Authors: Rohini Harracksingh (Children’s Assessment and Safeguarding Team) , Emmanuel Janagan Johnson (Louisana College)
This study explores the effects of child sexual abuse and exploitation of children. It also aims to assist in identifying the signs of child sexual abuse by examining the various possible effects on the victims. The authors continue the dialogue started by previous studies, thereby generating greater public awareness specifically targeted at expanding the information available to the population. Snowball sampling was adopted to select the respondents. The results show that how children develop social and emotional skills across the lifespan, with particular attention to childhood to overcome the trauma and it is better to equip citizens to recognize the signs of child sexual abuse so that they can report this crime and afford the victims the benefit of early and proper intervention, since victims themselves often do not engage in early reporting of such crimes. The findings of the research and the implications for the future research are also discussed.
Keywords: child sexual abuse, exploitation, social development, post-traumatic stressdisorder
How to Cite: Harracksingh, R. & Janagan Johnson, E. (2022) “An Exploratory Study on Child Sexual Abuse and Exploitation”, Social Development Issues. 43(2). doi: https://doi.org/10.3998/sdi.1823
In 2016, research was conducted to explore the effects of child sexual abuse (CSA) in Eastern Trinidad, as it was suggested that children may be at risk of experiencing sexual abuse. Reid, Reddock, and Nickering (2014) stated that there are many unreliable reports regarding the prevalence of child sexual abuse in Trinidad and Tobago. Under-reporting of this crime appears to be a trend in the Caribbean as another study conducted by THE United Nations International Children’s Emergency Fund (UNICEF) in Barbados made similar findings (Jones et al., 2009). It has been hypothesized that there are several reasons for such under-reporting in these societies. These include feelings of shame and embarrassment, fear of the abuser and of possible reprisal, reluctance on part of the family to admit what has happened, and the belief on part of many victims that the veracity of their story would be questioned (Jones et al., 2010). These deep-seated sociocultural issues are unlikely to change in the short term. Greater awareness toward the effects of child sexual abuse and its signs and symptoms is needed to improve the safety of children. This will have an effect in protecting the country’s human potential by allowing timely and appropriate intervention. Children display signs and symptoms and are themselves restricted for one reason or another for asking for the help which they urgently need. Snowball sampling was utilized to conduct interviews with respondents.
According to Hahn (2012), in the Caribbean region, child sexual abuse is underreported and as a custom sanctioned culturally. Hahn (2012) further cited Jamaica, where men often view themselves as having a right to perform sexual activities with girls who they are responsible for, while in Guyana children reported that sexual violence against them is frequently blamed on their clothing.
According to the UNICEF (2017), sexual violence against children is a gross violation of children’s rights, but it is an undeniable global reality across all countries and social groups. This social ill occurs in various forms and is deeply entrenched in cultural, economic, and social practices. The Rape Crisis Society of Trinidad and Tobago (2000), in its annual report, has defined child sexual abuse as follows: “Child sexual abuse is the sexual exploitation of a child by an adult, adolescent, or older child.” A report from the Children’s Authority of Trinidad and Tobago has indicated that there were nine hundred fifteen reported cases of child sexual abuse from May 18, 2015 to February 17, 2016. It is appalling to consider that this translates to approximately one in five children enduring sexual abuse in Trinidad and Tobago. Sexual penetration and sexual touching were among the highest reported types of child sexual abuse. Of these reported cases, 13.2% represented boys, while 86.8% involved girls (Kowlessar, 2016). From the available studies conducted in Trinidad and Tobago (and indeed other parts of the Caribbean such as the Eastern Caribbean and Barbados), the rate of child sexual abuse is distressing. These studies reveal that 70–80% of child sexual abuse victims are girls, and in 50% of these cases the perpetrators live with the victims. The available literature further highlighted that in the Caribbean, sexual abuse is accompanied by denial, silence, and adults failing to respond appropriately with many instances of children being sexually abused within the family (Perrault, 2011).
This study aims to assist in identifying the signs and symptoms of child sexual abuse by examining various possible effects on victims. It is further hoped that this study would continue the dialogue started by previous studies, thereby generating greater public awareness specifically targeted at expanding the information available to the population.
Child sexual abuse is defined as follows:
The misuse of power and authority, combined with force or coercion, which leads to the exploitation of children in situations where adults, or children sufficiently older than the victim to have greater strength and power, seek sexual gratification through those who are developmentally immature and where, as a result, consent from the victim is a non-concept. Such gratification can involve explicit sexual acts or may involve invasive and inappropriate actions not directly involving contact. (Johnson & James, 2016)
Studies conducted in the Eastern Caribbean, Barbados, and Trinidad and Tobago indicate that the rate of child sexual abuse is distressing. These studies reveal that 70–80 % of child sexual abuse victims are girls, and in 50% of these cases the perpetrators live with the victims (Perrault, 2011). Research suggests that most cases of child sexual abuse are never disclosed to authorities (Martin & Silverstone, 2013). Since this study is aimed at early detection through improved awareness of the observable effects of child sexual abuse among other things, as a short-term measure of tackling the prevailing problem of underreporting, the literature review focused on the issues of disclosure, effects, and identifying the signs of child sexual abuse.
