Background

Childhood sexual abuse is a major problem that affects people all over the world [1, 2]. Child sexual abuse is defined by the World Health Organization (WHO) as “the involvement of a child in sexual activity that he or she does not fully understand, is unable to give informed consent to, or for which the child is not developmentally prepared and cannot give consent, or that violates society’s laws or social taboos.” [3]. Child sexual abuse with rate ranged from 8 to 31% for females and from 3 to 17% for males [1].

The true prevalence of the different types of sexual abuse against women is not well known in Arab world [4]. There is no precise statistical data on sexual assault in Egypt. However, there are some reports on sexual assaults against children from some governorates in Egypt that were obtained from the Medico-Legal departments of Ministry of Justice in those governorates. In a previous study, reports on sexual assaults against children from January 2004 to December 2009 were collected from the Medico-Legal department of Ministry of Justice in the Suez Canal area, Ismailia and Port-Said offices, the total numbers of cases were 128, girls represented 69 of cases (53.9%), and boys represented 59 cases (46.1%) [5]. In Dakahlia Governorate, 650 cases of sexual offenses were reported in the period from 1996 to 2000 with female to male ratio was 3:2 [6]. In Sohag Governorate, there were 40 sexual assault cases from 2002 to 2003, with females representing 62.5% and males representing 37.5% [7].

Early life experiences can have long-term consequences on health across the lifespan [8]. In childhood and later adulthood, child sexual abuse can result in a number of physical and mental health issues [9,10,11]. This is because stresses during the first few years of life which is a critical period for brain development are more invasive and enduring than they are for children exposed to stress at older ages, and that they may have different outcomes [12, 13].

Depression is significantly linked to sexual abuse [14, 15] that tends to be associated with suboptimal treatment response and poor prognosis [16]. Depression, otherwise known as major depressive disorder or clinical depression is a significant mood condition that affects many people. People who suffer from depression have continuous emotions of hopelessness, and they lose the interest in the things they used to like [17, 18]. The impact of depression is great on women as it may lead to postpartum depression and marital satisfaction; Ahmed et al. [19] found that history of depression is one of the major risk factors for postpartum depression among women in Egypt. Osman et al. [20] found a significant negative correlation between depression and marital satisfaction among married Egyptian women. Previous studies have reported association between abuse and suicidal behaviors in individuals with or without depression [21], and the risk of suicide attempts increased by two to three folds than those without sexual abuse [22, 23].

Victims of child sexual abuse who report shame, self-blame and predictable stigma, leading to non-disclosure and avoidance of aid, subsequently negative social reactions, will be associated with poorer outcomes, like post-traumatic stress disorder (PTSD), depression, and maladaptive coping [24, 25]. In children, this has best been studied for child sexual abuse, where stigmatization (shame and self-blame) is a risk factor for adverse health effects [26].

An established risk factor for worsening the depression course in adults is early life trauma, specifically childhood maltreatment [27] which may consist of physical, sexual, or psychological abuse, as well as emotional neglect. Severe depression is strongly related to childhood emotional and physical abuse [28]. This relationship can be explained by the fact that childhood emotional and physical abuse affects personality, cognition, and behavior and can increase the sensitivity to life stress, both in childhood and adulthood [29]. Emotional and physical abuse alters how an individual perceive themselves and the world around them, with a great impact on self-esteem, and mental and physical development [30, 31]. Moreover, it is associated with increases in pessimistic thinking and negativity, feelings of sadness, and social avoidance and isolation [32]. Also, emotional and physical abuse can affect the whole person’s life, with intense feelings of worthlessness, hopelessness, helplessness and the loss of pleasure in activities and all other symptoms of depression [33, 34]. All of these factors are identified as predictors of the severity of depression [35]. In addition, childhood emotional and physical abuse is associated with severe, recurrent depression and resistant depression [36]. From a biological perspective, alterations to stress-response systems, specifically the hypothalamus–pituitary–adrenal (HPA) axis, as a result of prolonged stress in early development, have been proposed as a connection between childhood maltreatment and subsequent depression symptoms [37]. In addition, patients with depression who experienced childhood emotional and sexual abuse, and subsequently having a high level of depression, were reported a high rates of suicide thoughts and attempts. In particular, depressive symptoms were identified as partially mediating the relationships between childhood emotional and sexual abuse and suicide attempts, so, the higher level of depression was significantly related to suicidality [38, 39], hopelessness, and anhedonia, which are intimately related with depression and are specifically important factors associated with suicide.

