Child sexual abuse (CSA) is a significant social, psychological, and health problem with far-reaching implications for child victims, their families, and communities. Considerable negative effects can result from sexual abuse in childhood, including emotional distress, symptoms of post-traumatic stress disorder, behavioral problems, interpersonal difficulties, and problems with cognitive functioning, which may lead to academic failure (Berliner & Elliott, 2002; Jones, Trudinger, & Crawford, 2004). Later in life, CSA constitutes a significant risk factor for serious health and mental health problems (Hunt & Walsh, 2011). Although estimates vary depending on the sample and definition of sexual abuse used, research suggests that CSA is not uncommon around the world. One in five women and one in 13 men report having been sexually abused as a child (WHO, 2014). Furthermore, it is believed that the number of reported cases represents a minority of actual cases, as the problem is frequently underreported (Kini & Lazoritz, 1998).

In the State of Kuwait, there is currently no official definition for CSA, and most Kuwaiti researchers have chosen to use the World Health Organization’s definition for CSA. According to this definition, CSA is the involvement of a child in sexual activity that he or she does not fully comprehend, that he or she is unable to give informed consent to, for which the child is not developmentally prepared and cannot give consent, or that violates the laws or social taboos of society. Child sexual abuse occurs between a child and an adult or with another child who by age or development is in a relationship of responsibility, trust, or power, and the activity is intended to gratify or satisfy the needs of the other person (World Health Organization, 2014). Although there is still no large-scale national survey of the incidence or prevalence of CSA in Kuwait, some local retrospective studies do exist. Based on nationwide samples of students (Alkhawwari, 2015; Al-Fayez, Ohaeri, & Gado, 2012) and analysis of medical records of children (Al-Ateeqi, Shabani, & Abdulmalik, 2002; El-Hait, Moosa, & Victorin, 1987), the results suggest that CSA does exist in this small Arab and predominantly Muslim country. These studies call for the attention of experts associated with all responsible parties to investigate the issue and work collectively to treat CSA victims and prevent or minimize future incidents.

In 2010, the Children’s Rights Association, which was established in 2008 under the umbrella of the Kuwait Medical Association, conducted a study of the prevalence of violence and abuse against children in Kuwait. A sample of 2508 freshmen at Kuwait University completed the ICAST-R questionnaire proposed by the World Health Organization to study the exposure of people to abuse during childhood. The results showed a high rate of sexual abuse of children. 12 % experienced someone revealing their genitalia in front of them; 7 % had been forced to touch another person’s naked private areas; 2 % had been forced to appear without their clothes in front of people or for photography, video, or Webcams; 13 % had been exposed to sexual abuse in the form of touching their private body parts; and 2 % had been raped (Alkhawwari, 2015). In 2006, a study of a nationwide sample of 4467 senior high school students (mean age 16.9 years; 48.6 % boys) at government secondary schools revealed that 8.6 % of the sampled students had been sexually attacked in their lifetime, 5.9 % had experienced someone threatening to have sex with them, 15.3 % had experienced unwanted sexual exposure, and 17.4 % had had someone touch their sexual parts (Ohaeri & Al-Fayez, 2013). Furthermore, a revision of 60,640 medical records of children admitted to two major government hospitals in Kuwait between 1991 and 1998 revealed that 16 children showed evidence of abuse. The perpetrator was a parent in 75 % of the cases, which involved the following abuses: 13 physical, two sexual, and one Munchausen syndrome. In the two cases of sexual abuse, a non-family caregiver was involved (Al-Ateeqi, Shabani, & Abdulmalik, 2002). The authors of the study stressed that sexual abuse is rarely if ever voluntarily reported, and when accidently discovered, families tend to refuse any further action to avoid stigmatization, shame, and disgrace; this makes it very challenging to obtain accurate estimates of the number of CSA cases.

Social Work & CSA

According to the International Federation of Social Workers, the profession of social work “promotes social change, problem solving in human relationships and the empowerment and liberation of people to enhance well-being” (IFSW, 2012). This definition of social work clearly highlights the responsibility of the profession to intervene at the three levels of change promotion. First, the problem solving or treatment level after the fact. Second, the prevention level to stop or reduce a problem. Third, the awareness level to promote positive change and enhance human well-being. Thus, social work is at the forefront of social consequences and realities of CSA.