A study conducted by HIavka, Uggen, Macmillan, Kruttschnitt, and Gilgun (2008), which focused on children’s own understanding of sexual abuse, emphasized the way social and cultural meanings affect disclosure of sexual abuse. Shafe and Hutchinson (2015) examined the link between cultural practices and child sexual abuse. Based on their research, it was discovered that the role and attitude of family and community continue to be crucial factors in reporting of sexual abuse. Disclosure can be very difficult based on the orientation toward shared practices. This could provide insight as to why children in traditional households which do not discuss sexual matters are unwilling to report this type of abuse, as they feel shame and fear of possible repercussions associated with such disclosure. A study conducted by Pasura, Jones, Maharaj, De-Caires, and Johnson (2012) examined the conceptualization of childhood. The paper takes into consideration the way experiences shape the lives of children which is vital in understanding the definition of childhood. Report prepared by Jones and Jemmott (2016) examined Caribbean reports on child sexual abuse and focused on generating understanding more precisely within a frame of society, family systems, socioeconomic status, and historic traditions. The study found that child sexual abuse frequently co-occurs with other forms of maltreatments, escalates vulnerability to additional victimization, and leads to diverse problems, leaving impacts for complete life.
Qualitative research allows the researcher to use the method of nonprobability sampling applied through purposive sampling techniques. This is a nonrandom sampling technique which further supports the researcher in identifying an explicit social issue that warrants investigation. The use of purposive sampling technique in qualitative studies gives the reliance of a target group and assists the researcher in finding subjects that may be difficult to locate (Rubbin & Babbie, 2012). Although qualitative methods in research have their limitations, their aim is saturation of information; thus, for the purpose of this study, only five participants who are the victims of child sexual abuse and exploitation were selected.
The data were collected using both structured interviews and questionnaires, which were then analyzed balancing the need to stay close to the data with the need to think abstractly (Padgett, 2008). Bronfenbrenner’s (1994) ecological model is essential to understand the effects of child sexual abuse in any study. This model takes individual, familial, communal, and societal influences into consideration regarding resilience or risk for harm. Bronfenbrenner’s (1994) model is progressively evolving and is currently referred to as the bioecological model. Bronfenbrenner (1994) posits that external influences on the family have a major impact on individual’s development (Pittenger, 2016). Each participant was interviewed individually and completed a structured questionnaire as well as a standardized scale—the Children Revised Impact of Events Scale (CRIES). An in-depth interview guide was developed which examined individual and family history; family background and dynamics; onset of sexual abuse; duration, type, and tactics utilized by the perpetrator in maintaining secrecy; disclosure attempts and outcomes; perceptions and beliefs developed by the victim; nature and quality of significant relationships in childhood and adolescence; environmental contributors; social development; and cultural influences. Questions permitted room for participants to add comments that may not have been asked from them and were open-ended. All the interviews were conducted by the researcher (Alaggia, 2010).
Ethical approval was obtained from the University of the West Indies Ethics Committee. Ethical protocol was strictly observed by the authors by assuring that strict confidentiality would be maintained and the data would be stored in the office of prime investigator with a password protection. The researcher was aware of the sensitive nature of the subject matter. Therefore, Biestek’s (1961) principles of confidentiality, acceptance, nonjudgmental attitude, and client’s right to self-determination provided impetus to facilitate the research process. Emotional issues that arose and had to be addressed urgently were managed by utilizing social work skills.
Parents and guardians were explained in detail about the scope of the study, how the children would be interviewed, and all the interview questions were shown to them to get their consent. After getting their consent, signatures were obtained from the parents/guardians before the start of data collection. Parents/guardians unwilling to give their consent were not included in this research.
The data collected revealed numerous findings which are consistent with the available literature as it pertains to identifying the signs of sexual abuse among children. The small sample size became necessary due to time constraint, numerous delays, objections encountered in obtaining agency’s approval, and the general reluctance of participants based on perceived fears and social stigma. Owing to the small sample size comprising five children, findings cannot be generalized for the entire population, and certainly a larger scale study is necessary to produce valuable data to be more reflective and impactful on Caribbean societies.
