on this subject
in South Africa. In addition, the study had a number of exclusion categories,
such as incest and when a child was removed from the family, suggesting
that the more chronic forms of child sexual assaults were not included in the
study. The symptomatology present in this sample could arguably be lower
due to the sexual abuse mainly being one-time occurrences. We measured
three areas of mental health adjustment (depression, anxiety, and PTSD)
654 S. Mathews et al.

using validated international and locally adapted tools; however, we did

not control for previous experience of sexual violence nor exposure to other
forms of violence, which could inflate levels of PTSD symptomatology within
the group. Given these constraints, this study provides us with important
insights into adjustment post sexual assault and whether our current practice
is meeting the needs of children and their caregivers.
Children’s mental health adjustment post sexual abuse is critical to
prevent long-term mental health problems. Current care practices promote
therapeutic services for the child, yet evidence suggests that few children
access specialized services and rely mainly on the emotional support of par-
ents or a trusted adult, which is critical for long-term recovery. This study
found that many families lacked the ability to aid children in their recov-
ery, as secondary trauma experienced by caregivers exacerbated by their
own experiences of trauma limited their ability to provide the child with
necessary support. The referral-based, child-centered focus of support ser-
vices does not promote the development of a supportive family environment,
which appears to be critical. An integrated services approach should be pro-
moted with a focus on strengthening parents’ ability to support children, as
they have to understand and respond appropriately to their child’s behavior
within the home environment. Enhancing current parenting practices and
support systems for families through the early identification of vulnerable
families is critical to preventing and reducing the risk of child sexual abuse.
Promoting interventions to strengthen parent–child relationships can also
reduce the risk of child sexual assault as well as the long-term effects thereof.

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AUTHOR NOTES

Shanaaz Mathews, MHP, PhD, is an associate professor in the Faculty of

Health Sciences and the director of the Children’s Institute at the University
of Cape Town. Her main research interests include gender based violence
against women and children, intimate femicide, fatal child abuse, the shaping
of violent masculinities and multidisciplinary approaches to strengthen child
protection. She received her MPH at the University of Cape Town and her
PhD at the University of the Witwatersrand.
Naeemah Abrahams, MPH, PhD, is a professor in the Faculty of Nursing at
the University of Cape Town and Senior Specialist Scientist in the Gender
nd Health Research Unit at the South African Medical Research Council. Her
main areas of research include research in gender-based violence, including
risk factor studies of men who use violence against women, femicide, health
sector responses to gender based violence, stigma in sexual assault reporting,
adherence to postexposure prophylaxis after sexual assault, and violence
within school settings.
 Mental Health Adjustment Post Sexual Assault 657

Rachel Jewkes, MBBS, MSc, MFPHM, MD, is a professor in the School of

Public Health at the University of the Witwatersrand and is the director of
the Gender and Health Research Unit at the South African Medical Research
Council. She has extensive experience in population-based surveys on vio-
lence against women and male perpetration within South Africa and as
technical expert internationally. She has also led a groundbreaking RCT eval-
uation of Stepping Stones in South Africa. She also serves as member of the
U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) Scientific Advisory
Board, the WHO Expert Advisory Panel on Injury and Violence Prevention
and Control, and the WHO and the WHO’s Strategic and Technical Advisory
Committee for HIV-AIDS.