The current study focuses on the prevention level of social work intervention, where social work assumes a proactive role, in an attempt to prevent CSA from taking place by suggesting school-base intervention program for children in kindergartens.

Recent epidemiological research and clinical reports document that a significant percentage of child sexual abuse occurs before the age of seven (e.g., WHO, 2014; Cupoli & Sewell, 1988). As a result, prevention programs for preschoolers have appeared. Since 1977, a series of CSA prevention programs have been implemented in schools and communities in the USA, Canada, Australia, China, and some other countries to increase public awareness of the CSA problem (Finkelhor & Strapko, 1992; Finkelhor, 1994; MacMillan, Fleming, Trocme, et al., 1997; Chen & Chen, 2005; Hunt & Walsh, 2011). However, there were scarce attempts in the Middle Eastern countries to explore this area in both research and practice. In some countries, there were some awareness lectures and workshops for children, parents and teachers presented by volunteer groups and NGO members, but they have not been assessed scientifically, nor documented. For example, a volunteer team of seven female students at King Abdulaziz University in Saudi Arabia, called “Enough of me”, conducted a number of prevention and awareness workshops and lectures for both parents and children received positive local media recognition (“Enough of me”, 2016), but there was no scientific evaluation of the experience.

A solid body of studies has demonstrated that school-based programs are able to increase children’s knowledge and skills related to CSA prevention (e.g., Baker, Gleason, Naai, Mitchell, & Trecker, 2012; Topping & Barron, 2009; Tutty, 1997). In particular, recent research has indicated that beginning primary prevention with preschoolers is feasible and that children as young as three years old can learn to recognize inappropriate touching and acquire self-protection skills (Kenny, Wurtele, & Alonso, 2012; Wurtele & Owens, 1997). In Amman, a study aimed to identify the effect of a prevention program in increasing the first grade female student awareness of sexual abuse and enable them to acquire the concepts of self-protection was conducted (Jibril & Al-Harasis, 2012). Participants of the study consisted of (50) first grade students who responded to personal safety questionnaire and to ‘What If ‘Situations Test Which was prepared to measure the capacity of children to recognize and resist and report inappropriate touches. The selected sample for the program consisted of (18) students who received the lowest scores on both, the personal safety questionnaire, and the ‘What If ‘Situations Test. Then the sample was randomly split into two groups, experimental group which consisted of (9) students who received the counseling prevention program for a period of 7 weeks (two, 30-min sessions per week). Whereas the control group consisted of (9) students who did not receive the counseling prevention program. The results showed that there were significant differences between the experimental group and the control group in both the awareness and acquisition of concepts of personal safety measures in favor of the experiment group. For these reasons, the current study suggests the application of CSA prevention programs targeting kindergarten age children.

The success of any prevention program and lessons taught at preschools and kindergartens depends on the support of parents (Chen, Dunne, & Han, 2007; Chen & Chen, 2005). Parents who have concerns about these programs or believe they are harmful in any way may not allow their children to participate, possibly precluding their exposure to this information. For those children who do participate, parents can help reinforce prevention concepts and skills, answer questions, and correct their children’s misconceptions (Wurtele, Kvaternick, Lopez, Franklin, & Durlap, 1991). Thus, determining the public’s views about CSA prevention programs is essential.

Few studies have surveyed public and parental’ prevention-related attitudes and beliefs worldwide (e.g., Wurtele, Kvaternick, & Franklin, 1992). Research of this nature is particularly limited for the Middle East and the Arab Peninsula, and there have been no studies for Kuwait. To reduce this knowledge gap, the current study addresses several research questions:

  • RQ1: How often do parents and caregivers discuss sexual abuse with their children, and what is the content of their discussions?

  • RQ2: What are the reasons that some parents and caregivers choose not to discuss sexual abuse with their children?

  • RQ3: Do people who discuss CSA with their children differ from those who do not in terms of attitudes and beliefs related to CSA?

  • RQ4: To what degree do participants agree with the suggested content of the CSA prevention program?

  • RQ5: What are parents and caregivers’ beliefs about the possible impacts such programs can have on their children?