The findings analyzed against prevailing theories and the existing bodies of work suggest that children in Trinidad and Tobago are generally not safe and need greater care and protection from sexual abuse. Children seem to be continuously at risk of being abused sexually with a possibility that this abuse is repeated, and fear in one form or another being used to procure silence, thereby preventing effective detection and remediation.
More frequently, these acts appear to be committed by persons who share a close relationship and are well known to the child such as family members or neighbours; this is congruent with the study conducted by Pasura et al. (2012). The immediate effect of this abuse on children is often heart-rending if not catastrophic, and includes the following:
Post-traumatic stress disorder (PTSD)
Decreased academic performance
Depression and emotional scarring
The data analyzed from the CRIES suggest that all subjects sampled for this research were at a risk of suffering from PTSD because of the trauma associated with sexual abuse. All participants scored above 17 in the intrusion and avoidance scales; this is outlined as the criteria necessary for a possible diagnosis of PTSD. This is generally described as a debilitating condition that follows an event that the person finds terrifying, either physically or emotionally, causing the person who has experienced the event to have persistent frightening thoughts and memories, or flashbacks, of the ordeal (Parekh, 2017).
Some of the symptoms described by the participants were synonymous with the persons who had suffered PTSD. There is a strong possibility that such children have a high possibility of developing additional complications associated with this major mental health condition if it remains undiagnosed and untreated. All participants described having nightmares and sleep disruptions. Additionally, some of them reported feeling sad and becoming isolated or withdrawn. These are classic symptoms associated with PTSD (Filipas & Ullman, 2006).
Filipas and Ullman (2006) examined the psychological effects of child sexual abuse as well as factors that contributed to revictimization in adult abuse. The study highlighted the link between maladaptive coping strategies and revictimization; stating that further studies are required into coping mechanisms because maladaptive coping creates a predisposition to sexual revictimization. Based on the research, there seems to be a link between avoidance forms of coping and symptoms associated with PTSD such as withdrawing from others, emotional numbing, and trying to forget the abuse, which can also lead to revictimization. Lev-Wiesel (2008) reviewed numerous studies examining the long-term impact of child sexual abuse, and found that the complications include numerous psychological, behavioral, and social difficulties such as: depression, psychological distress, low self-esteem, substance abuse, attempted suicide, severe posttraumatic stress, psychopathology disorders, harmful behaviors toward self, and dissociative disorders.
The prevalence of serious sexual assault in childhood (up to the age of 16) was reported in the context of a community mental health study executed by Bagley and Ramsay (2008) in a random sample of women. The findings report that 22% of women reported sexual abuse during childhood and that sexually abused women were twice as likely to have poor mental health problems compared to women who were not abused. This reiterates the necessity for early reporting of this crime, as well as specific intervention, proven to be effective in addressing child sexual abuse to prevent the future mental health issues (Bagley & Ramsay, 2008).
All participants in the sample for this study reported a decline in academic performance, which showed that the child was enduring sexual abuse. According to literature, school performance could be negatively affected because of child sexual abuse (Odhayani, Watson, & Watson, 2013). School personnel and parents should therefore become more attune to such signs by being provided professional training through seminars and such material. Indeed, the common Caribbean response of penalizing a child for declining grades is to be reexamined as a potential red flag for further enquiry into possible abuse.
Sixty percent of participants reported feeling isolated and losing interest in activities such as playing. Studies support these findings. Such studies noted that impairments in social functioning are common among children who are abused sexually, often resulting in feelings of social isolation (Herbert, Langevin, & Bernier, 2013). These findings are further supported by the research conducted by Brown et al. (2008), who examined behavioral indicators of sexual abuse and highlighted self-imposed social isolation as one of the effects that sexual abuse has on children. Social isolation is a common indication and consequence of child sexual abuse. Karakurt and Silver (2014) indicated that poor social skills and interpersonal relationships were one of the most common issues among individuals who are abused sexually in childhood. This is more notable when the abuse is committed by a parent, which affects negatively the child’s capacity to foster trusting and affectionate relationship.
The data collected in this study also indicated that 60% of children reported feeling ashamed, 60% said they felt sadness, and 40% stated they had suicidal thoughts because of being abused sexually. Participants of the study reported feelings of shame, confusion, sadness, and depression. Research conducted by Herbert et al. (2013) examined behavioral indicators among sexually abused preschoolers in comparison to preschoolers not abused sexually. Results of Herbert et al.’s study (2013) elaborated that sexually abused children reported higher levels of depressive symptoms than their nonabused counterparts.
Stigmatization and feelings of shame are experienced frequently by children who survive sexual abuse; because of these feelings, children would feel a sense of being different from their peers, making them vulnerable to establish feelings of social isolation. The literature also states that feelings of shame are frequently felt by children who survive sexual abuse. Sadness appears to be a crucial factor described by children who were abused sexually and was a key symptom of depression. Child sexual abuse leads to depression and emotional scarring. Research done by Hassan, Gary, Killion, and Lewin (2015) stated that African Americans reported externalized behaviors such as being more physically aggressive and demonstrating anger, in comparison to Latino participants reporting more internalized behaviors such as depression. Suicidal thoughts are frequently linked to depression or depressive symptoms.
