Early-married and sexually abused girls differ in their psychiatric outcomes

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ContentslistsavailableatScienceDirect

Child

Abuse

&

Neglect

Early-married

and

sexually

abused

girls

differ

in

their

psychiatric

outcomes

Nusret

Soylu

a,∗

_,

_Muhammed

_Ayaz

b

_,

_Tu˘gba

_Yüksel

c

a_Inonu_University,_Faculty_of_Medicine,_Department_of_Child_and_Adolescent_Psychiatry,_Malatya,_Turkey b_Istanbul_Arel_University,_Faculty_of_Science_and_Letters,_Department_of_{Psychology, ˙Istanbul,}_Turkey c_Dicle_University,_Faculty_of_Medicine,_Department_of_Child_and_Adolescent_Psychiatry,_Diyarbakır,_Turkey

a

r

t

i

c

l

e

i

n

f

o

Articlehistory:

Received22February2014

Receivedinrevisedform22May2014 Accepted31May2014

Availableonline30June2014 Keywords:

Childandadolescent Sexualabuse Earlymarriage Psychiatricdisorder

a

b

s

t

r

a

c

t

Earlymarriageandsexualabusearethetwoofthemostfrequenttypesofchildhoodabuse. Althoughearlymarriageisalsoatypeofsexualabuse,itisassociatedwithdifferent physi-cal,social,andmentaloutcomesthansexualabusealone.Thepurposeofthisstudywasto compareearly-marriedgirlsandsexuallyabusedgirlswhowerereferredforforensic eval-uationinTurkeyintermsoftheirsociodemographiccharacteristics,mentaldisorderrates, andmentalsymptomseverity.Weincluded63adolescentgirlsforwhomajudicialreport hadbeendemandedandwhowereunder15yearsoldwhentheyweremarriedbutwere notyet18yearsoldduringtheevaluation(15.51±0.78)and72sexuallyabusedadolescent girlsbetween14and18yearsold(15.80±1.10)inthisstudy.Followingapsychiatric eval-uation,thestudyparticipantscompletedtheChildPosttraumaticStressDisorderReaction Index(CPTS-RI)andtheBriefSymptomInventory(BSI).WeusedtheWindowsSPSS16.0 softwareprogramtoassesstheresults.Atleastonepsychiatricdisorderwasdeterminedin 44.4%oftheearly-marriedand77.8%ofthesexuallyabusedcases(p<0.001).Adiagnosisof PTSDorASDwasobservedin11.1%oftheearly-marriedcasesandin54.2%ofthesexually abusedvictims(p<0.001).MDDwasdeterminedin33.3%oftheearly-marriedcasesand 56.9%ofthesexuallyabusedcases(p=0.006).TheCPTS-RIscoresofthesexuallyabused victimswerehigherthanthoseoftheearly-marriedcases(p<0.001).Allofthesubscale scoresoftheBSIwerehigherinthesexuallyabusedadolescentsthanintheearly-married cases(p<0.001).Althoughearlymarriagehasseverephysical,socialandmentaloutcomes, itisnotassevereassexualabuseintermsofpsychiatricdisorderratesandthepsychiatric symptomseverityitcauses.

Introduction

Rootedinhumanhistory,childnegligenceandabuseareimportantpublichealthproblems,theextentofwhichisnot

preciselyknownbecausetheyusuallyremainasecret(Fallonetal.,2010;Teeuw,Derkx,Koster,&VanRijn,2012).Ofallthe

typesofnegligenceandabuse,sexualabuseisprobablythemostdestructiveforchildrenandtheirfamilies(Aktepe,2009).

Sexualabuseinvolvesforcingorenticingachildoryoungpersontotakepartinsexualactivities,includingprostitution,

whetherornotthechildisawareofwhatishappening(Glaser,2008).Theglobalprevalenceofthesexualabuseofchildren

∗ Correspondingauthor.

http://dx.doi.org/10.1016/j.chiabu.2014.05.017

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isconstantlyincreasing.Accordingtosomesocialstudies,4–9%ofmenand12–35%ofwomenareexposedtothistypeof

abusebeforetheageof18(Putnam,2003).

Oneofthemostfrequentformsofchildabuseworldwideischildmarriage(UNICEF,2005).Childmarriagegenerally

referstothemarriageofachildwhoisunder18yearsofage(UNICEF,2012;Nour,2009).Becausethemajorityofthese

marriagesareperformedwithouttheconsciousconsentofthechild,theyarealsodeﬁnedas“earlyandforcefulmarriages”

(Özcebe&Bic¸er,2013).Earlymarriageinterruptsthechildhoodofgirlsandtakesawaytheirfundamentalrightssuchas

beingabletoleavetheirparentsoftheirownvolition,freedomofexpression,education,entertainment,playinggames,and

protectionfromsexualabuse(Santhya,2011).Thus,childmarriagesareconsideredanabuse(Özcebe&Bic¸er,2013).

