INTRODUCTION

Children represent the most susceptible group to socio-behavioral threats. Research indicates that children face a high risk of mistreatment in various settings, including society at large, educational environments, at home, in the workplace, and even within legal and care institutions [1]. Two serious risks to children’s well-being are bullying victimization (BV) and childhood sexual abuse (CSA) [2]. Worldwide, CSA affects approximately 15% to 20% of girls and 8% of boys [3]. The socioeconomic impact of CSA is also substantial. According to a United Nations Children’s Fund report, the economic costs of physical, psychological, and sexual abuse against children may amount to as much as US$7 trillion globally [4]. A meta-analysis of 65 studies from 22 countries, which provided an overall international figure on CSA, revealed that 7.9% of boys and 19.7% of girls had experienced sexual assault before reaching the age of majority [5].

Bullying can manifest in various forms and degrees of severity, including verbal, physical, and relational bullying as well as cyberbullying [6]. Such experiences in youth can have long-term social and psychological health consequences. Consequently, childhood bullying is recognized as a major public health concern by the World Health Organization [7]. Victims of bullying are comparatively likely to engage in criminal activity and to experience addiction, suicide, and various disorders [8]. A report by the United Nations Educational, Scientific and Cultural Organization indicates that approximately one-third of children worldwide have experienced bullying at least once in the preceding month, with 7.3% reporting being bullied on 6 or more days during that time [8]. A global report from 2006 revealed that the percentage of children who had been bullied in the previous 2 months ranged from 15% to 64% across countries [1].

Gender differences in BV are influenced by factors such as type, age, and time. Research indicates that boys are more vulnerable to physical and verbal bullying, whereas girls are at a greater risk for relational and cyber BV. The prevalence and trends of BV vary across the globe, with some regions reporting a decline in BV rates among students. Longitudinal studies provide valuable insights into changes in BV over time; however, further research is necessary to gain a comprehensive global perspective [9-12]. Cross-national data on BV rates are derived from a variety of sources, including the Health Behavior in School-aged Children study, the Global School-based Student Health Survey, and the Program for International Student Assessment. These studies examine health, well-being, and behaviors among adolescents in numerous countries [9,13,14].

Among cross-national studies, the Global Burden of Disease (GBD) study represents the most extensive worldwide observational epidemiological study to date. This research provides thorough assessments of risk factor burdens by age, gender, and location [2]. To our knowledge, no comprehensive analysis has yet examined the longitudinal trends of CSA and BV across all countries. The present study offers a global overview of the prevalence of these forms of violence against children over time. Additionally, it investigates potential factors that may account for variations in CSA and BV rates among countries, including human development index (HDI), gender, and continent [15].

METHODS

In this longitudinal study, we analyzed the age-standardized summary exposure values (as risk-weighted prevalence rates, typically reported on a scale from 0 to 100%) of CSA and BV, extracted from the GBD Results Tool. This resource is available at https://ghdx.healthdata.org/gbd-results-tool and is associated with the Institute for Health Metrics and Evaluation (IHME). On the left panel of the website, users can select and apply appropriate parameters and filters to the query, such as gender, location, and year. The GBD represents the most extensive worldwide observational epidemiological study to date, detailing mortality and morbidity from major diseases as well as health risk factors. This research assessed the risk factor burden by age, gender, and cause at global, regional, and national levels. The GBD team extracted exposure rate estimates from various sources, including publications such as randomized controlled trials, cohort studies, household surveys, census data, satellite data, population registries, and vital registration [16]. The CSA exposure rate indicates the proportion of the population that has experienced intercourse or other contact abuse before the age of 16 years, with the perpetrator or partner being more than 5 years older than the victim. The BV exposure rate represents the proportion of the school-attending population that has been exposed to BV within the past year. Further details on how CSA and BV were measured in the GBD study have been previously described [2]. For this research, the CSA and BV rates per 1 000 000 people were compiled for 204 countries and territories from 1990 to 2019. The rates used in the GBD study indicate lifetime prevalence; that is, they account for instances of abuse or victimization experienced by individuals at any point in their lives before data collection. The rates were extracted for both girls and boys across all countries. Countries with an HDI below 0.7 were categorized as low or medium in terms of human development, while those with an HDI of 0.7 or higher were classified as high or very high [17]. The HDI is a composite measure reflecting several key dimensions of human development, including a long and healthy life, access to knowledge, and a decent standard of living. This study compared the trends in CSA and BV rates in countries with low versus high HDI. Additionally, trends in CSA and BV were explored separately for countries within Asia, Australia and Oceania, Africa, Europe, South America, and North America. While GBD maintains the anonymity of microdata, the data sources used for GBD estimates are publicly available and accessible.