Method

Participants

In the State of Kuwait, there is no official institutional review board (IRB), yet the researcher applied all the required ethical considerations. Surveys were completed by a non-probability sample of 320 participants. Surveys and a cover letter explaining the survey’s purpose, researcher’s contact information, and assuring the respondents voluntary participation and confidentiality of any given information, were distributed at various locations (e.g., university campuses, various governmental agencies and ministries, malls, and cafes) in the six governorates of the State of Kuwait. The response rate was 85.5 % (400 questionnaires were distributed, 342 were returned, and 22 questionnaires were disregarded for being incomplete).

Questionnaire

The questionnaire was developed based on literature review, with alterations made to match the current study’s goals and ensure cultural sensitivity. The intent of the survey was to measure the attitudes and beliefs of participants about CSA prevention programs for kindergarteners. The survey was divided into six sections: (a) demographic information and whether or not participants had ever talked to their children about CSA (four items); (b) involvement of participants in personal CSA prevention including discussing possible abusers or perpetrators (six items), inappropriate actions (4 items), and skills (five items); (c) reasons for not talking to their children about CSA (eight items); (d) attitudes toward teaching different CSA prevention concepts/topics (18 items, Cronbach’s alpha = .57); (e) beliefs regarding the risks and benefits of CSA prevention programs (11 items; Cronbach’s alpha = .68); and (f) whether or not participants would allow their children to participate in CSA prevention programs. Except for three demographic questions on gender, marital status, and age, all of the survey questions asked respondents to either answer with yes/no, or agree/disagree.

Results

Demographic Characteristics of the Participants

Three hundred and twenty participants (163 females and 157 males, mean age = 31.6 years, SD = 10.32) completed a self-administered 57-item questionnaire. Among the participants, 57.5 % were married, 35.6 % single, 5.3 % divorced, and 1.6 % widowed.

It should be noted here that in the instruction section of the questionnaire, single and childless participants were instructed to answer the questions related to attitudes and beliefs in the survey “as if” they had children, except for the items related to actual behaviors with children related to CSA.

RQ1: How Often do Parents and Caregivers Discuss Sexual Abuse with Their Children, and What is the Content of Their Discussions?

Table 1 summarizes participants’ involvement in prevention efforts with their children. The results showed that only 37.8 % of participants had talked to their children about issues related to child sexual abuse. Of participants who reported discussing any topics of sexual abuse with their children, 84.4 % warned their children that “Someone might lure you with gifts and candy to respond to their requests”, and 82.6 % warned that “Someone might trick you into their car”, yet only 33 % discussed the possibility that “Someone might make you touch their body inappropriately”. Furthermore, the most warned about possible perpetrator of sexual abuse was strangers (over 75 %). As shown by the results, the majority of participants’ discussions with their children about CSA covered “stranger-danger” by focusing on warnings about cars, bribes, and gifts. In addition, although most participants warned their children about strangers, known adults, and children, only a few children were warned about relatives, siblings, and parents as possible perpetrators. As for the skills taught to children, the majority of participants (93.4 %) told their children to scream for help when they face any inappropriate behavior, to say no to all situations that make them uncomfortable (90.1 %), to tell their parents about such occurrences (90.9 %), to try to escape immediately (79.3 %), and to fight back (61.2 %).

Table 1 Topics discussed by participants with the children (n = 121)
Full size table

RQ2: What are the Reasons that Some Parents and Caregivers Choose not to Discuss Sexual Abuse with Their Children?

Table 2 summarizes the different reasons participants gave for not discussing any CSA topic with their children. The two main reasons given were that “It had not occurred to me” and “My child is too young”. The two least common reasons given were “My child is safe from CSA” and “Discussing this topic with my child is against my religious beliefs”.

Table 2 Reasons given for not talking to children about CSA topics (n = 199)
Full size table

RQ3: Do People who Discuss CSA with Their Children Differ from Those Who Do not In Terms of Attitudes and Beliefs Related to CSA?

Comparisons between participants who had discussed sexual abuse (n = 121) and those who had not (n = 199) showed that 51.2 % of females had discussed the topic compared to only 24 % of the males [χ(1) = 25.14, p < .01]. In addition, the difference between participants based on marital status was significant [χ(3) = 18.7, p < .001]: 47.3 % of married participants discussed topics of CSA compared to 41.2 % of divorced participants, 22.8 % singles, and 20 % widowed. In terms of their agreement with what should be taught in CSA prevention programs, the responses were equivalent for both groups with no significant difference (16.71 vs. 16.47, p = .147). As for the participants’ beliefs about the positive influence CSA prevention programs might have on children, there was no significant difference [t(318) = 1.04, p = .56] between participants who did talk to their children about CSA topics (M = 4.76, SD = 2.28) and those who did not (M = 4.62, SD = 1.90).

