Victimization among adolescent children of female sex workers: findings from the Children of At-Risk Parents (CARP) study in Uganda

doi:10.21203/rs.3.rs-1881258/v1

Background: Female sex workers (FSWs) live in high-risk environments, experience high levels of adversity and have multigenerational trauma that can negatively affect their children, yet there is only minimal information on victimization among children of FSWs. This study aimed to evaluate the association between maternal sex work and victimization among adolescents in Uganda.

Methods: The sample consisted of 294 respondents to the Children of At-Risk Parents (CARP) study, a comparative cross-sectional quantitative study among adolescents in Northern Uganda. We collected data among 147 adolescent children (10-17 years) of FSWs and 147 adolescent children of non-FSWs. We screened for victimization using the Juvenile Victimization Questionnaire. The data were analyzed using STATA version 14.

Results: The prevalence of lifetime victimization stood at 99.3% but on average, each adolescent experienced 12.4 out of 34 different victimizations. Significantly, the adolescent children of FSWs were exposed to more victimizations than their comparators (13.4 vs 11.5; p<0.01). Specifically, compared with the adolescent children of non-FSWs, more adolescent children of FSWs experienced kidnap (15.8% vs 4.8%; p<0.01), emotional abuse (65.8% vs 50.0%; p<0.05), neglect (37.4% vs 21.1%; p<0.01), physical intimidation (10.2% vs 4.1%; p<0.05), relational aggression (36.4% vs 18.4%; p<0.01), verbal aggression (68.7% vs 46.9%; p<0.001), sexual victimization (31.3% vs 17.7%; p<0.01), verbal sexual harassment (20.4% vs 5.4%: p<0.001), exposure to murder scene (42.9% vs 26.5%; p<0.01), witness to domestic violence (39.5% vs 26.5%; p<0.05), and witness to murder of relatives (31.3% vs 21.1%; p<0.05). Conversely, the adolescent children of non-FSWs reported more caregiver victimization (98.0 vs 92.5; p<0.05) than the adolescent children of FSWs.

Conclusions: Disproportionately, children of FSWs are more likely to experience victimization than children of non-FSWs. Therefore, government and development partners must deliberately develop policies and programs targeting victimizations among children of FSWs.

Adolescents

female sex workers

at-risk parents

victimization

Victimization is a public health crisis that affects people at all levels and can lead to lasting health problems (1,2). Victimization encompasses adverse childhood events like physical and emotional abuse and neglect, sexual abuse, bullying, property violence, community violence, peer/sibling violence, and witnessing violence (3,4). Most victimization occurs during childhood, and 50% of children aged 2-17years experience at least one form of victimization each year (6). Globally, 70% of the population experienced at least one victimization during their lifetime (5). Africa registers only a small number of studies on victimization, yet it is the continent with the highest rate of child maltreatment (7). A national report showed that up to 75.4% of adolescents in Uganda experience victimization (8). Several factors, including poverty, make the situation worse for adolescents in conflict-affected settings like Northern Uganda (9), where people are still undergoing economic recovery from the more than 20 years of armed conflict that devastated their livelihoods and forced more than 80% of households to survive on subsistence farming (10,11). Many FSWs live in high-risk environments, experience high levels of adversity, and have multigenerational trauma that puts adolescent children of FSWs at risk of victimization (12–14).

If left untreated, childhood victimization can lead to lasting health problems like re-victimization, intimate partner violence, sexual assault (15), dating violence (16), depression (17,18), or suicide (19,20). Likewise, victims are at greater risk of acute stress disorders, posttraumatic stress disorders, substance use disorders, mood disorders, anxiety disorders, and personality disorders (21). Exposure to victimization can exacerbate pre-existing mental health disorders or even precipitate the new onset of mental disorders (21). Victimization can negatively impact a child's growth and development, affect memory, distort stress regulation, and impair cognition (22–24). Moreover, adult survivors of victimization are at risk of physical and mental health problems like substance abuse, obesity, and sexually transmitted infections (25).