Statistical Analysis

The CSA and BV rates were depicted using bar charts. These charts present the mean proportion of the population that had ever experienced CSA or BV, respectively. The means were calculated across all participating countries, considering the reported prevalence rates of CSA and BV from each nation. A latent growth model (LGM) was applied to evaluate the trend of CSA and BV rates over time. LGMs are valuable for analyzing longitudinal data, as they can accommodate heterogeneity in growth patterns and track changes in the trajectories of phenomena over time. In this study, a linear LGM was employed to investigate the developmental trajectories of CSA and BV prevalence across multiple time points. We explored various LGM specifications, including both linear and non-linear models with free scores. While non-linear models offered flexibility in depicting the observed trends, they did not consistently improve the model fit. Instead, a linear model with linear scores demonstrated superior fit indices across various goodness-offit measures. An unconditional model was applied to capture the fundamental growth pattern. In this model, the coefficients (intercept and slope) are derived from the observed data without the inclusion of additional explanatory variables. In other words, the unconditional model does not integrate predictors or covariates to account for differences in growth trajectories.

We stratified the data by gender and analyzed the trends across geographical regions and HDI levels. The continuous response variables in the LGM analysis were the summary exposure rates of CSA and BV, measured longitudinally from 1990 to 2019 at 5-year intervals. The LGM enabled the estimation of the initial level (or intercept) and the rate of change over time (or slope). In this model, the intercept coefficient represents the estimated overall mean value of the outcome initially, in 1990. The slope coefficient indicates the rate at which the outcome (CSA or BV rate) has changed over time. Essentially, the slope coefficient estimates the overall trend in the response rate over the study period. The direction of the slope sign indicates whether the trend was increasing (positive) or decreasing (negative) over the relevant interval. To evaluate the statistical significance of differences between genders, we applied repeated measures analysis of variance. Statistical analyses were performed using Mplus version 6.12 (Muthén & Muthén, Los Angeles, CA, USA) and SPSS version 23 (IBM Corp., Armonk, NY, USA).

Ethics Statement

Due to the reliance on the IHME database, informed consent was not necessary for this study, as it involved only the extraction and analysis of aggregated, non-identifiable, and non-individual data. The study received approval from the Ethics Committee of Shahid Beheshti University of Medical Sciences (Ethic No. IR.SBMU.RETECH.REC.1401.301). All methods were conducted in accordance with relevant guidelines and regulations.

RESULTS

The mean CSA and BV rates—averages based on available data from 204 countries—are reported in Figure 1 for both genders over the study period. The charts depict the mean proportion of the population that had ever experienced CSA or BV. As shown, the mean BV rate was higher in boys than in girls for all time points (p<0.001). Additionally, the mean CSA rate appeared higher in girls than in boys; however, this difference was not statistically significant (p=0.352).

The mean rates of CSA and BV across countries with low versus high levels of human development are presented in Figure 2. As indicated, the CSA rate was consistently higher in countries with low HDI compared to those with a high value of the index.

The trends in CSA and BV, as assessed by LGM, are presented in Table 1. Among girls in countries with an HDI of less than 0.7 (intercept=112.2; slope=-0.1), the estimated initial rate of CSA was 112.2 per 1 million population in 1990. This rate exhibited a non-significant decreasing trend, indicated by a slope of -0.1, from 1990 to 2019.

Based on the calculated intercept coefficients, in 1990, the overall mean rate of CSA was higher in countries with an HDI below 0.7 (117.7 for boys and 112.2 for girls) compared to nations with an index of 0.7 or higher (71.9 for boys and 80.5 for girls). The slope coefficients for CSA presented in Table 1 reveal no significant temporal trend for boys or girls in countries with an HDI ≥0.7 or those with an HDI <0.7 (p>0.05). Regarding BV, the 1990 rate in countries with an HDI ≥0.7 exceeded that in countries with an HDI <0.7 (60.8 vs. 52.1 per 1 000 000 boys and 44.3 vs. 35.9 per 1 000 000 girls), with higher rates evident in boys. Additionally, a significant increasing trend in BV was observed for both boys and girls in countries with HDI ≥0.7 as well as those with HDI <0.7 (p<0.001).