Althoughmanycountrieshavelegalarrangementsforearlymarriage,thesearenotsufﬁcientpreventativemeasures,

duetofactorssuchaspovertyandaneedtoreinforcesocialbondsandbeliefs.Therefore,childmarriagescontinue(Nour,

2006).Ithasbeenindicatedthat36%ofwomenworldwidebetweentheagesof20and24weremarriedbeforereachingthe

ageof18(UNICEF,2006).Moreover,ina2008studythatfocusedontheTurkishpopulationandhealth,itwasdetermined

that14.0%ofwomenbetweentheagesof20and24wereforcedintomarriagebeforereachingtheageof18(Hacettepe

UniversityInstituteofPopulationStudies,2009).AccordingtotheTurkishCivilCode,themarriageageis17forbothwomen

andmenandis16incasesthatarejudiciallydeterminedtobeurgent(TurkishCivilCode,2001).However,theTurkishPenal

Codedoesnotincludeanyguidancetoindividualswhomarrybeforereachingthisage.Intheeventofdiscoveringearly

marriages,ifthoseinvolvedarenot15yearsold,themarriagesareregardedas“sexualchildabuse”andpunishmentsare

givenonthisbasis(TurkishPenalCode,2004).

Theliteratureincludesa numberofstudiesthat haveexaminedthementaleffectsofsexualabuseonchildrenand

adolescents(Bedietal.,2011;Bernard-Bonnin,Hébert,Daignault,&Allard-Dansereau,2008;Dubeetal.,2005;

Kendall-Tackett,Williams,&Finkelhor,1993;McLeer,Deblinger,Henry,&Orvaschel,1992;Mullers&Dowling,2008).Sexualabuse

inchildrenmayresultinpsychiatricdisordersincludingbehavioralproblems,anxiety,substanceabuse,suicidalbehavior,

borderlinepersonalitydisorder,depressionandposttraumaticstressdisorder(PTSD)(Hornor,2010).Incontrast,thestudies

thathavebeenconductedonearlymarriageshavegenerallyfocusedonthesocial,sexual,andpregnancyproblemsofthese

marriages(Clark,Bruce,&Dude,2006;Ertem,Saka,Ceylan,De˘ger,&C¸iftc¸i,2008;Nour,2009;Santhya,2011).Juristically,

earlymarriageisevaluatedassexualabuseinTurkey,andthejudicialprocessisconductedaccordingly(TurkishPenalCode,

2004).However,socialvaluesandculturalbeliefshavenormalizedearlymarriagesinsomeregionsofTurkey,wherethey

arefrequentlyobserved(GrandNationalAssemblyofTurkey,CommitteeonEqualityofOpportunityforWomenandMen,

2009).Moreover,theindividualsinvolvedareexposedtosexualabuseandanumberofpsychosocialstressorsassociated

withearlymarriage(Nour,2009).Earlymarriageisalsoassessedassexualabuse;however,wehypothesizedthatitsmental,

physical,andsocialoutcomesdifferfromthoseofsexualabuseduetothereasonsmentionedearlier.Becauseearlymarriage

isnormalizedbyasectionofsociety,weexpectedtheratesofmentaldisordersandtheseverityofmentalsymptomstobe

lowerinthesecasesthanincasesofsexualabusealone.Thus,inthisstudyconductedinTurkey,wecomparedgirlswho

hadbeenforcedintoearlymarriageandhadexperiencedsimilarforensicandmentalevaluationswithsexuallyabusedgirls

intermsoftheirsociodemographiccharacteristics,ratesofpsychiatricdisorderscausedbyatraumaticeventandseverity

ofpsychiatricsymptoms.

Method

StudyPopulation

Thestudyincluded63early-marriedgirls,whohadbeensenttotheChildPsychiatryOutpatientDepartmentofGaziantep

Children’sHospital,Turkeyfortreatmentandajudicialreportbetween1June2011and31December2012,and72sexually

abusedgirls,whohadbeensenttothesamehospitalforthesamereasonsbetween1June2012and31December2012.

Theearlymarriagegroupconsistedofgirlswhowerenotyet15yearsoldwhentheymarriedandwhowereyounger

than18duringtheevaluation.Thesexuallyabusedgroupwascomposedofgirlsinthesameagegroupwhohadbeen

exposedtosexualabuseincludingtouching(penetration,petting,sexualtouching,andbeingforcedintoprostitution).In

theclinicalevaluation,theWechslerIntelligenceScaleforChildren-Revised(Wechsler,1974)orWechslerAdultIntelligence

Scale–FourthEdition(Wechsler,2008)wasadministeredtogirlswhowerethoughttohaveanintellectualdisability.An

intellectualdisabilitywasnotdeterminedinanyofthegirlswhohadbeenforcedintoearlymarriage.Inthesexuallyabused

group,the7girlswhowerefoundtohaveanintellectualdisabilitywerenotincludedinthestudy.Ofthoseforcedinto

earlymarriage,4gavetheanswer“none”toallofthequestionsintheChildPosttraumaticStressReactionIndexandBrief

SymptomInventory,whichwasinconsistentwiththeﬁndingsofthepsychiatricexamination.Becausethese4girlswere

thoughttobehidingtheirsymptoms,theywerenotincludedinthestudy.