The high victimization rate, along with the few studies on the phenomenon in Africa (7), is a wake-up call for more research on victimization in the continent. Furthermore, one literature review noted that research on children of FSWs is limited (26). Another study reported a considerable knowledge gap on the health of children of FSWs (27), but the situation could be worse for children of FSWs in conflict-affected settings like Northern Uganda (28). There is a need for research that understands the health needs of children of FSWs to inform public policies and programs (29) to reduce adverse health outcomes among children of at-risk parents (CARP). This study aimed to determine the impact of maternal sex work on adolescent victimization in Uganda. We postulated that children of FSWs were at greater risk of victimization than children of non-FSWs. Findings will help raise public awareness, inform policies and programs, and develop interventions that protect the rights and health of CARP like FSWs and the LGBTQI + community.

The aim, design and setting of the study

We conducted a comparative cross-sectional study in Gulu City in Northern Uganda, where people continue to suffer from more than 20 years of war. Most FSWs in Gulu live and work in Gulu City (30). In Gulu, FSWs live in poverty even though most (89.3%) joined sex work due to poverty (12). Moreover, FSWs in Gulu are highly mobile (12) and thus, could have less time for parenting (31). The study aimed to determine the association between maternal sex work and child victimization. We collected quantitative data between November and December 2021 among 147 adolescent children of FSWs and a comparative 147 adolescent children of non-FSWs living in the same neighbourhood as FSWs.

Sample, sample size estimation and sampling

The sample size was calculated using the formula (32) for comparative proportion (n = 4[Zα_1/2+ Z_β]² P(1-P)] / [{P₁-P₂}²]); where Zα_1/2= 1.96 at type 1 error of 5%, Z_β= 0.842 at 80% power, P₁-P₂ = difference in proportion of events in the two groups, and P = pooled prevalence. Based on the literature showing that 75.4% of Ugandan adolescents experienced at least one victimization (8), assuming a higher proportion (90%) of adolescents of FSWs experiencing victimization, at 95% confidence interval (CI), 80% power, and for equal samples in the two groups, the minimum sample size was 105 adolescents per group. Assuming a design effect of 1.25 and adjusting for non-response by 10%, the minimum sample size was 146 adolescents per group.

We utilized respondent-driven sampling (RDS) to reach eligible FSWs (33,34). RDS is an efficient method to get hidden populations in a short period while minimizing costs and maximizing security for both staff and respondents (35). Initially, we purposively selected three peers and gave each three coupons to recruit nine seeds from nine famous residences of FSWs. Further, we presented two vouchers to the peers to recruit two other seeds from locations where FSWs solicited sex (brothels, lodges, bars, clubs, streets, and homes). After that, each seed received three coupons to recruit three FSWs from their social network, and the cycles continued until the desired number of participants was reached. Each FSW came along with her oldest eligible adolescent in the household. The FSWs who recruited their peers were diligently taken through the eligibility criteria to ensure they brought the correct adolescent-FSW pairs. Before enrolment, each adolescent-mother team was re-screened by the research assistant. Lastly, we monitored the coupons manually through a coupon log notebook.

After completing data collection among the adolescent children of FSWs, we used data on the residents of FSWs to guide a fractional sampling technique to determine the proportions of adolescent children of non-FSWs from each of the parishes where FSWs live. Using systematic sampling, the research assistant selected every fifth household to screen for eligibility and invited each eligible mother to accompany their oldest adolescent. To be considered an FSW, the mother must have received money or goods in exchange for sexual services and consciously defined her activities as income-generating. In addition, she must have been an active FSW during the one year of data collection. Conversely, a non-FSW must have never received money or goods in exchange for sexual services. Lastly, we ensured that the non-sex working mothers lived in the same neighbourhood as the FSWs for at least one year before data collection.