Table 2 presents a trend analysis of CSA rates, delineated by gender and region. The LGM model could not be fitted for certain regions due to non-convergence, resulting in the absence of valid estimates for these areas (denoted by “N/A” in the table). The model was fitted separately for each region, and the findings are applicable only to regions for which the model converged. As indicated by the intercept coefficients in Table 2, at the beginning of the study period, the highest CSA rates for boys and girls were observed in Africa (131.2 and 119.2 per 1 000 000 persons, respectively). In contrast, the lowest rates were found among Asian girls and European boys (61.5 and 70.7 per 1 000 000 individuals, respectively). The slope coefficients indicate no significant changes in the CSA rate within the various regions, apart from a significant decrease among Asian girls (slope=-0.1, p=0.015). Globally, at the beginning of the study period, girls experienced higher CSA rates than boys (as indicated by intercept coefficients of 90.7 vs. 87.1). Notably, the global CSA rates for girls showed a declining trend from 1990 to 2000, followed by a rising trend after 2000, yielding in an overall increase over time (slope=0.2; p=0.029).

Table 3 displays the results of the BV trend analysis in various regions, with data separated for boys and girls. The analysis indicated an upward trend for all regions and both genders (p<0.05). While the initial intercept coefficients indicate that European countries had the highest starting rates of BV (63.1 and 50.3 per 1 000 000 persons for boys and girls, respectively), the slope coefficients suggest that the increase in rates was less pronounced in Europe compared to other regions. The steepest increases in BV were observed in African populations for both boys and girls, with slope values of 3.7 and 4.0 per 1 000 000 persons, respectively (p<0.001). Globally, boys exhibited a higher rate of BV than girls. An increasing trend over time was evident for both genders, with slopes of 2.3 in boys and 2.4 in girls (p<0.001).

DISCUSSION

CSA and BV are serious issues that societies currently face. These experiences are known to influence a broad spectrum of long-term psychiatric, psychosocial, and physical health outcomes [4]. According to our review of the literature, research on the rates of CSA and BV is predominantly descriptive or cross-sectional within subpopulations, with longitudinal trends remaining poorly documented. Consequently, this study evaluated the trends in CSA and BV rates across 204 countries and territories over three decades, from 1990 to 2019.

Overall, our results indicate a significant increasing trend in the BV rate over recent decades in countries with an HDI of 0.7 or higher, as well as in nations with an HDI below 0.7. This increase may seem counterintuitive given the extensive efforts to educate individuals, families, and children during this period. Indeed, for countries with a higher HDI, a decline was anticipated, yet the opposite was observed [4]. This could be attributed to an increased rate of disclosure caused by these educational efforts. Moreover, as Russell et al. [18] have suggested, while these prevention strategies are valuable, their effectiveness is potentially compromised because they are largely school-based. The authors contend that current prevention programs, which are centered on schools and youth, overlook broader social and environmental factors that contribute to CSA and BV. Accordingly, the limited impact of school-based prevention strategies may stem from an insufficient understanding of these issues among the general population [18].

In our study, the prevalence of CSA did not demonstrate a significant temporal trend in countries with an HDI of 0.7 or higher, nor in those with an HDI below 0.7. However, CSA was generally more frequent in countries with an HDI below 0.7 for both genders. This finding aligns with prior research indicating a higher prevalence of CSA in countries with lower HDI [19]. Several factors contribute to this phenomenon, including the socioeconomic status of the population, instabilities due to armed conflicts, the impact of uncontrolled natural disasters, and widespread political violence [20].

In the present study, the highest rates of CSA were observed among African boys and girls. This finding aligns with prior research reporting that Africa displayed the highest prevalence of CSA [21]. Contributing factors may include unrest, unstable living conditions, and increasing poverty in these regions [20]. Conversely, the lowest rate of CSA was found among Asian girls, with a significant downward trend. Our research suggests that preventive programs for CSA have not been implemented in Asia. The relatively low rates in Asia could instead stem from a combination of regional factors, such as cultural practices, healthcare infrastructure, and public health initiatives. Furthermore, cultural or ethnic backgrounds shape the experiences of children in these populations, and cultural taboos may prevent open discussions about sexual abuse [22]. In general, data are typically obtained from reported cases, yet most incidents remain unreported. The Rape, Abuse, and Incest National Network has compiled statistics indicating that approximately two-thirds of sexual assaults are not reported [23].

In our dataset, the global rates of CSA were similar between genders. This finding is potentially unexpected, as it is commonly assumed that girls experience higher rates [20]. This observation could be attributed to several factors. First, fewer protections may be in place against CSA for boys due to the lower expectation of its occurrence. Second, events involving boys could be more likely to be disclosed, while families may underreport CSA incidents involving girls due to societal stigma. Additionally, boys are relatively vulnerable to sexual violence in different contexts, such as sports and exercise [24]. Regarding BV, rates were higher among boys than girls, with significant upward trends noted across all regions and in both genders; this pattern corroborates findings from another study [25]. However, these results are not consistent across the literature, as some research has suggested a decreasing trend [26]. While prevention programs have been introduced in certain societies, such as the United States, their effectiveness appears to be more pronounced in combating specific types of BV, such as relational and physical bullying [27]. Notably, many societies have not implemented such programs. The rising use of social media among children is recognized as a risk factor that has heightened the likelihood of bullying or violence [28]. Additionally, digital self-harm may represent a key factor, displaying a strong and positive association with BV [29].

