**4. Discussion**

Health care, child protection and legal systems continue to be challenged by the recognition of the societal scourge of child sexual abuse and strive to understand its complexities and how best to meet the myriad of interdisciplinary challenges. For more than 30 years, in many countries, medical doctors have been charged with the diagnosis, treatment and managemen<sup>t</sup> of victims of sexual abuse. Their effort has been generally independent of the larger systems needed to provide protection, prevention and prosecution.

Hungary has just begun to deal with this societal issue. To the best of our knowledge, this is the first Hungarian population-based study to have researched characteristics of CSA for both girls and boys. We have been working to address the common myths regarding CSA and raise public awareness that CSA in Hungary can no longer to be 'another hidden pediatric problem', as stated by Kempe in 1977 [28].

In Hungary, during recent decades, child sexual abuse has become a priority for medical and criminal law professionals due to its frequent prevalence, serious adverse health effects and potential for lifetime consequence for the victim. In Hungary, when a disclosure occurs, the emergency, gynecology and pediatric departments are commonly the portal for entry, and gynecologists (for female victims), and pediatricians and traumatologists (for male victims), are generally the 'first reporters' when sexual abuse is suspected. Reporting and engagemen<sup>t</sup> of social services and law enforcement brings resources and critically important collaboration. Despite the robust association between gynecological symptoms and a history of CSA, no population-based central/eastern European data are available. Knowledge of the exact number of sexually abused children and the establishment of a systematic approach to address the medical and legal needs of alleged child victims are ye<sup>t</sup> to be developed.

We were able to identify differences between CSA and rape. In the majority of cases (96.5%), force had not been used: children were mostly abused by perpetrators (65.3%) they knew and trusted. In one-third (boys) and one-fifth (girls) of the victims, the accused perpetrator of CSA was a family member and it was a domestic sexual attack (31%). In these cases, because of the long time interval

between the sexual contact and the revelation (40.1%), the chance of identifying forensic evidence was lost. The time that passes between the abusive event and the physical examination is of grea<sup>t</sup> importance. Most sexually abused children will not have signs of genital or anal injury, especially when examined non-acutely.

Children who may have been abused should be examined by a physician to diagnose and treat any effect of the alleged sexual contact, which includes the identification of injuries, treatment for sexually transmitted infection (STI) and the collection of forensic evidence if present. The reality is that less than 5% of children will have diagnostic findings of sexual contact, and 3–5% will have an STI. Biological evidence (sperm) of recent abuse can be successfully secured (abuse within the past 24 h if before puberty, within the past 72 h in pubertal girls), and for medical reasons if there is any bleeding [29]. The most available evidence is what the child victim provides in their account of the inappropriate sexual contact.

As many as 30.8% of boys and 20% of girls reported histories of multiple occurrence of sexual contact. A delayed disclosure is typical for abuse, and since most injuries that children incur as a result of sexual contact will be superficial and heal without any lasting residual, most medical examinations show neither acute nor healed findings [30]. It has been proved that a single incomplete hymenal rupture can heal in 9 days, and a complete rupture in 24–30 days, after the trauma [31]. The most important reason for the paucity of abnormal findings is the nature of the abuse itself, as most perpetrators have little intent of actually harming the child, and if they do, the injuries are generally superficial. Although many nonmedical professionals may believe that it should be possible for a doctor to determine if a child has been 'penetrated', this is not always the case once children enter puberty and the hymenal membrane increases its elasticity and distensability. Determining 'penetration' in the prepubertal child is less of a challenge because of the lack of elasticity of the hymen, and when true vaginal penetration occurs, there is an accompanying history of pain, bleeding and diagnostic residual. That said, most prepubertal children experience penetration into the vaginal vestibule and not the vagina. Illustrative of the challenge of determining whether a pubertal child is a virgin is confirmed by a study in which only 2 (6%) of 36 pregnan<sup>t</sup> teenagers manifested clear evidence of a prior penetration injury, and only 4 (11%) had suspicious, though not definitive, findings: "'Normal' does not mean 'nothing happened'" [32]. Normal findings are the rule, not the exception, in victims of child sexual abuse, with or without penetration, whether chronic or acute [33–35].

Special attention is required in cases in which a member of the child's family carried out sexual abuse. During the study-period, we saw only 8 male (30.7%) and 71 female (17.7%) cases in which the first instances of abuse were reported. The highest frequency was observed under the age of 10 years for boys and between the ages of 11 and 14 years for girls. The actual number was probably much higher than 79, because of underreporting. In almost every case, the child reported threats to maintain secrecy including threats of physical abuse if they disclosed. The mothers feared losing their homes, and possibly their children. This is the foundation on which multiple and chronic sexual abuse can continue. Most of the CSA cases occurred during the summer months when children were on holiday from school. Conversely, those children who were the victims of rape perpetrated by strangers (30.8% by boys and 35% by girls) presented immediately, and with more obvious findings (sperm found in 118 cases), as they had family support and immediate examination could be performed (in 100 cases, 23.5%). Unfortunately, few children reveal sexual contact immediately following CSA, which limits the opportunity to recognize injuries and collect forensic evidence. Sexual abuse is usually a chronic, complex, and often particularly traumatizing incident for the victim, frequently committed by family members or other trusted persons in the setting of relationship dependence and strong authority relationships [36].

In Hungary, since the decision made by the constitutional court on 4 September 2002, the perpetrator and the victim in CSA cases can be of the same sex. With that decision, the Law took account of the results of reported studies in male victims. In the case of a victim under 18 years of age, legal proceedings can be initiated by the victim's parent, carer or guardian. The new act (from 1 July 2003) was intended to ensure considerate behavior towards the victim. The evidence given by the victim can be recorded on videotape and this tape can be used later during legal proceedings. In 2012 a new Penal Code was introduced dealing with sexual crimes. The essence of the legal change was that where the previous Penal Code had focused on the defense of gender morality and public interest, the new Penal Code focused on the individual, gender integrity and gender self-determination. None of the laws prescribe obligation of charges, but the ordinances of the private proposal and the desuetude of criminality have been changed. In 2012 our governmen<sup>t</sup> announced the Year of Child-friendly Justice; within the framework of the National Court of Justice, a work-team was established in order to evolve the concept of child-friendly justice. The elements of child-friendly justice have been continuously becoming the part of legal practice. In Hungary, the greatest challenge is not only to create the Penal Code, but also to assure its enforcement. The experience of child sexual abuse has the potential to result in long-term emotional and behavioral consequences for the victim. When children are suspected of experiencing sexual victimization, they deserve professionals who are knowledgeable, skilled, sensitive professionals capable of formulating objective opinions that do not further betray their trust, allowing justice to be served.

In our study, only 205 (48%) of 426 cases had legal proceedings initiated. Delivery of the judgements against the 41 (9.6%) perpetrators who were ultimately sentenced took several years in each of the cases. The low proportion of charges and the long time interval needed for a judgement in the Hungarian legal system demonstrate the challenges associated with successful prosecution. It is of grea<sup>t</sup> importance to organize more family planning centers for young families, children and teenagers to have access to appropriate health care services and suitable education to protect them from sexual abuse.