Data collection and management

An experienced and trained psychiatric clinical officer worked with a qualified data clerk to collect de-identified data through clinician-administered face-to-face interviews using digitally created case report forms (CRFs) on electronic tablets. We built digital CRFs using the widely used, secure, and auditable web-based research electronic data capture (REDCap) with automated validation checks (36). There were backup paper-based CRFs in the unlikely event that the REDCap fails on a particular occasion. The study tools were developed in English, translated into the local language (Acholi) by a language expert, and then reviewed for translation accuracy, cultural adaptation, and language appropriateness. The joint reviewers included the language expert, two native psychiatric clinical officers, a native psychiatric nursing officer, and the principal investigator- a physician from Acholi. Before data collection, translated tools were pre-tested among ten adolescent-mother pairs. We interviewed both adolescents and mothers since some maternal and family factors are risk factors for victimization. We obtained sociodemographic and general health characteristics and then screened for lifetime childhood victimization using the Juvenile Victimization Questionnaire (JVQ) (4). The basic JVQ contained questions on 34 forms of victimization with yes/no responses and covered five general areas of concern: conventional crime, child maltreatment, peer and sibling victimization, sexual victimization, and witnessing and indirect victimization (4). Then, we collected data on maternal sex work status, sociodemographic characteristics, alcohol and drug use, maternal childhood victimization and major depression.

Statistical analysis

Participants’ characteristics and univariate results were summarized using proportions for categorical variables and mean with standard deviation (SD) or median with interquartile range (IQR), as appropriate, for continuous variables. Furthermore, we examined the difference in childhood victimization between the adolescent children of FSWs and the comparative group using chi-square tests. We used Fisher's exact test whenever there was any cell with an expected count of less than 5. In addition, we tested for the difference in mean using two-tail t-tests. Associations with p-values less than 0.05 were considered statistically significant. We used STATA version 14 for analysis.

Participant and public involvement

Our previous works informed the current study among the same population of FSWs (12,37,38). While disseminating our last findings, FSWs suggested that future studies investigate children's mental health since many of their children might be living in harsh environments. Thus, the FSWs were involved in identifying the current topic of research. We engaged FSW peers in the planning and conduct of the study, especially during the recruitment of FSWs and their adolescent children. We will involve the FSWs and the public during the dissemination of findings.

Socio-demography of adolescents

This study involved 294 adolescents. All the invited adolescent-mother pairs were eligible and enrolled in the study with a 100% response rate. The median age (IQR) of the adolescents was 12 (10-14) years, but the adolescent children of FSWs were younger than their comparators (12 [10-13] vs 13 [10-15] years; p<0.05). Almost two-thirds (62.9%) of participants were females, but with no sex difference between the two groups of adolescents; half (49.6%) were Catholic, and the majority (92.5%) had primary or no education, and 17.0% dropped out of school. More adolescent children of FSWs were out of school compared to their comparators (23.1% vs 10.9%: p<0.01). Additionally, 5.4% of the adolescents were sexually active, but more adolescent children of non-FSWs were sexually active than the adolescent children of FSWs (7.5% vs 3.4; p=0.123). Lastly, 78.2% of adolescents were unaware of their HIV status [Table 1].

Table 1: Comparative characteristics of adolescent children of FSWs and adolescent children of non-FSWs

