اطلاعات درباره سوء استفاده جنسی و مهارت های حفاظت از خود: یک مطالعه بر روی نوجوانان چینی زن با عقب ماندگی ذهنی خفیف

Abstract Objective: This study aimed to examine the level of sexual abuse knowledge and self-protection skills in a sample of female Chinese adolescents with mild mental retardation. It was hypothesized that the participants would exhibit impoverished knowledge on sexual abuse and related self-protection strategies. Method: A total of 77 female Chinese adolescents aged from 11 to 15 years old who met the inclusion criterion of the study were recruited from four special schools for mental retardation. The Chinese versions of the Personal Safety Questionnaire and the “What If” Situation Test (Wurtele, 1990) were administered orally to the participants during individual interviews. Results: Participants were more able to accurately recognize inappropriate than appropriate touches and sexual requests, and possessed limited information about sexual abuse. They were also inadequate in protecting themselves against sexual abuse, and had the most difficulty in reporting the sexually abusive incident and characteristics of the offender. Regression analyses also showed that their sexual abuse knowledge was the best predictor for self-protection skills. Conclusion: The present findings provided strong cross-cultural support to previous Western studies that found females with mild mental retardation of high risk to sexual abuse and in need of specially designed prevention program to enhance their competency against sexual victimization and exploitation. With modification and refinement, measurement scales used in the Western general population could be extended to Chinese adolescents with mental retardation. Suggestions on the design of the sexual abuse prevention programs, limitations of the present study, and recommendations for future studies were also discussed.

Introduction SEXUAL ABUSE VICTIMIZATION is a pervasive problem among individuals with mental retardation Beail and Warden 1995, Brown et al 1995, Elvik et al 1990, Hames 1996, Tharinger et al 1990 and Turk and Brown 1993, and its prevalence may be higher than the estimated prevalence within the general population Baker and Duncan 1985 and Ludlow 1991. Sexual abuse of these individuals often occurs repeatedly and over protracted periods of time in a variety of settings, including institutions, community residential facilities, and other service settings; and involves caregivers and other providers, family members, peers with mental retardation, and other acquaintances Beail and Warden 1995, Furey 1994, Mansell et al 1992, Sobsey 1994 and Turk and Brown 1993. Individual risk factors that increase these people’s vulnerability to sexual victimization include their impoverished sexual knowledge Brantlinger 1985, Edmonson 1988 and McCabe 1993, a lack of sex education Fenwick 1994 and Ludlow 1991, lifelong physical and emotional dependence on adults Furey 1994 and O’Day 1983, impaired verbal and social abilities Singer 1996 and Sobsey 1994, and a lack of knowledge on sexual abuse preventive skills Haseltine and Miltenberger 1990 and Watson 1984. The ecological models, on the other hand, argue that cultural, community, and family responses to mental retardation also increase the risk for sexual abuse Belsky 1980, Bronfenbrenner 1977 and Garbarino and Stocking 1980. With the social stigma and low status ascribed to them, individuals with mental retardation are often denied of their rights to sexual expression and opportunities to social interaction, and are fostered to comply and depend on their caregivers and institution staff Sobsey 1994 and Sundram and Stavis 1994. The misconceptions about the asexuality of these people may also result in a failure of the community, service providers, and caregivers to recognize the potential risk of sexual abuse and exploitation, to detect such incidents when they occur, or to protect and assist the victims Hames 1996, Mansell et al 1992, Sobsey 1994 and Tharinger et al 1990. Among the identified risk markers, inadequate sexual knowledge remains the most salient factor regarding sexual victimization of individuals with mental retardation. Studies have shown that these people’s level of sexual knowledge is generally lower than those without mental retardation Hall and Morris 1976, McCabe 1993 and Watson and Rogers 1980. While they may know the gross anatomical differences between sexes, these people often have vague ideas about the internal organs and possess either inadequate or distorted information concerning conception, contraception, venereal disease, homosexuality, and sterilization. Their limited sexual knowledge is mainly due to their inadequate verbal or communicative skills to ask people about sexual matters, a lack of reading ability to use books and magazines as sources of information, and deprived opportunities for sex education in segregated special schools or institutions. Despite evidences to the contrary, people with mental retardation are often sexually stigmatized and perceived as either