Materials

SociodemographicInformationForm.Thisform,whichwasgeneratedbythoseconductingthestudybasedonareview

ofthecurrentliterature,askedtheparticipantstoprovideinformationregardingtheirsociodemographiccharacteristics,

education,familycharacteristics,theeducationallevelsoftheirparents,theirhistoryofsmokingandalcoholorsubstance

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ChildPosttraumaticStressReactionIndex(CPTS-RI).Pynoosetal.developedthisindextoexaminetheseverityofsymptoms

ofposttraumaticstressdisorder(PTSD).TheCPTS-RIisasemi-structuredLikertscalewith20entriesandwasdevelopedto

evaluatethestressreactionsthatchildrenandadolescentsundergoaftervarioustraumaticexperiences.Incompletingthe

scale,respondentsmarkoneofthefollowingaccordingtothefrequencylevelwithwhichemotions,thoughts,orbehaviors

areexperienced:“none,”“seldomly,”“veryseldomly,”“frequently,”“veryfrequently.”Atotalscorebetween12and 24

implieslow-levelPTSDsymptoms;atotalscorebetween25and39impliesmedium-levelPTSDsymptoms;atotalscore

between40and59impliesseverePTSDsymptoms;andatotalscoreover60impliesveryseverePTSDsymptoms.Atotal

of40pointsiscorrelatedwithadiagnosisofclinicalPTSD(Pynoosetal.,1993).ATurkishvalidityandreliabilitystudywas

conductedonthisindexbyErden,Kılıc¸,Uslu,andKerimo˘glu(1999).Thetest–retestreliabilitywas.86,andtheCronbach’s

alphainternalconsistencywas.75(Erdenetal.,1999).

BriefSymptomInventory(BSI).TheBSIisaself-assessmentscalethatisappliedtoscreenforavarietyofpsychological

symptomsandwasdevelopedbyDerogatisin1992.ItistheshortformoftheSymptomChecklist(SCL)-90-Randwas

developedasaresultofstudiesconductedwiththelatter.Amongthe90itemsthatweredistributedinto9factorsofthe

SCL-90-R,the53itemswiththehighestloadineachfactorwereselected,andashortscalethatcouldbeadministeredin

10minwasobtainedinasimilarform(Derogatis,1993).In2002,areliabilityandvaliditystudyoftheTurkishformwas

conductedwith59713-to17-year-oldadolescents.Inthisstudy,itwasdeterminedthattheCronbach’salphavaluesofthe

subscalesvariedbetween.70and.88,andthevalueobtainedforthetotalscorewas.94(S¸ahin,Batıgün,&U˘gurtas¸,2002).

Thesubscalesincludesomatization,obsessivecompulsivedisorder,interpersonalsensitivity,depression,anxietydisorder,

hostility,phobicanxiety,paranoidthoughts,psychoticism,andadditionalitems.Theglobalindexesofthescaleincludea

globalseverityindex,positivesymptomstotal,andpositivesymptomsdistressindex.

Procedures

WebeganthestudyafterreceivingethicscommitteeapprovalfromGaziantepUniversity.Early-marriedandsexually

abusedvictimsareprimarilytakentotheChildFollow-upCenterinthebodyofourhospital.Generally,asocialworker

conductsapre-assessmentwiththevictimsandtheirfamilies.Then,apsychologisttrainedinforensicinterviewingtakesthe

testimonyofvictimsinamirrorroom.Ifnecessary,theforensicexpertperformsaphysicalexaminationonthevictimsonthe

sameday.AccordingtotheTurkishPenalCode,ifthementalhealthofsexuallyabusedvictimshasdeterioratedduetosexual

abuse,thepunishmentoftheabuserwillincrease.Thus,aftertheevaluationisperformedintheChildFollow-UpCenter,cases

arereferredtotheChildPsychiatrypolyclinicinanotherdepartmentofthehospitaltoevaluatewhetherthepatients’mental

healthhasdeterioratedduetothesexualabuseandtoarrangefortheirtreatment.Here,theprimaryresearcher,whowas

achildandadolescentpsychiatrist,conductedaclinicalinterviewbasedontheDSM-IVwiththechildandherfamilyforat

least40min.Attheendoftheinterview,theparticipantswereinformedaboutthestudy.Wecreatedapersonalinformation

formandusedthistocollectsociodemographiccharacteristics,marriageandabusefeatures,andmentaldiagnoseswiththe

consentoftheparticipants.TheparticipantsthencompletedtheCPTS-RIandtheBSIwithinapproximately20mininthe

companyofthechildpsychiatristwhoperformedtheinterview.Theﬁrstresearchercompletedthescalesforthosewho

wereilliterateafterreadingthequestionsaloudandobtainingverbalanswersfromtheseindividuals.Theparticipantswho

hadnotbeendiagnosedorwhodidnothavetheirparentswiththemintheﬁrstinterviewwerereevaluatedinthecompany

oftheirparentsorcaregiveroneweeklater,andthescalesusedinthestudywerecompletedduringthissecondinterview.