Character	FSWs’ children N (%)	Non-FSWs’ children N (%)	P-value	Total (%)
Age in years median (IQR)	12.0 (10-13)	13 (10-15)	0.046*	12 (10-14)
Sex
Male	58 (39.5)	51 (34.7)	0.398	37.1
Female	89 (60.5)	96 (65.3)		62.9
Education level
≤Primary	138 (93.9)	134 (91.2)	0.375	272 (92.5)
Secondary	9 (6.1)	13 (8.8)		22 (7.5)
Currently in school
No	34 (23.1)	16 (10.9)	0.005**	50 (17.0)
Yes	113 (76.9)	131 (89.1)		244 (83.0)
Religion
Catholic	71 (48.3)	75 (51.0)	0.170	146 (49.7)
Protestant	12 (8.2)	22 (15.0)		34 (11.5)
Other Christian	50 (34.0)	41 (27.9)		91 (31.0)
Muslim	14 (9.5)	9 (6.1)		23 (7.8)
HIV status
Negative	24 (16.3)	32 (21.8)	0.204	56 (19.1)
Positive	6 (4.1)	2(1.4)		8 (2.7)
Unknown	117 (79.6)	113 (76.9)		229 (78.2)
Sexually active
No	142 (96.6)	136 (92.5)	0.123	278 (94.6)
Yes	5 (3.4)	11 (7.5)		16 (5.4)

* = p < 0.05, ** = p < 0.01, *** = p < 0.001

Socio-demography of mothers of adolescents in Gulu City

The median maternal age was 30 (27-35) years, though FSWs were significantly younger than non-FSWs (29 vs 32; p<0.01). The majority (89.1%) of mothers were living in rentals, but more FSWs (98.6% vs 81.6%; p<0.001) were living in rentals than non-FSWs. Most mothers (51.0%) were divorced but FSWs were more likely (p<0.001) to either never marry (22.5% vs 2.0%) or be divorced (55.1% vs 46.9%). Significantly more FSWs were the main household income earners than the non-FSWs (92.5% vs 71.4%; p<0.001). The majority of mothers (41.5%) were earning below the lowest-earning quartile (≤Ush100, 000 [US$ 30]) with no significant variation in earnings between FSWs and non-FSWs. Moreover, non-FSWs were more likely to have another adult living in the same household than the FSWs (38.8% vs 25.2%; p<0.05). More FSWs than non-FSWs reported drinking alcohol (76.2% vs 12.2%; p<0.001), getting drunk in the previous 6 months (74.8% vs 4.8%; p<0.001), and using street drugs (33.6% vs 1.4%; p<0.001). FSWs were likelier to leave their children to sleep alone without adults than the non-FSWs (51.7% vs 4.8%; p<0.001). Lastly, one-third (33.3%) of the mothers were living with HIV, but more FSWs than non-FSWs were living with HIV (40.1% vs 26.5%; p<0.05) [Table 2].

Table 2: Maternal characteristics compared between FSWs and non-FSWs

Character	FSWs N (%)	Non-FSWs N (%)	P-value	Total (%)
Median age (IQR) in years	29 (27-32)	32 (28-37)	0.001**	30 (27-35)
Education level
≤Primary	102 (69.4)	107 (72.8)	0.520	209 (71.1)
Secondary	45 (30.6)	40 (27.2)		85 (28.9)
They live in a rental
No	5 (3.4)	27 (18.4)	<0.001***	32 (10.9)
Yes	142 (96.6)	120 (81.6)		262 (89.1)
Marital status
Never married	33 (22.5)	3 (2.0)	<0.001***	36 (12.3)
Married/cohabiting	8 (5.4)	47 (32.0)		55 (18.7)
Divorced	81 (55.1)	69 (46.9)		150 (51.0)
Widowed	25 (17.0)	28 (19.1)		53 (18.0)
Highest income earner
Mother	136 (92.5)	105 (71.4)	<0.001***	241(82.0)
A household member	11 (7.5)	42 (28.6)		53 (18.0)
Maternal income (Shillings)
Q1: ≤100,000	66 (44.9)	56 (38.1)	0.603	122 (41.5)
Q2: >100,000-≤150,000	27 (18.4)	32 (21.8)		59 (20.1)
Q3: >150,000-≤210,000	18 (12.2)	23 (15.7)		41 (14.0)
Q4: >2100,000	36 (24.5)	36 (24.5)		72 (24.5)
Another adult in the household
No	110 (74.8)	90 (61.2)	0.012*	200 (68.0)
Yes	37 (25.2)	57 (38.8)		94 (32.0)
Drink alcohol
No	35 (23.8)	129 (87.8)	<0.001***	164 (55.8)
Yes	112 (76.2)	18 (12.2)		130 (44.2)
She got drunk in the last six months
No	40 (27.2)	140 (95.2)	<0.001***	180 (61.2)
Yes	107 (72.8)	7 (4.8)		114 (38.8)
Use street drug
No	97 (66.4)	145 (98.6)	<0.001***	242 (82.6)
Yes	49 (33.6)	2 (1.4)		51 (17.4)
Left children to sleep alone
No	13 (8.8)	118 (80.3)	<0.001***	131 (44.6)
Sometimes	58 (39.5)	22 (15.0)		80 (27.2)
Always	76 (51.7)	7 (4.8)		83 (28.2)
HIV status
Negative	88 (59.9)	108 (73.5)	0.013*	196 (66.7)
Positive	59 (40.1)	26.5)		98 (33.3)