Children who were sexually abused report stigma and also, their caregivers experiencing shame and self-blame for having a child with sexual abuse and may be hesitant to seek mental health help [40], the caregivers felt devaluation of the self for having a child with sexual abuse [41].

Even though the concept of child sexual abuse is unknown in Arab countries in terms of cultural beliefs and family dynamics yet, numerous recent reports document child abuse in Arabian regions [42].

Unfortunately, Arab female adolescents are discouraged from reporting being physically, sexually, or psychologically abused within their families due to a culture and education that views child sexual abuse as a thorny issue, which may increase their feelings of loneliness and isolation, which are strongly linked to various psychiatric disorders [43]. As a result, it goes unrecognized, under-reported, and inadequately handled. To date, only a few studies have looked at the connection between childhood sexual abuse and depression and suicidal ideation in depressed women in Arab countries, and none have looked at the role of childhood sexual abuse related stigma in depressed women. So, it is important to understand the underlying dynamics of their symptomology and target the underlying factors associated with abuse at any stage of their life, in order to provide early and effective treatment.

Methods

At the psychiatric outpatient clinic at a University in Egypt, between March 2019 and December 2019. A consecutive sample of 160 depressed women was recruited in this cross-sectional study; the patients were depressed according to DSM-5 criteria for depression. Exclusion criteria were depression with psychotic features, presence of psychotic disorders, and substance abuse. All the patients were under pharmacological treatment, in the form of antidepressants. Patients’ personal information was collected using a structured questionnaire for socio-demographic data (age, residence, level of education, marital status, occupation, family history of major depression, and its duration and age of onset). A self-report questionnaire divided the participants into two groups: those who had experienced sexual abuse as a child (group I) and those who had not experienced sexual abuse as a child (group II). In a private room in the outpatient clinic, the depressed women were interviewed. After the participants had received a thorough description of the study, they signed a written informed consent form.

The following measures were applied:

  1. 1.

    The Structured Clinical Interview for the DSM-5 clinical version (SCID-5-CV) was used to settle the diagnosis of major depressive disorder [44]. It guides the clinician step by step through the DSM-5 diagnostic process. Interview questions are provided conveniently along each corresponding DSM-5 criterion, which aids in rating each as either present or absent. The SCID-5-CV is an abridged and reformatted version of the Research Version of the SCID; the structured diagnostic interview is most widely used by researchers for making DSM diagnoses for the past 30 years [44].

  2. 2.

    Beck Depression Inventory, second edition (BDI-II) for evaluation the severity of depression. It consists of a collection of 21 self-report questions. Each query is graded on a scale of 0 to 3. Mild depression is indicated by a score of 14 or higher, moderate depression by a score of 20 or higher, and extreme depression by a score of 29 or higher. In this study the Arabic version of the revised edition of the Beck Depression Inventory was used [45].

  3. 3.

    The Beck Hopelessness Scale (BHS) was used to measure hopelessness. The Beck Hopelessness Scale (BHS) is a 20-item, self-rated scale. The patient responds with true or false to detect the pessimistic attitude. Higher scores indicate more hopelessness [46].

  4. 4.