Tocomparethementaloutcomesofearlymarriageandsexualabusemoreaccurately,mentaldisorders(suchasADHD)that

werepresentbeforetheabuseormarriagewerenottakenintoconsiderationduringthecomparison.

StatisticalAnalysis

WeusedtheSPSSforWindows16.0softwareprogramtoconductthestatisticalanalysis.Weperformedcomparisonsof

thecontinuousvariablesthatshowedanormaldistributionbetweenthetwogroupsusingtheindependentsamplettest,

aparametrictest,andwecomparedthecontinuousvariablesthatshowednonormaldistributionbetweenthetwogroups

usingtheMann–WhitneyUtest.WeusedPearson’sChi-squaretesttocomparethevariablestoobtainacategoricalvalue

withgroups.Weacceptedapvalueof0.05assigniﬁcant.

Results

Table1illustratesthesociodemographiccharacteristicsofthestudyparticipants.Theaverageageoftheearly-married

groupwas15.59±0.84 (ranging between14 and 17.8years),and theaverageageof thesexually abusedgroupwas

15.80±1.06(rangingbetween14and17.7years).Wedeterminednosigniﬁcantdifferencebetweenthetwogroupsin

termsofaverageage(p=0.228).

Themarriageageofthoseintheearly-marriedgroupvariedbetween12.8and14.90years(14.23_±0.59),andwe

deter-minedtheaverageagegapbetweenthemandtheirhusbandstobebeing7.68±4.20years.Alloftheparticipantshad

experiencedsexualintercourseinvolvingvaginalpenetrationwiththeirhusbands.Atotalof17.5%(n=11)statedthatthey

hadbeenforcedintomarriage;17.5%(n=11)statedthattheyhadbeenexposedtophysicalviolencefromtheirhusbands,

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Table1

Sociodemographiccharacteristicsofthecases.

Earlymarriage(n=63) Sexualabuse(n=72)

n % n %

Educationalstatus

Illiterate 7 11.1 0 0.0

Noschooleducationbutliterate 5 7.9 0 0.0

Dropofffromprimaryschool 32 50.8 13 18.1

Primaryschoolstudent 0 0.0 12 16.7

Graduatedprimaryschool 16 25.4 10 13.9

Dropofffromhighschool 3 4.8 18 25.0

Highschoolstudent 0 0.0 19 26.4

Smokingstatus Present 14 22.2 21 29.2 Absent 49 77.8 51 70.8 Alcoholuse Present 4 6.3 13 18.1 Absent 59 93.7 59 81.9 Substanceuse Present 2 3.2 8 11.1 Absent 61 96.8 64 88.9

Livingwith(beforemarriageandabuse)

Parents 43 68.3 46 63.9 Mother 10 15.9 16 22.2 Father 7 11.1 2 2.8 Relatives 3 4.8 1 1.4 Inaninstitution 0 0.0 7 9.7 Maternaleducation Illiterate 41 65.1 22 30.6

Graduatedhighschool 1 1.6 3 4.2

Graduateduniversity 0 0.0 1 1.4

Paternaleducation

Illiterate 15 23.8 2 2.8

Graduatedhighschool 3 4.8 9 12.5

Graduateduniversity 0 0.0 3 4.2

Monthlyincomeofthefamily

Minimumwageorbelow 55 87.3 51 70.8

Abovetheminimumwage 8 12.7 21 29.2

foundthat30.2%(n=19)oftheearly-marriedgroupwerepregnant,39.7%(n=25)alreadyhadachild,6.3%(n=4)hadtwo

children,and23.8%(n=15)wereneitherpregnantnorhadachild.Ofatotalof52pregnanciesthathadbeenexperienced,

76.9%wereunplannedand34.6%wereunintended.

Forthevictimsofsexualabuse,wedeterminedthetypeofthesexualabusetobetouchingthebodyforsexualpurposesin

25%(n=18)ofthecases,pettingin8.3%(n=6)ofthecases,vaginalpenetrationin34.7%(n=25)ofthecases,analpenetration

in20.8%(n=15)ofthecases,oralpenetrationin2.7%(n=2)ofthecases,andbeingforcedintoprostitutionin8.3%(n=6)

ofthecases.Atotalof56.9%(n=41)oftheindividualshadbeenexposedtomultipletypesofsexualabuse.Theabuserwas

someoneknowntothevictimin70.8%(n=51)ofthegroupandafamilymemberin12.5%(n=9)ofcases.