* = p < 0.05, ** = p < 0.01, *** = p < 0.001

Prevalence of childhood victimization among adolescents in Gulu City

Childhood victimization is highly prevalent (99.3%) among adolescents in Northern Uganda. On average, each adolescent experienced 12.4 out of the 34 types of victimization measured. The most common types of victimization among participants were caregiver victimization (95.2%), conventional crime (94.6%), and witnessed/indirect victimization (92.2%), while the least common type of victimization was sexual victimization (24.5%). Further analysis showed that the adolescent children of FSWs experienced more victimization than the adolescent children of non-FSWs (13.4 [6.4] vs 11.5 [5.1]; p<0.01).

Conventional crime

Conventional crime is the second most reported form of victimization, with up to 94.6%of participants experiencing at least one type of conventional crime. The most typical types of traditional crimes reported were personal theft (84.0%) and vandalism (72.4%). While the least commonly reported conventional crimes were bias attacks (1.7%) and kidnap (10.2%). Generally, there were no significant differences in experiencing conventional crimes between adolescent children of FSWs and those of non-FSWs. However, adolescent children of FSWs were more likely to be kidnapped than those of non-FSWs (15.8% vs 4.8%; p<0.01).

Caregiver victimization

Caregiver victimization is the most reported victimization among adolescents, with up to 95.2% reporting at least one type of caregiver victimization. The commonest caregiver victimization was physical abuse (91.5%), while the least common form of caregiver victimization was custodian interference (21.8%). Generally, adolescents of non-FSWs were more likely to experience caregiver victimization than adolescent children of FSWs (98.0% vs 92.5%; p<0.05). Furthermore, the adolescent children of non-FSWs were more likely to report physical abuse than those of FSWs (96.6% vs 86.4%; p<0.01). Conversely, the adolescent children of FSWs were more likely to report emotional abuse (65.8% vs 50.0%; p<0.05), neglect (37.4% vs 21.1%; p<0.01), and custodian interference (25.8% vs 17.7%; p= 0.09) than their comparators.

Peer/sibling victimization

Slightly more than three-quarters (77.9%) of adolescents reported peer/sibling victimization, with no variation between the two study groups. The most common peer or sibling victimizations were verbal aggression (57.8%) and peer or sibling assault (46.7%). Meanwhile, the least common peer and sibling victimizations were physical intimidation (7.1%) and dating violence (7.1%). Specifically, adolescent children of FSWs where more likely to report physical intimidation (10.2% vs 4.1%; p<0.05), relational aggression (36.4% vs 18.4%; p<0.01), and verbal aggression (68.7% vs 46.9%; p<0.001) than the adolescent children of non-FSWs.