asexual, sexually incompetent, or possessing uncontrollable libido and perverted sexual habits Abramson et al 1988, Burt 1973 and Ludlow 1991. In the past decades, segregation, institutionalization, and surgical sterilization or castration have variously been proposed to restrict sexual expression of these people. Staff of institutions for mental retardation have routinely discouraged all forms of sexual expression by their residents, even masturbation in private, to avoid scandal or reputation damage Hames 1996 and Sundram and Stavis 1994. Even parents of offsprings with mental retardation may refuse to believe that their offsprings have sexual needs and feelings and reject attempts at providing sex education in the mistaken belief that ignorance will prevent sexual activity, sexual education will jeopardize their innocence, or sexual information will overstimulate their concern with sex Abramson et al 1988, Alcorn 1974 and Watson and Rogers 1980. A few parents may accept their offsprings’ need for sex education, but often transfer this responsibility for training to the professionals. Adequate large-scale sex education programs for people with mental retardation are generally lacking Ludlow 1991, McCabe 1993 and Tharinger et al 1990. A majority of these programs have preplanned or group curriculum sequences adopting from those provided for normal school children, and have not taken into account the varying needs and (dis)abilities of individuals with mental retardation Edmonson 1988, Ford 1987 and O’Day 1983. These programs have focused mainly upon cleanliness, morality, and good health habits; and are geared toward teaching inhibition rather than reducing anxiety and increasing appropriate heterosexual behaviors. Moreover, this type of sexuality curriculum often fails to address real-life problems confronted by these people, such as the high incidences of sexually transmitted diseases, sexual abuse and exploitation, and unwanted pregnancy; and provides little or no information on how to protect themselves against these problems Ludlow 1991 and Tharinger et al 1990. Many researchers have pointed out that this population needs sexual abuse prevention programs that address competency enhancement against sexually abusive circumstances Haseltine and Miltenberger 1990, Sobsey 1994 and Sundram and Stavis 1994. Recent studies have documented that such programs are effective in improving these people’s knowledge of social and sexual skills Foxx and Faw 1992 and Foxx et al 1984 as well as acquiring self-protective skills Haseltine and Miltenberger 1990 and Singer 1996. There is a paucity of studies on sexual abuse in Chinese societies, and a computerized literature search from 1976 to 1996 failed to show any study on sexual abuse and mental retardation among the Chinese. The authors argued that certain aspects of traditional Chinese culture may have increased the risks of sexual abuse for Chinese with mental retardation. In Chinese societies, a strong moralistic view is attached to the etiology of mental retardation. Having offspring with mental retardation is regarded as a punishment for parents’ violation of Confucian teachings, such as dishonesty, misconduct, or filial impiety (Lin & Lin, 1981); therefore, these parents are expected to bear the full responsibility to care for these offsprings. However, these parents often engage in either avoidance coping strategies such as wishful thinking, denial, and social withdrawal, or appeal to fate to deal with the situation (Cheung & Tang, 1995), and reject training or intervention programs for their offsprings. The suppression of sexuality in traditional Chinese culture and the lack of overt affectionate expression within the family and interpersonal relationships (Goodwin & Tang, 1996) makes it difficult for these parents to talk about sexual matters, accept the need for sex education and training, and articulate their concerns of sexual victimization of their offspring (Chen & Tang, 1997). Purpose of present study The present study is the first to explore sexual abuse and mental retardation in a Chinese community in Hong Kong. It aimed to examine the level of sexual abuse knowledge and self-protection skills in a sample of female Chinese adolescents with mild mental retardation. The target sample was chosen since female adolescents, especially those with mental retardation, are among one of the high-risk groups for sexual abuse Beail and Warden 1995, Dunne and Power 1990, Sobsey 1994 and Turk and Brown 1993. It was hypothesized that this sample would exhibit impoverished knowledge on sexual abuse and related self-protection strategies. Second, this study also explored whether it was feasible to extend assessment instruments designed for use in the Western general population to Chinese adolescents with mental retardation. Findings of the study will not only point to the importance of sexual abuse prevention programs for these individuals, but will also reflect on aspects of inadequacy that are of particular relevance to Chinese to facilitate the design of prevention programs.