Duringtheevaluation,allofthepatientsintheearly-marriedgroup(n=63)and56.9%(n=41)ofthesexuallyabused

groupdidnotattendaschoolappropriatefortheirage(2₌_35.210,_p_<_0.001)._We_found_that_the_monthly_income_of_the

familieswasprimarilytheminimumwageorbelowintheearly-marriedgroup(2₌_6.199,_p₌_0.013)._A_total_of_31.2%_of_the

early-marriedgroupand36.1%ofthosewhohadbeensexuallyabusedlivedseparatelyfromoneorbothoftheirparents

beforemarriageortheabuse(2₌_0.285,_p₌_0.593)._The_mothers₍2₌_22.683,_p_<_0.001)_and_fathers₍2₌_19.554,_p_<_0.001)

oftheearly-marriedindividualshadlowerlevelsofprimaryandaboveeducationthandidtheparentsofthosewhohad

beensexuallyabused.

MentalEvaluationResults

Table2illustratesthementaldisordersthatdevelopedinthegroupsfollowingtheearlymarriageorsexualabuse.We

observedatleastonementaldisorderin44.4%(n=28)oftheearly-marriedgroupand77.8%(n=56)ofthosewhowere

sexuallyabusedfollowingthemarriageorsexualabuse(2₌_15.882,_p_<_0.001)._Although_we_observed_{post-traumatic}_stress

disorder(PTSD)oracutestressdisorder(ASD)andmajordepressivedisorder(MDD)atahigherrateinthesexuallyabused

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Table2

Comparisonofcasesintermsofmentaldisordersdevelopingaftermarriageandsexualabuse.

Mentaldisorder Earlymarriage(n=63) Sexualabuse(n=72) Statisticsa

n(%) n(%) 2 _p

Psychiatricdisorder 28(44.4%) 56(77.8%) 15.882 <0.001 PTSDorASD 7(11.1%) 39(54.2) 27.728 <0.001 Majordepressivedisorder 21(33.3%) 41(56.9%) 7.543 0.006 Adjustmentdisorder 7(11.1%) 0.0(0.0%) 8.438 0.004 Conductdisorder 0(0.0%) 4(5.6%) 5.136 0.123 Conversiondisorder 3(4.8%) 1(1.4%) 1.371 0.339 Generalizedanxietydisorder 3(4.8) 0(0.0%) 4.651 0.099

a_Chi-square_test.

Wefoundthat34.9%(n=22)oftheearly-marriedgroupdevelopedsuicidalthoughtsfollowingtheirmarriage,and79.2%

(n=57)ofthosewhohadbeensexuallyabuseddevelopedsuicidalthoughtsfollowingtheabuse(2₌_27.098,_p_<_0.001)._A

totalof20.6%(n=13)oftheearly-marriedgroupand40.3%ofthosewhohadbeensexuallyabusedhadsuicidalthoughts

duringtheevaluation(2₌_6.049,_p₌_0.014)._Similarly,_25.4%_(n₌₁₇₎_of_the_{early-married}_group_and_37.5%_(n₌₂₇₎_of_those

whohadbeensexuallyabusedhadattemptedsuicideatleastoncefollowingthemarriageorabuse(2₌_2.268,_p₌_0.132).

Althoughthere wasnosigniﬁcantdifferencebetweenthetwogroupsinterms ofsmoking(2₌_0.844,_p₌_0.358)_or

substanceabuse(2₌_3.086,_p₌_0.079),_alcohol_abuse₍2₌_4.183,_p₌_0.041)_was_higher_in_the_sexually_abused_group.

ComparisonoftheTwoGroupsinTermsofTheirScaleScores

Table3illustratesthecomparisonofthetwogroupsintermsoftheirCPTS-RIandBSIsubscalesscores.Wefoundthatthe

meanscoreswerehigherinthosewhohadbeensexuallyabusedthanthoseintheearlymarriagegroup(p<0.05).Atotalof

15.9%(n=10)oftheearlymarriedcasesand65.3%(n=47)ofthesexualabusecasesobtainedascoreof40oraboveonthe

CPTS-RI(2₌_33.62,_p_<_0.001).

Discussion

Earlymarriageandsexualabusearetwoofthemostcommonandfrequentformsofchildhoodabuse.Inthepresentstudy,

wecomparedearly-marriedgirlsandsexuallyabusedgirlsintermsoftheirsocio-demographiccharacteristics,psychiatric

disorderrates,andseverityofpsychiatricsymptoms.