Sexual victimization

Sexual victimization is the least reported childhood victimization, with slightly less than one in four (24.5%) adolescents experiencing at least one type of sexual victimization. Adolescent children of FSWs were more likely to report experiencing sexual victimization than adolescent children of non-FSWs (31.3% vs 17.7%; p<0.01). The most common sexual victimization was verbal sexual harassment (12.9%). Adolescent children of FSWs were more likely to report verbal sexual harassment than the adolescent children of non-FSWs (20.4% vs 5.4%: p<0.001). Besides verbal sexual harassment, there was no other significant difference in sexual victimization between the adolescent children of FSWs and the adolescent children of non-FSWs.

Witnessed and indirect victimization

Up to 92.2% of adolescents experienced witnessed/indirect victimization. The commonest witnessed/indirect victimization was witnessing assault without a weapon (78.9%) and witness to assault with a weapon (68.0%). The least common form of indirect victimization was witness to random shooting (5.4%). Compared to the adolescent children of non-FSWs, the adolescent children of FSWs were more likely to experience exposure to murder scene (42.9% vs 26.5%; p<0.01), witness to domestic violence (39.5% vs 26.5%; p<0.05), and witness to murder of relative (31.3% vs 21.1%; p<0.05) [Table 3].

Table 3: Juvenile victimization among adolescents in post-conflict Gulu City

Characteristic	FSWs N (%)	Non-FSWs N (%)	p-value	Total N (%)
*C. conventional crime*	140 (95.2)	138 (93.9)	0.607	278 (94.6)
C1. Robbery	97 (66.0)	93 (63.3)	0.626	190 (64.6)
C2. Personal theft	127 (86.4)	120 (81.6)	0.265	247 (84.0)
C3. Vandalism	103 (70.6)	109 (74.1)	0.491	212 (72.4)
C4. Assault with weapon	87 (59.2)	79 (53.7)	0.347	166 (56.5)
C5. Assault without weapon	97 (66.0)	95 (64.6)	0.806	192 (65.3)
C6. Attempted assault	91 (61.9)	100(68.0)	0.271	191(65.0)
C7. Kidnap	23 (15.8)	7 (4.8)	0.002**	30 (10.2)
C8. Bias attack	5 (3.4)	0 (0)	0.060	5 (1.7)
*M. Caregiver victimization*	136 (92.5)	144 (98.0)	0.028*	280 (95.2)
M1. Physical abuse	127 (86.4)	142 (96.6)	0.002**	269 (91.5)
M2. Emotional abuse	96 (65.8)	75 (50.0)	0.011*	171 (58.4)
M3. Physical or emotional neglect	55 (37.4)	31 (21.1)	0.002**	86 (29.2)
M4. Custodian interference	38 (25.8)	26 (17.7)	0.090	64 (21.8)
*P. Peer and sibling victimization*	120 (81.6)	109 (74.1)	0.122	229 (77.9)
P1. Gang or group assault	56 (38.1)	52 (35.4)	0.628	108 (36.7)
P2. Peer or sibling assault	78 (53.0)	65 (44.2)	0.129	143 (48.6)
P3. Physical intimidation	15 (10.2)	6 (4.1)	0.042*	21 (7.1)
P4. Relational aggression	53 (36.0)	27 (18.4)	0.001**	80 (27.2)
P5. Verbal aggression	101 (68.7)	69 (46.9)	<0.001***	170 (57.8)
P6. Dating violence	21 (7.1)	21 (7.1)	0.258	21 (7.1)
*S. Sexual victimization*	46 (31.3)	26 (17.7)	0.007**	72 (24.5)
S1. Sexual assault by a known adult	11 (7.5)	5 (3.4)	0.123	16 (5.4)
S2. Sexual assault by an unknown adult	8 (5.4)	2 (1.4)	0.103	10 (3.4)
S3. Sexual assault by peer/sibling	8 (5.4)	8 (5.4)	1.000	16 (5.4)
S4. Forced sex includes an attempt	14 (9.5)	6 (4.1)	0.064	20 (6.8)
S5. Flashing/sexual exposure	16 (10.8)	10 (6.8)	0.218	26 (8.8)
S6. Verbal sexual harassment	30 (20.4)	8 (5.4)	<0.001***	38 (12.9)
S7. Statutory rape	4 (2.7)	8 (5.4)	0.238	12 (4.1)
*W. Witnessed and indirect victimization*	137 (93.2)	134 (91.2)	0.515	271 (92.2)
W1. Witness to domestic violence	58 (39.5)	39 (26.5)	0.018*	97 (33.0)
W2. Witness to parent assaulting	80 (54.4)	73 (49.7)	0.414	153 (52.0)
W3. Witness to assault with a weapon	96 (65.3)	104 (70.8)	0.317	200 (68.0)
W4. Witness to assault without a weapon	115 (78.2)	117 (79.6)	0.775	232 (78.9)
W5. Burglary of family household	97 (66.0)	83 (56.5)	0.094	180 (61.2)
W6. Witness to the murder of a relative	46 (31.3)	31 (21.1)	0.047*	77 (26.2)
W7. Exposure to a murder scene	63 (42.9)	39 (26.5)	0.003**	102 (34.7)
W8. Exposure to war	50 (34.0)	47 (32.0)	0.710	97 (33.0)
W9. Witness to random shooting	10 (6.8)	5 (3.4)	0.185	15 (5.1)
*Types of victimization* (mean [SD])	13.4 (6.4)	11.5 (5.1)	0.005**	12.4 (5.8)