Results The internal consistency of various scales was first computed and their results were summarized in Table 1. The self-protection skills scale showed satisfactory internal consistency for the total score (α = .79) as well as for its three subscales (α = .82 for REPORT, .82 for TELL, and .70 for DO). However, the SAY subscale of the self-protection skills and the Inappropriate Request Recognition scale demonstrated only marginal internal consistency (α = .58, .54, respectively). It is noted that the three items which comprised the scale on participants’ recognition of inappropriate sexual advances may be too simple or not simple enough to tap their actual knowledge. Supplementary items or alternative scales may be necessary to provide a more informative profile of participants’ knowledge in the area. Furthermore, the Personal Safety Questionnaire also showed low internal consistency (α = .42), suggesting that this scale may contain heterogeneous items that do not belong to the described domain. Thus, results pertaining to this scale should be viewed with caution. Future studies should analyze the item composition of the scale to improve its internal structure as well as to explore whether the items are relevant to the local situations and target sample. Table 1. Means and Standard Deviations of Variables and Mean SD Range Alpha Age 13.44 1.34 11–15 Intellectual Functioning 59.87 5.18 56–69 The “What If” Situation Test Inappropriate Request Recognition (0–3) 2.93 .25 2–3 —a Appropriate Request Recognition (0–3) 1.62 1.04 0–3 .54 SAY (0–6) 3.35 1.88 0–6 .59 DO (0–6) 2.25 1.90 0–6 .70 TELL (0–6) 2.56 2.48 0–6 .82 REPORT (0–6) 1.31 1.74 0–6 .82 Total Skills (0–24) 9.23 5.45 0–21 .79 Personal Safety Questionnaire (0–12) 7.48 1.92 3–11 .42 legend Note. a Internal consistency cannot be computed. legend Numbers in parenthesis represent the possible range of scores. Table options Participants’ responses to questions on sexual abuse knowledge and what they would do in various hypothetical sexually abusive situations were summarized in Table 1 and Table 2. Results showed that about 93.5% of the participants could accurately recognize the three given situations that were related to inappropriate sexual advances. However, participants were less able to discriminate appropriate touches of body parts by adults. About 16.9% of the participants failed to recognize situations involving appropriate touches and sexual requests, and only 24.7% could achieve correct responses for the three given situations. In addition, no participant provided the correct responses to all 12 sexually abusive situations of the Personal Safety Questionnaire (PSQ), and only 26% could identify correctly 9 to 11 out of the 12 depicted situations. On average, the participants knew only 62.1% of the sexual abuse knowledge as measured by the PSQ (Mean = 7.48, SD = 1.92). Table 2. Distribution of Participants Across Various Scores of the Criterion Measureslegend Criterion Measures The “What If” Situation Test (0) (1) (2) — (3) Inappropriate Request Recognition — — 6.5% — 93.5% (0) (1) (2) — (3) Appropriate Request Recognition 16.9% 28.6% 29.8% — 24.7% (0) (1–2) (3–4) (5) (6) SAY 10.4% 23.4% 37.6% 11.7% 16.9% (0) (1–2) (3–4) (5) (6) DO 26.0% 23.8% 24.7% 6.5% 9.1% (0) (1–2) (3–4) (5) (6) TELL 39.0% 18.2% 15.5% 1.3% 26.0% (0) (1–2) (3–4) (5) (6) REPORT 51.9% 23.4% 16.9% 5.2% 2.6% (0) (1–8) (9–16) (17–21) (24) Total Skills 5.2% 42.9% 40.3% 11.6% — Personal Safety Questionnaire — 7.8% 66.2% 26.0% — legend Note. Numbers in parenthesis represent the scores of the measures. Table options Results on the verbal reports of what participants would do in sexually abusive situations also revealed these people’s inadequacies to protect themselves against sexual abuse. No participant could reach the criterion