Ourstudyrevealedthatfamiliesinbothgroupshadlowsocioeconomicandeducationlevels,whichismoreapparentin

theearly-marriedcases.Brown,Cohen,Johnson,andSalzinger(1998)statedthatbrokenfamilies,aloweconomicstatus,and

alowlevelofeducationofmotherswereamongtheriskfactorsforchildabuse(Brownetal.,1998).Socioeconomicstatusis

unrelatedtotheincidenceofchildsexualabuseinpopulationstudies(Berliner&Elliott,1996),butthereisan

overrepresen-tationoflowersocioeconomicgroupsinclinicalsamples(Bentovim,Boston,&VanElburg,1987).Thereisaclearrelationship

betweenchildhoodsexualabuseandtheeducationallevelsofparents(Aktepe,2009).StudiesconductedinTurkeywith

sexuallyabusedindividualswhoshowedthatthevictims’mothersgenerallyhadeducationlevelsofprimaryschooland

lower(Çengel-Kültür,Çuhadaroglu-Çetin,&Gokler,2007;Bahali,Akçan,Tahiroglu,&Avci,2010;Bilginer,Hesapçıo˘glu,&

Kandil,2013).Ofthemanyreasonstoforcechildrenintomarriage,thefamily’sﬁnancialsituationisprominent(Ahmad, Table3

ComparisonofcasesintermsofChildPosttraumaticStressReactionIndexandBriefSymptomInventorysubscalescores.

Earlymarriage(n=63) Mean±SD Sexualabuse(n=72) Mean±SD Statistics ta _p CPTS-RI 23.81±19.9 51.26±16.4 8.37 <0.001 BSI Depression 6.41±6.31 14.27±7.43 6.30 <0.001 Anxiety 5.91±6.85 12.74±6.51 5.69 <0.001 Psychoticism 3.59±4.37 8.74±4.84 6.13 <0.001 Somatization 5.48±5.41 12.07±7.37 5.59 <0.001 Obsessive–compulsive 5.85±6.17 12.09±5.72 5.83 <0.001 Interpersonalsensitivity 4.80±4.57 9.69±4.20 6.23 <0.001 Hostility 5.05±6.09 9.47±5.27 4.34 <0.001 Phobia 4.09±4.75 9.14±4.73 5.95 <0.001 Paranoia 5.46±5.22 10.39±4.48 5.69 <0.001 GlobalSeverityIndex 0.44±0.29 0.72±0.23 6.15 <0.001 CPTS-RI:ChildPosttraumaticStressReactionIndex;BSI:BriefSymptomInventory.

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2004;Gottschalk,2007;Nour,2009;UNICEF,2001).Familieswithalowsocioeconomicstatusconsidergirlstobean

eco-nomicburdenandconsequentlyforcethemintoearlymarriage(GrandNationalAssemblyofTurkey,CommitteeonEquality

ofOpportunityforWomenandMen,2009;T.R.MinistryofFamilyandSocialPolicies,2011).Similarly,ithasbeenstated

thattherateofearlymarriageincreasesastheeducationalleveloftheparentsdecreases(HacettepeUniversityInstituteof

PopulationStudies,2009;T.R.MinistryofFamilyandSocialPolicies,2011).

SexualabusemightresultinseveralpsychiatricdisordersincludingPTSD,depression,anxiety,drugaddiction,suicidal

behaviorandborderlinepersonalitydisorder(McLeeretal.,1992).Intheirreviewof45studies,Kendall-Tackettetal.(1993)

observedpsychiatricsymptomsin64–79%ofsexuallyabusedchildren,andtherateofpsychiatricdisordersfollowingsexual

abusewasreportedin67.1%–87.9%ofthevictimsinstudiesinTurkey(Ayaz,Ayaz,&Soylu,2012;Bahalietal.,2010;Gökc¸

e-˙Imren,Ayaz,Yusufo˘glu,&RodopmanArman,2013;Soylu,Pilan,Ayaz,&Sönmez,2012).Intheorderofprevalence,these

studiesfoundthatthementaldisordersdevelopedmostfrequentlybysexuallyabusedvictimswerePTSD,MDD,conduct

disorders,andanxietydisorder(Ayazetal.,2012;Bahalietal.,2010;Gökc¸e-˙Imrenetal.,2013;Soyluetal.,2012).Inour

study,77.8%ofthesexuallyabusedgirlsdevelopedatleastonementaldisorder,andPTSDandMDDwerefoundtobethe

mostfrequent;thisresultisinlinewiththeresultsofotherstudiesconductedinTurkeyandothercountries.Theexisting

literaturedoesnotincludesufﬁcientdataonthementalhealthoutcomesofearlymarriages.Inourstudy,itwasfound

that44.4%oftheearly-marriedgirlsdevelopedatleastonementaldisorder.Theratesofmentaldisorderwerefoundto

belowerintheearly-marriedcasesthanamongsexualabusevictims.Inaddition,theseverityofmentalhealthsymptoms

suchasdepression,anxiety,hostility,andinterpersonalsensitivity,whichwedeterminedwiththeBSI,wasalsolowerin

theearly-marriedgroup.Ourresultsshowedthatthepsychiatricdisorderratesandseverityofpsychiatricsymptomswere

lowerintheearly-marriedgirlsthaninthegirlswhohadbeensexuallyabused.

