title: The public health crisis of child sexual abuse in low and middle income countries: an integrative review of the literature.
abstract: OBJECTIVE
  Theoretical and empirical studies conducted to ascertain the incidence and characteristics of child sexual abuse (CSA) in developing countries around the world are inconsistent and poorly synthesized. In order to prevent and respond to these heinous acts, clinicians and policymakers require a substantive body of evidence on which to base interventions and treatment programs. The purpose of this study is to conduct an integrative review of the literature concerning CSA in non-industrialized nations. Ultimately, this evidence could be used to drive research and policy implementation in this area.
  
  
  METHODS
  An integrative literature review of publications identified through a comprehensive search of five relevant databases (PubMed, CINAHL, EMBase, PsycINFO, and Web of Science) regarding the incidence and characteristics of all forms of child sexual assault in low and middle-income countries (LMICs) since 1980. Independent and collective thematic assessment and analysis was utilized to identify major concepts of the phenomenon.
  
  
  RESULTS
  Forty-four articles were identified. These represented 32 separate low or middle-income countries. More studies were identified in low-income countries, and there was a disproportional distribution of studies conducted on regions of the world. CSA has been identified at all levels of society in nearly every region and continent of the world. It is being falsely perceived as a new phenomenon in some developing countries, most likely as a result of increases in CSA reporting. Researching and discussing CSA is difficult because of the sensitive and taboo nature of the topic. Four major themes emerged including difficulty of accurate measurement, barriers to reporting, barriers to justice, and the false perception of CSA as a new phenomenon. Themes of early marriage, human trafficking, sexual coercion and forced first sex, and males as victims have been identified as characteristics and topics placing individuals at risk for CSA. Poverty and its resultant social or family strain are exacerbating factors to CSA.
  
  
  CONCLUSIONS
  There is inadequate representation of CSA research in LMICs, and an increasing awareness that sexual abuse of children is an endemic threat to the health and safety of children worldwide. This review lays the foundation for an array of further areas of analysis to explore the expanse of unanswered questions that remain regarding the phenomena of CSA in low and middle-income countries.
  
  
  CONCLUSIONS
  Healthcare workers hold a unique position and responsibility for identifying and responding to CSA.
authors.affiliation: Department of Community and Public Health, Johns Hopkins School of Nursing and Center for Refugee and Disaster Response, Bloomberg School of Public Health, Baltimore, MD, United States. Electronic address: tveenem1@jhu.edu.
authors.forename: Tener Goodwin
authors.initials: TG
authors.lastname: Veenema
authors.affiliation: Johns Hopkins School of Nursing, Baltimore, MD, United States. Electronic address: Thorton.clifton@gmail.com.
authors.forename: Clifton P
authors.initials: CP
authors.lastname: Thornton
authors.affiliation: Johns Hopkins School of Nursing, Baltimore, MD, United States. Electronic address: Acorley3@jhu.edu.
authors.forename: Andrew
authors.initials: A
authors.lastname: Corley
mesh_terms: D002648:Child; D002650:Child Abuse, Sexual / Q000706:statistics & numerical data*; D003906:Developing Countries; D006801:Humans; D015994:Incidence; D007182:Income
keywords: Child sexual abuse; Child welfare; Developing countries; LMICs (low and middle income countries); Public health