This study was designed to examine trends in behavioral risks among children, illuminating their patterns and predisposing factors. The aim is to develop improved strategies that support the achievement of target 16.2 of Goal 16—one of the United Nations Sustainable Development Goals—which seeks to end abuse, trafficking, exploitation, and all forms of violence and torture against children. Goal 16 is dedicated to promoting peace, justice, and strong institutions. It includes specific targets for reducing violence, combating the illicit arms trade, and reinforcing the rule of law. This goal is particularly relevant to our study, as it underscores the need to address issues such as sexual and gender-based violence, which are intertwined with the outcomes of CSA and BV [30].

This study has several limitations. The GBD relies on data from various countries, which may lead to inconsistencies due to differences in data collection methods and quality. Nevertheless, the GBD’s comprehensive systematic review of both published and unpublished sources is designed to present a complete overview of global health. However, the Bayesian meta-regression model used to integrate data could introduce bias and uncertainty. Moreover, standardized definitions and measurements of BV and CSA may not fully reflect the diversity and complexity of these issues across cultures and contexts. Despite these imperfections, these indicators remain the best tools available for cross-country comparisons. Crucially, the comparability of CSA and BV data across countries may be constrained by variations in cultural factors, reporting practices, and the nature of the surveys utilized. Nonetheless, the GBD study has implemented rigorous methodologies to maximize the comparability of these indicators. These include the use of standardized measurement tools and harmonization processes.

The GBD study also employs correction factors to compensate for the underreporting of BV and CSA. However, these factors may not completely capture the complexities of reporting practices. The observed increase in global BV rates may stem from a genuine rise in incidents; alternatively, it may reflect heightened awareness and reporting, rather than representing a definitive trend in occurrence. Further research is required to discern the factors contributing to this pattern. Additionally, the absence of data on CSA and BV rates in certain countries at specific times necessitates that the GBD study provide estimated rates. Notably, the diversity of its sources is not only central to the GBD’s existence but also underpins its status as the most comprehensive worldwide epidemiological study.

Finally, while the LGM model generally yielded reliable estimates for most regions, it failed to converge in certain instances due to a limited number of cases, a variance of zero, or missing data. Consequently, we could not provide estimates for these regions. Importantly, these areas may exhibit different underlying patterns of CSA, and the absence of estimates could obscure insights regarding actual prevalence. Future research should be focused on gathering more data and improving the model’s fit in these areas to gain a fuller picture of the issues.

In this study, no significant trends were observed in CSA rates for boys or girls across countries with high or low human development. Globally, however, CSA rates for girls increased significantly over time. Regarding BV rates, an upward trend was observed in both high-HDI and low-HDI countries, with populations in Africa exhibiting the most pronounced increases. Globally, boys exhibited higher BV rates than girls, with both genders experiencing increases over time.

In conclusion, our study offers valuable insights into the global and regional trends of CSA and BV. These findings can be instrumental in guiding policymakers, researchers, and healthcare practitioners. With an understanding of these trends, policymakers can strategically focus on areas with rising rates to improve the safety and well-being of children. We also acknowledge the need for further research to explore this topic in greater depth.

Notes

Data Availability

The datasets analyzed during this study are available in the Global Health Data Exchange at https://ghdx.healthdata.org/gbd-results-tool.

Conflict of Interest

The authors have no conflicts of interest associated with the material presented in this paper.

Funding

None.

Author Contributions

Conceptualization: Alavimajd H, Borumandnia N. Data curation: Alavimajd H, Borumandnia N. Formal analysis: Borumandnia N, Alavimajd H. Funding acquisition: None. Methodology: Alavimajd H, Gohari MR, Borumandnia N. Project administration: Alvani MS, Fattahi P, Kheirolahkhani Y. Visualization: Borumandnia N, Alavimajd H. Writing – original draft: Borumandnia N, Alvani MS, Fattahi P, Kheirolahkhani Y. Writing – review & editing: Alavimajd H, Gohari MR, Borumandnia N.

Acknowledgements

Figure. 1.

Mean proportion of the population that had ever experienced childhood sexual abuse (A) and bullying victimization (B) by gender.

Figure. 2.

Mean proportion of the population that had ever experienced childhood sexual abuse (A: girls, B: boys) and bullying victimization (C: girls, D: boys) by human development index (HDI). An HDI <0.7 indicates low or medium human development, while a value ≥0.7 denotes high or very high development.

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Figure & Data

References

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