Sexualabuseisanacuteandchronictraumathatisdetrimentaltotheemotionalandsexualdevelopment,interpersonal

relationships,andself-conﬁdenceofthevictim(Aktepe,2009).Incontrast,earlymarriagemeansleavingparentsandpeers

atanearlyage,becomingacquaintedwithsexualitybeforecompletingthenecessarymentalandphysicaldevelopment,and

beingexposedtopregnancy,birthandphysicalandemotionalviolencebythepartnerandhisfamily,whichmayresultin

multipleandchronictraumas(Figueiredo,Pacheco,&Costa,2007;Nour,2009;Raj,Saggurti,Lawrence,Balaiah,&

Silver-man,2010).PTSDhasbeenreportedtobethemostfrequentmentaldisorderencounteredinsexuallyabusedchildrenwitha

rateof40–50%(Bernard-Bonninetal.,2008;McLeeretal.,1992).Similarresultshavealsobeenobtainedinstudiesconducted

inTurkey(Ayazetal.,2012;Bahalietal.,2010;Gökc¸e-˙Imrenetal.,2013;Soyluetal.,2012).Althoughtheliteratureincludes

severalstudiesthataddressthetraumaticmentaloutcomesofsexualabuse,therearecurrentlyaninsufﬁcientnumber

ofstudiesthatinvestigatethetraumaticeffectsofearlymarriage.OurresultsshowedthatthePTSD/ASDratesandPTSD

symptomseveritywerelowerintheearly-marriedgroupthaninthesexuallyabusedgroup.Turkishsocietytraditionally

supportsearlymarriages,andthesemarriagesaregenerallyperformedwithasocialagreement(GrandNationalAssembly

ofTurkey,CommitteeonEqualityofOpportunityforWomenandMen,2009).Therefore,webelievedthatourearly-married

groupwouldnotperceiveearlymarriage,whichhasbeennormalizedbysociety,tobebeingastraumaticassexualabuse

alone.Themultipleandchronictraumas,takingonresponsibilitiessuchascaringforafamily,homeandchildrenbefore

beingready,unplannedandunintendedpregnancies,lowsocialsupportandtheeconomicdifﬁcultiesthatareexperienced

intheseinstancesarethoughttoresultinMDDandadjustmentdisorderratherthanPTSD.

Anincreasingnumberofstudieshavesuggestedthatthefrequencyofsuicidalthoughts,plans,andactsinadolescents

isgreatlyincreasedbytheexperienceofpsychologicaltrauma(Hill,Castellanos,&Pettit,2011;Miller,Esposito-Smythers,

Weismoore,&Renshaw,2013;Venta,Ross,Schatte,&Sharp,2012).Numerousstudieshaveshownthatsexualabuse,which

causesseriousmental traumainvictims,alsoincreasestherisk ofsuicidalbehavior (Bedietal.,2011;Martin,Bergen,

Richardson,Roeger,&Allison,2004;Plunkettetal.,2001).Thesocio-culturalcharacteristicsofthesouth-easternregion

ofTurkey,wherethisstudywasconducted,givewomenhaveanegativesocialanddomesticposition;somestudieshave

reportedthatyoungwomenlivinginthisareahavemadefrequentattemptsatsuicide(Alptekin,Duyan,&Demirel,2006;

Sır,Özkan,Altında˘g,Özen,&Oto,1999;Yıldız,2008).Inthepresentstudy,wefoundthattheratesofsuicidalbehavior

werehighinboththevictimsofsexualabuseandtheearly-marriedgirls.Althoughthenumbersofbothsuicidalthoughts

andsuicidalattemptswerehigherinthesexuallyabusedgroup,thisdifferencewasstatisticallysigniﬁcantforonlysuicidal

thoughts.Thismaybebecausesexuallyabusedindividualsdevelopmentaldisordersthatincreasetheriskofsuicidethan

thosewhoexperienceanearlymarriage.