To detect whether there was a difference between participants who did and did not discuss CSA issues with their children in the likelihood of allowing their children to participate in CSA prevention programs, a χ2 test of independence was performed. The results showed that the relation between these variables was not significant [χ(1) = 2.42, p = .120]. The two groups showed a similar interest in allowing their children to be part of CSA prevention programs.

RQ4: To What Degree Do Participants Agree with the Suggested Content of the CSA Prevention Program?

Table 3 reports the percentages of participants who agreed on the various prevention concepts that should be taught to children. There was strong agreement among participants with the statements “children should be taught that if they are being abused, they should tell their parents or a trusted adult, such as a teacher or a social worker” (98.8 %), “they can say no to anyone who tries to act inappropriately with them” (98.1 %), and “they should be taught how to report if they have been sexually abused” (97.8 %). Concepts less frequently supported by participants were “teaching children how to fight back” (74.7 %) and that “sometimes adults do not believe a child who reports being abused” (64.4 %).

Table 3 Percent of participants’ agreement with concept/content of CSA programs
Full size table

RQ5: What are Parents and Caregivers’ Beliefs About the Possible Impacts such Programs can have on Their Children?

As seen in Table 4, participants strongly agreed that CSA programs help prevent child sexual abuse (93.4 %) and strengthen children by making them more confident to deal with any SA incidence (90.9 %). Participants disagreed with the statements that CSA programs are useful for girls only (89.1 %) and that children who live in religious homes do not need prevention programs because they “are protected against CSA” (87.8 %). The results showed a moderate agreement with the statement that it is important that all preschoolers be part of CSA prevention programs (62.5 %), yet results showed similar moderate agreement with the statement that preschoolers and kindergarteners are too young to learn about CSA programs (70.3 %). In addition, over 88 % of all participants agreed to allow their children to participate in a CSA prevention program, and 65 % believe that “Only professionals should deliver CSA programs, not the parents”.

Table 4 Beliefs about CSA prevention programs
Full size table

Discussion and Conclusions

Discouragingly, yet not surprisingly, only 37.8 % of the participants of this study reported discussing any topic of sexual abuse with their children. Additionally, similar to the findings of Wurtele et al. (1991), the majority of the participants of this study focused their discussions of CSA on “stranger-danger”. A possible reason why so many participants had not explored CSA topics with their children could be that they had not received such education themselves. The relative emphasis on “stranger-danger” followed from participants’ beliefs about the types of dangers and who might try to molest their children. Fewer participants mentioned abuse by a known adult, a relative or an older child, and almost none mentioned possible abuse by a sibling or parent. Thus, the majority of participants appeared to believe that children are unlikely to be sexually abused by familiar people. The known fact is that children are most often sexually abused by someone they know and trust. Approximately three quarters of reported cases of child sexual abuse are committed by family members or other individuals who are considered part of the victim’s “circle of trust (U.S. Department of Health and Human Services, 2007). To help children recognize potential abuse, it is essential that parents and children be made aware of the most common types of perpetrators and actions of abuse.

Another important finding of this study is that participants strongly support the idea of school-based prevention programs for young children as a way to reduce the risk of sexual abuse. Although the current national body of literature has no results of similar topics investigated before to be used for comparison, the result encourages greater investigation of possible experimental application of such programs within a sample of kindergartens as a first step toward better understanding and generalizing of their merits for reducing the risk of CSA.