    Scale for Suicidal Ideation (SSI) was used for measuring suicidal ideations in depressed women. There are 19 products in all. The level of suicidal ideation was graded on a 3-point scale from 0 to 2 for each item. The higher the score, the more severe the suicidal ideation. A cumulative SSI score of 6 or higher was used as a cutoff point for the presence of suicidal ideation [47].

  5. 5.

    Childhood sexual abuse. It was evaluated with the use of a self-report questionnaire; the questions of this questionnaire were derived from the National Population Survey, a Canadian survey of sexual abuse. The answers to the questions were coded as “yes” or “no.” The main questions of the questionnaire are “When you were growing up, did any adult ever do any of these things to you against your will?” Exposed themselves to you more than once, threatened to have sex with you, touched the sex parts of your body, tried to have sex with you or sexually attacked you [48]. Its Cronbach`s alpha in our sample was 0.88.

  6. 6.

    Scale for Stigma: To assess stigma associated with sexual abuse in children, we used the extended version of the Coffey et al. stigma scale, which consists of nine elements. According to Gibson, the stigma scale has Cronbach’s alpha 0.93 for internal consistency [49]. Its Cronbach’s alpha in our sample was 0.90. The questions are as follows: (1) How ashamed do you feel about this experience? (2) How much do you think others would blame you for what happened? (3) How much do you think you are different from other women because of this experience? (4) How much do you feel tainted (“dirtied”) by this experience? (5) How concerned are you that other people will think something negative about your sexuality if they found out? (6) How concerned are you about what other people would think of you if they found out what happened? (7) How embarrassed are you about telling people what happened? (8) How concerned are you about people not respecting you as much if they were to find out what happened? (9) How concerned are you about how other people would react if they were to find out what happened?

    The scale of suicidal ideation, hopelessness scale, the scale of childhood sexual abuse, and the scale of stigma were translated from English to Arabic and back translated with semantic adaptation by two independent bilingual language expert translators.

  7. 7.

    Previous history of suicide attempts: It was assessed by direct question “Have you ever tried to commit suicide?”

Statistical analysis

The data analysis and sample size calculation (with 80% power) were performed using the statistical package for social sciences (SPSS version 25) released 2017, created by IBM, Armonk, New York, United States of America [50]. The sample size was calculated according to the following total number of depressed female patients coming to the outpatient clinic of the psychiatric department of our university hospital was 510 cases during the period of the study. Prevalence of child abuse among depressed women in a previous study was 20.7% [51], so at confidence interval 95%, the sample size was calculated to be 169 cases. Frequencies and percentages were used to reflect the categorical data. The mean and standard deviation were used to describe continuous data. The t-test for continuous variables was used to compare classes, with a 95% confidence interval. To measure discrepancies between classes, the Chi-square was used for categorical variables. The data were analyzed using multiple and logistic regression. If the P value is less than 0.05, it indicates a significant difference.

Results

Of the 160 depressed women, 19 (11.8%) (group I) reported a history of childhood sexual abuse (group I) under 15 years by adult male (family member and friends to the family); all of them reported childhood sexual history in the form of touching of the sex organs of their body with trial to have sex (attempted vaginal intercourse without penetration) more than once (mean (SD) = 3.18 (1.32), while 141 (88.2%) without a history of childhood sexual abuse (group II). In terms of age, education, job status, marital status, and family history of depression, there were no statistically significant variations between the two groups. By comparing groups, I and II, there was a substantial decrease in the age of onset of depression, a significant increase in the period of depression, the number of hospitalizations, the Beck Depression Inventory, and the Beck Hopelessness Scale mean scores in group I (P = 0.001, P = 0.02, P = 0.02, P = 0.004, P < 0.001, P = 0.005 respectively) compared to group II. In addition, there was a substantial rise in the number of patients with suicidal ideations and prior suicide attempts in group I (P = 0.001) Table 1.