Weobservedthatthegreatmajorityofourearly-marriedparticipantswereeitherpregnantoralreadyamother.In

addition,unplannedandunintendedpregnancieswerealsofrequentinthisgroup.Ourstudydidnotincludearelevant

detailedevaluation;however,anumberofstudieshavestatedthatadolescentpregnanciesareassociatedwithhigherrates

ofcomplicationsandanincreasedmortalityriskformotherandchild(Demiretal.,2000;Kongnyuyetal.,2008;Rajetal.,

2010;S¸imsek,Kabalcıo˘glu,&Kurcer,2005);mortalityriskisﬁvetimesgreaterinthepregnanciesofgirlsyoungerthan

theageof15thanforpregnanciesinwomenintheir20s(IPPF,2006).Atendencytowardsexuallytransmitteddiseases

alsoincreasesinparallelwiththesepregnancies(Clarketal.,2006).Inaddition,earlymarriagesrestrictthefreedomsof

girlsandpreventthemfromdevelopingpersonallyandhavingaccesstoeducation(GrandNationalAssemblyofTurkey,

CommitteeonEqualityofOpportunityforWomenandMen,2009;Nour,2009).Theeducationallivesofallour

early-marriedgirlsareapparentlyinterrupted.Deprivedofeducationalaccess,thesechildrenarealsodeprivedoftheirabilityto

joinproductivesociety,thatis,tohaveajobandwork(Boran,Gökc¸ay,Devecio˘glu,&Eren,2013;GrandNationalAssembly

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tobeabarriertothedecreaseofpoverty,theextensionofeducation,theprocurementofgenderequality,theprotection

ofchildren’slives,andthepromotionofhealth,whicharerequiredforcommunitydevelopment.Ourresultsandthoseof

previousstudiesleadustobelievethat,althoughthementalhealthoutcomesofearlymarriagemaynotbeassevereas

thoseofsexualabuse,itsphysicalandsocialoutcomesmaybemoresevere.

InTurkey,whengirlsthatareforcedintomarriageatanageyoungerthan15arepresentedtothejudicialauthorities

anevaluationismadeastowhetheramentaldisorderhasdevelopedortheyoungperson’smentalhealthhasdeteriorated

followingthesexualabuse.Thisisrequiredbylaw.Thesementalevaluationsalsohavegreatimportanceforthepunishments

thatareimposedattheendofthejudicialprocess(TurkishPenalCode,2004).Theresultsofthepresentstudyrevealedthat

sexuallyabusedgirlsshowedpsychiatricsymptomsandhadahigherrateofdiagnosisofpsychiatricdisordersthandid

early-marriedgirls.However,theseresultsmightbebecausetheearly-marriedgirlsrevealedalowernumberofsymptoms

ofmentalhealthproblemsthanwereactuallypresentattheendofthejudicialprocessduetothefearthattheirhusbandsand

parentswouldbepunished.Thus,itmaybeinconvenienttofocusononlysexualabuseandmentaldisorderdevelopment

inevaluationsof,punishmentsfor,andprecautionsagainstearlymarriages.Inaddition,becauseitisgenerallyimpossible

toremovetheindividualsfromtheabusiveenvironment,theexistenceofmultipletraumasandmanypsychologicalstress

factorsinthesecasesleadsustobelievethatmentalsymptomsmaybemoreresistanttotreatmentandfarmorechronic

thanwepreviouslythought.Thereisaneedforstudiesthatexaminethecourseofsymptomsinearly-marriedindividuals.

Ourstudyhassomelimitationsinthatthementalevaluationwasconductedduringthejudicialprocess,themental

disorderswerenotdiagnosedwithstructuredinterviews,thecaseswereevaluatedinonlyacross-sectionalway,andthe

girlswerenotfollowedforalongperiod.Becauseoursamplegroupincludedonlycasesreferredforforensicevaluation

inthesoutheasternregionofTurkey,whereearlymarriagesarecommon,ourresultsmaynotfullyrepresentgirlsforced

intoearlymarriageinTurkeyoraroundtheworld.However,thestudyisalsostronginsomerespectsinthatallofthe

participantswerecomprehensivelyevaluatedbyachildpsychiatrist,ascalewasusedinthestudyandalloftheparticipants

weresociallyexamined.Webelievethatthisstudycouldmakeanimportantcontributiontotheliteraturebecauseitis,to

thebestofourknowledge,theﬁrsttocomparesexuallyabusedandearly-marriedindividualsintermsofmentaldisorders

andseverityofsymptomsofmentalhealthproblems.

Asaconsequence,wecomparedtheearly-marriedgirlsandthosewhoweresexuallyabusedintermsoftheir

sociodemo-graphiccharacteristics,psychiatricdisorderrates,andseverityofpsychiatricsymptoms.Wefoundthattherewasahigher

rateofinterruptiontotheeducationofearly-marriedgirlsandthattheirparentshadlowerlevelsofeducation.Wealso

foundthatthenumberofsuicidalthoughtsandthedevelopmentofPTSD/ASDandMDDwerehigherinthesexuallyabused

groupandthatthenumberofadjustmentdisorderswashigherintheearly-marriedgroup.Inaddition,theseverityofPTSD

andsymptomsofmentalhealthproblemsdeterminedwiththeBSIwashigherinthesexuallyabusedgroup.

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