performance of being able to report the use of adequate self-protection skills in all the 12 depicted sexually abusive situations (i.e., a score of 24); and about 5.2% of the participants failed to use any self-protection strategies. On average, the participants possessed about 38.5% of the criterion self-protection skills (Mean = 9.23, SD = 5.45). When the WIST self-protection skills scores were further broken down into specific skills scores, the participants seemed to have the most difficulty in reporting the incident and characteristics of the offender, and about half of them (51.9%) did not demonstrate the ability to do so. In addition, about 39% of the participants did not know how to or would not tell a resource person about the inappropriate situations, 26% failed to report skills that would remove themselves from the abusive situations, and 10.4% would not verbally refuse the inappropriate sexual advances. A majority of the participants showed inadequacies in various specific self-protective skills, and only a small percentage of them could report the correct use of specific self-protection skills in all the given situations, such as 16.9% for SAY, 9.1% for DO, 26% for TELL, and 2.6% for REPORT. Associations between the variables were determined by Pearson correlation analyses and results were summarized in Table 3. Participants’ age and intellectual functioning were not related to the recognition of inappropriate and appropriate touches, verbal reports of the use of specific self-protection skills, and sexual abuse knowledge (p > .05). Participants’ ability to recognize inappropriate touches was generally not linked to the recognition of appropriate ones, but related to their verbal reports on the use of DO and overall self-protection skills (r = .26, .23, respectively; p < .05). Participants’ sexual abuse knowledge, on the other hand, was associated with the recognition of appropriate touches, TELL, REPORT, and WIST total self-protection scores (r = .40, .29, .31, and .34, respectively; p < .01). Table 3. Correlations of Variableslegend 1 2 3 4 5 6 7 8 9 10 1. Age — 2. Intellectual Functioning −.13 — 3. Inappropriate Touch Recognition −.07 −.19 — 4. Appropriate Touch Recognition −.13 .05 .06 — 5. SAY .13 −.05 .13 .17 — 6. DO .11 .03 .26∗ −.09 .12 — 7. TELL .05 −.02 .15 .03 .13 .26∗ — 8. REPORT .19 −.01 .14 .12 .12 .25∗ .79∗∗∗ 9. WIST Total Scores .07 −.01 .23∗ .03 .43∗∗∗ .59∗∗∗ .78∗∗∗ .77∗∗∗ — 10. Sexual Abuse Knowledge −.13 .16 .20 .40∗∗∗ −.19 .17 .29∗∗ .31∗∗ .34∗∗ legend Note. ∗ p < .05; ∗∗ p < .01; ∗∗∗ p < .005. Table options Regarding participants’ verbal description of what they would do in hypothetical abusive situations, their SAY scores were unrelated to DO, TELL, and REPORT scores, but the latter three were generally correlated with each other (r ranged from .25 to .79, p < .05). Participants’ total self-protection skills scores were not related to their age, intellectual functioning, and recognition of appropriate touches (r = .07, −.01, and .03, respectively; p > .05); but were positively associated with the recognition of inappropriate touches and sexual abuse knowledge (r = .23, .34, respectively; p < .04). Stepwise multiple regression analysis was also performed to determine the most robust factor in predicting whether participants would adopt adequate self-protection strategies when encountering sexually abusive situations. Participants’ total self-protection skills scores were used as the dependent variables, with age, intellectual functioning, recognition of inappropriate and appropriate touches, and sexual abuse knowledge as predictors. Results showed that, among all the variables, sexual abuse knowledge was the only significant predictor for self-protection skills (R = .39, p = .006, 15.48% of the variance accounted for).