When comparing participants who did and did not discuss sexual abuse with their children, the two groups were similar in most demographic variables, although females were more likely to discuss the topic. This result was similar to results reported for different cultures (e.g., Chen & Chen, 2005; Lalor, 2004) and could be explained in light of the fact that mothers and females in general are the primary caregiver in most cultures and have closer relations with the children. Furthermore, when asked about the reasons for not discussing sexual abuse with their children, most participants said that it had not occurred to them to do so, which may have been related to their lack of experience with victims or perpetrators. In addition, the topic of CSA is not a familiar topic for neither the local media, nor educational curriculum in Kuwait. Another reason reported by survey participants was that they viewed their children as being too young to understand the topic, suggesting a need to inform parents about the incidence of sexual abuse and that even young children are at risk for victimization. Other reasons given for not discussing sexual abuse related to lack of knowledge, suggesting a need to provide parents with assistance, materials, and skills to discuss the topic with their children of different ages. A noteworthy and positive finding of the study was the very low percentage of participants reporting religious beliefs as a reason for not discussing CSA issues with their children (3.5 %), which is contrary to what was expected in an Arab and Islamic culture. This is a positive finding because religious beliefs are usually difficult and very resisting to change, and it would have been difficult to work on the application of the idea of preventive programs if the findings were different. Furthermore, the vast majority of the participants reported that they do not consider their children to be safe from CSA, and only five participants reported thinking so. This is again encouraging finding because it indicates that the need for CSA prevention programs is the norm.

When asked about the content and concepts that should be taught in CSA prevention programs, participants’ views were consistent with what is frequently included in prevention programs. The vast majority of study participants agreed on the main concepts of these programs, suggesting that their content list could be used as a basis for creating the pioneer and first school-based kindergarten prevention programs in Kuwait. Furthermore, over half of participants express their preference of having CSA prevention programs once implemented to be delivered by professions and not parents. This result could be seen as a call for social workers to step up and take the lead in planning and delivering CSA prevention programs, and assessing their results.

Based on the data collected by this survey, social workers can take the next step and begin to outline a preliminary program of CSA prevention using the concepts that were most supported by participants in the study as main curriculum components. In addition, they may build a parallel awareness campaign for the public based on the shortcomings highlighted by the findings of the study such as the lack of information related to possible abusers, the possible onset of CSA incidents, skills needed to discuss topics of CSA with children, skills to notice signs of possible abuse, and the appropriate ways to deal with them and ways to report them.

Furthermore, social workers can reach out to respectful and influential public figures such as religious leaders, local stakeholders, educators, and health professionals, to speak out about CSA using concrete data and scientific knowledge, in order to gain momentum to the issues of CSA in Kuwait, to pave the road toward successful application and outcomes of future CSA prevention programs.

Despite of the important findings of the current study, some limitations should be noted. Given the exploratory nature of the study, the study questionnaire was designed to be simple and easy to administer, and the non-confrontational questions might make the survey relatively superficial. The psychometric properties of the questionnaire would need to be improved before implementing larger applications and assessments of change over time. Another limitation is the use of a relatively small and convenient sample of participants, which prevents generalizing the results. There remains a need for similar studies using larger and more representative samples in the future. Furthermore, conducting qualitative studies using focus groups of parents and social workers, and in-depth interviews in future research can shed brighter light on possible barriers and their underpinning beliefs to the implementation of CSA prevention programs, and ways to overcome them from the viewpoints of both parents and social workers.

In general, participants supported the inclusion of CSA intervention programs in kindergartens. For the most part, they believed that these programs could help prevent sexual abuse. However, 35.3 % of the sample expressed concern that participation in CSA programs may make children afraid of all strangers, lead them to make up stories of sexual abuse, or make them afraid to receive safe hugs and touches from parents. However, the suggested school-based prevention programs to prevent sexual abuse aim to improve children’s abilities to recognize inappropriate physical contact and to empower children to disclose any inappropriate actions by any perpetrator (Renk, Liljequist, Steinberg, Bosco, & Phares, 2002).

In conclusion, “Sex” remains a very sensitive topic in Kuwait, a Muslim, conservative society. Thus, contrary to the stated support for CSA prevention programs expressed by participants of this study, such programs will likely meet some resistance. Therefore, the content and delivery tools of such programs in Kuwait should be designed very carefully to address cultural sensitivities and public concerns. According to the core definition and most important standards of practice, culturally sensitive programs and interventions are the heart and soul of the social work profession (NASW, 2000). Social workers are equipped with the needed theoretical knowledge to understand CSA issues, trained to deal with both the children and their families, they have the skills needed to tackle the resistance of the stakeholders and the public regarding the sensitive nature of CSA, and they are willing to serve within the principles and ethics of social work. Therefore, social workers should reclaim their roles and responsibilities as advocators for the victims, educators for the families and children, and facilitators of multi-level, multi-tasked, interdisciplinary groups and teams for a greater holistic approach in dealing with the prevention of CSA.