Table 1 Demographic and clinical characteristics comparison of depressed women with and without history of childhood sexual abuse (n = 160)
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Using multiple regression model for the increased severity of depression, the history of childhood sexual abuse and its related stigma were the most significant predictors for the increased severity of depression (P = 0.008 and P = 0.01 respectively). Also, hopelessness was a significant predictor (P = 0.04) Table 2.

Table 2 Multiple regression analysis for variables predicting the severity of depression (BDI-II scores) in depressed women (n = 160)
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Using logistic regression model of the predictors for the presence of current suicidal ideations, the history of childhood sexual abuse and its related stigma were the most significant predictors (OR = 3.47, P = 0.006 and OR = 2.97, P = 0.009 respectively). Also, increased severity of depression and hopelessness were significant predictors (OR = 1.13, P = 0.05 and OR = 1.34, P = 0.03 respectively) Table 3.

Table 3 Logistic regression model for variables predicting the presence of current suicidal ideations in depressed women (No = 160)
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Discussion

Only women were included in this study because child sexual abuse history is more frequently declared by females (12.8%) than males (4.3%), also females being more likely to internalize their reactions to stress (e.g., depression) and males most probably externalize stress (e.g., aggressive behavior) [52, 53]. The prevalence of childhood sexual abuse in this study was 11.8%. In previous studies it varies from 6 to 71% among females [1, 54,55,56,57], with prevalence at the higher end of the range when the abuse not involving contact, e.g., obscene phone calls, exhibitionism, and harassment [56]. In this study, the childhood sexual abuse in our sample was involving contact so the prevalence of childhood sexual abuse in our sample was not so much high.

In line with many studies [58,59,60,61,62,63,64,65], our findings showed that depressed women with a history of childhood sexual abuse were more likely than those without that history to have a higher depression intensity, higher levels of hopelessness, higher rates of suicidal ideas, and higher rates of previous suicidal attempts. Contrary to our findings, some investigators have reported that depressed women with a history of childhood sexual abuse did not differ from those without, on depression severity [59, 61, 66]. The explanation for the strong correlation between the history of childhood sexual abuse and increased severity of depression in our results is that, Egypt, where this research was conducted, has a predominantly Islamic culture dominated by traditional values [67], which includes a cultural disapproval of any kind of sexual interaction between male and female prior to marriage. As a result, women who have experienced childhood sexual abuse may have a false impression that they committed an unforgivable sin, which is expressed in a higher level of associated stigma and, as a result, higher levels of depression. So, the related stigma plays a significant role in the increased severity of depression.

An important finding in this study was the strong association between the stigma related to childhood sexual abuse and the higher level of depression and a current suicidal ideation in depressed women. Similar results reported by Messman-Moore and Coates [63] who showed that child maltreatment often arises self-loathing, shame, and self-blaming, which may increase liability to using self-punishment as a self-management mechanism to decrease tension coming from self-criticizing state [28]. This finding implicates the correction of the related stigma and distorted cognitions that needs extensive psychotherapy to facilitate the resolution of faulty sensation of guilt and shame, thus helping relieve the depression and the suicidal ideations. Also, the society organizations should play an important role to raise the awareness and to give the suitable support to that sector of suffering females.

There are some limitations of this study: since the analysis is cross-sectional, no cause–effect relationship can be established. Another drawback is that by using self-report tests to gather retrospective data, there is a chance that the participants will not remember or will remember incorrectly. However, the tragic essence of childhood sexual assault histories raises the likelihood of accurate detail recall. Also, the study did not include a healthy control for comparison. Despite these limitations, this is the first study to look into the connection between the stigma associated with a history of childhood sexual abuse and depression intensity and suicidal ideation in depressed women in Egypt.

Conclusions

Childhood sexual abuse and its related stigma were associated with an increased severity of depression and presence of current suicidal ideations in depressed women. Identification of childhood sexual abuse and its related stigma in depressed women is highly important for proper management of depression. Correction of the related stigma will facilitate the resolution of the faulty sensation of guilt and shame, thus helping relieve the depression and the suicidal ideations.