* = p < 0.05, ** = p < 0.01, *** = p < 0.001

Since the very nature of sex work in Uganda can put children of FSWs at risk of victimization, understanding the epidemiology of childhood victimization in this population is of public health importance since untreated victimization can lead to lasting negative impacts on survivors' physical and mental health. To the best of our knowledge, currently, there is no information on victimization among children of FSWs. Thus, this study is the first to comprehensively report victimization among adolescent children of FSWs and CARP as a whole using an approach by Finkelhor, Ormrod et al. (2004) that enables cross-cultural comparisons (4).

Generally, there is a very high prevalence of lifetime childhood victimization (99.3%) among adolescents in Gulu City. The current prevalence of any victimization among the adolescent in Gulu City is much higher than those reported in the low and middle-income countries [76.8%] (39), China [71%] (40), United States [80%] (41), Spain [83%](42), Mexico [85.5%] (43), and Chile [92.6%] (44). This points to a high level of poly-victimization in this disadvantaged population which can lead to various psychopathology and psychological distress during childhood and adult life(45). Thus, there is a need for urgent multi-level family-focused interventions to prevent re-victimizations and treat victims using trauma counselling and other appropriate psychotherapies to avoid a vicious cycle of victimization, psychological distress and re-victimization (46).

On average, each adolescent experienced 12.4 out of the 34 possible types of victimization as measured by the JVQ. This is much higher than the average number of lifetime victimizations of 3.7 reported in the United state (47). The high level of victimization points toward more severe victimization among adolescents in Northern Uganda, perhaps due to the rampant use of corporal punishment by parents, teachers and other members of society despite the government ban (48) on corporal punishment. A previous report indicated that nine in every ten parents or guardians in Northern Uganda used nonviolent discipline methods, psychological aggression, or corporal punishment to discipline their children (49). Likewise, a previous report indicated that physical abuse, emotional abuse, and poly-victimization were strongly associated with beliefs supporting aggression among adolescents in Northern Uganda (50); thus, community beliefs that perpetuate corporal punishment against children need to be discouraged through education, dialogue and strict implementation of the national law against corporal punishment.

This is the first study that examines victimization among adolescent children of FSWs. Findings showed that adolescent children of FSWs had higher rates and severity of victimization than the adolescent children of non-FSWs within all the five domains of JVQ. We postulate that the disproportionate rates and severity of victimization among adolescent children of FSWs were due to the pervasive nature of sex work stigma, the toxic legal environment in which FSWs operate, and the poor mental health of FSWs (51). The disproportionate rate and severity of victimization among adolescent children of FSWs are concerning since victims may become adults who commit crimes and sex offences (52,53) and may develop depression during their lifetime (54). Thus, we call for robust family-centred public health interventions to prevent and manage child and adolescent victimization among children of FSWs and other CARP like the LGBTQI+ in Uganda, the United States, and elsewhere.

Strengths and limitations of the study

To the best of our knowledge, this is the first attempt to study victimization among children of FSWs systematically. Nevertheless, this study had some limitations. First, the cross-sectional nature of the study design precludes inferring causality. Therefore, future studies should use longitudinal methods like cohort studies to explore the causal pathways of victimization among children of FSWs or other CRAP. Secondly, study data may have been negatively influenced by recall bias since we asked participants about personal experiences of traumatizing events. Thirdly, this study implored some sensitive information relating to childhood victimization that might have been difficult to answer and thus might be under-reported. However, we took time to develop good rapport and trust with the participants to reduce the chance of information bias. Lastly, the study may have been affected by hidden confounding not adjusted for in this study, but we tried as much as possible to include the most known confounders.

Victimization is highly prevalent among adolescents in Uganda and disproportionately affects the children of FSWs. Thus, the government and development partners need to develop policies and interventions targeting the prevention and management of victimizations, especially among the children of FSWs.

CRAP: Children of At-Risk Parents, CRF: Case Report Forms, HIV: Human Immunodeficiency Virus, IQR: Interquartile Range, JVQ: Juvenile Victimization Questionnaire, RDS: Respondent Driven Sampling, SD: Standard Deviation, FSWs: Female Sex Workers, and TASO: The AIDS Support Organization.

All methods were carried out in accordance with relevant guidelines and regulations or the Declaration of Helsinki.

Ethics approval and consent to participate

One research assistant, the psychiatric clinical officer and a trauma counsellor provided immediate trauma counselling for all re-traumatized participants and linked all adolescents and mothers with mental disorders to Gulu Regional Referral Hospital. We obtained ethical clearances from TASO (TASOREC/051/2021-UG-REC-009) and University of Minnesota institutional review boards (STUDY00013794), and the Uganda National Councils of Science and Technology (HS1769ES). Since we collected data from the adolescents and their mothers, each mother provided written informed consent for her participation and that of the adolescent. Then, each adolescent provided an assent to participate. We maintained participants’ privacy and confidentiality throughout the conduct of the study, data analysis and presentation of results. The adolescent-mother pairs were reimbursed $4 for their time and transport.

Availability of data and materials

All data generated or analysed during this study are included in this published article [and its supplementary information file].

Competing interests

The authors declare that they have no competing interests.

Funding

The author(s) disclosed receipt of the following financial support for the research of this article: As part of his post-doctoral fellowship, SO received a $10,000 grant from the National Institutes of Health (NIH) Fogarty International Center (FIC). Grant Number: D43TW009345-10 through the Northern Pacific Global Health (NPGH) Fellowship. However, the funder had no role in the design of the study and collection, analysis, and interpretation of data and in writing the manuscript.

Author contributions

SO conceived and designed the study, collected and entered data, conducted data analysis, interpreted the findings, and wrote the first draft of the manuscript. AC, NN, MM and MK conceived and designed the study, supported data analysis, and critically reviewed the draft manuscript. All authors read and approved the final manuscript for publication.

Acknowledgements

We acknowledge Prof. Noah Kiwanuka and Dr Levicatus Mugenyi (PhD) for their insightful contributions to the study designs, TASO for permitting the use of TASO Gulu as a site for data collection, Mr Odur Williams and Mr Wokober Norbert Brian for their role as research assistants, Ms Akello Martha, the executive director of Voice of Community Empowerment (VoiCE)-a community-based organization for mobilizing FSWs, and the FSWs for supporting smooth conduct of this study.

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No competing interests reported.

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Victimization among adolescent children of female sex workers: findings from the Children of At-Risk Parents (CARP) study in Uganda

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