Findings are in agreement with those by Hassan et al. (2015), where participants stated that they generally felt anger, sadness, and depression, and some reported experiencing suicidal thoughts. According to the research conducted by Karakurt and Silver (2014), undisputed evidence exists linking child sexual abuse to a significant risk of psychopathology, specifically PTSD, depression, and substance abuse. There are reported marked variations among survivors of child sexual abuse regarding the degree of harm, welfare, and overall ability to function.
There appears to be a link between patriarchal societies and the prevalence of child sexual abuse. Children and adolescents are subjected to abuse for reasons that include patriarchal ideology, worsened by age-related hierarchies in some societies such as Africa and Asia, which explains underreporting. Education continues to be an effective tool in minimizing or eradicating these forms of abuses. The study carried out by Shafe and Hutchinson (2015) is relevant to the present study because Caribbean societies continue to function heavily under patriarchal models. Male dominance is perpetuated, with many females being dependent on males to be the breadwinners and providers of the family. This, as discussed previously, has a serious implication regarding the motivations for underreporting or nonreporting of child sexual abuse. In agreement with Shafe and Hutchinson’s recommendations, one of the main recommendations arising from the findings of this research is to embark upon strong education campaigns aimed at generating increased awareness on the topic of child sexual abuse. Social workers should certainly become advocates to this cause and strive to promote greater levels of public awareness aimed at providing information to the population. This would ultimately result in increased reporting and early detection of this societal malady.
Former prime minister of Trinidad and Tobago Kamla Persad-Bissessar has highlighted in a recent newspaper article the need for all to do more to safeguard our young women and girls. She promoted equal rights while stating that we need to end discrimination against females in our society. The article cited Persad-Bissessar as stating that far too often young women and girls endure discrimination based solely on gender and are subjected to poverty, abuse, and denial of educational opportunities (Chan Tack, 2017). The above article has emphasized the point in relation to patriarchal societies presently existing within many Caribbean regions where males dominate and retain power at every level of the society. Females continue to experience discrimination due to these existing ideologies and are often controlled by males. Based on previous studies as mentioned above in the section on literature review, there appears to be a link between such cultural norms and child sexual abuse. As such it is imperative to comprehend such culturally acceptable norms in order to effectively break the cycle and perpetuation of child sexual abuse in Trinidad and Tobago and the Caribbean region.
Kwhali, Martin, Brady, and Brown (2016) examined child sexual abuse and contemporary social work analyzing the findings, discussions, and implications of practice in the United Kingdom. Their research is relevant to the present study as it stemmed from a noticeable decline in the cases of child sexual abuse, with questions surrounding the possibility that practitioners were failing to report occurrences of child sexual abuse or child sexual exploitation. The majority of social workers interviewed in this study reported an overall sense of confidence in discussing and managing cases of familial child sexual abuse while noting that confidence was eroded due to heavy caseloads and staff shortage (Kwhali et al., 2016).
This point is notably relevant to practice of social work in Trinidad, where many organizations struggle with staff shortage because of lack of funding and resources, resulting in high caseloads with staff becoming overburdened. This leads to challenges to manage competently the cases of child sexual abuse. As a former school social worker with three years’ of experience, the first author can confirm such challenges based on this exposure. One school social worker being assigned approximately six schools is impracticable and highly ineffective. In order for social work practice to become more effective in combating child sexual abuse in Trinidad and Tobago, staffing issues need to be addressed urgently. Additionally, it is necessary to review policies specifically pertaining to first-line personnel who respond to the cases of child sexual abuse. Owing to the nature of such cases, particularly the traumatic experiences of victims, all first-line responders should be subjected to mandatory weekly psychological counselling/debriefing sessions designed explicitly to address the possible transference of trauma from victims to responders. Participants of the study carried out by Kwhali et al. (2016) made mention to the time constraints regarding building a therapeutic relationship with the victims of child sexual abuse and emphasized that preparation and reflection were necessary tools, although rarely available, to manage such cases.
Allnock and Hynes (2012) conducted research on therapeutic services for sexually abused children and noted considerable evidence documenting the effectiveness of cognitive behavioral therapy such as recommended by the National Institute for Health and Clinical Excellence which included the use of Cognitive Behavioural Therapy (CBT) as a first-line therapeutic approach in treating the symptoms of sexual abuse. This could be utilized in guiding intervention locally. Social workers in the research conducted by Kwhali et al. (2016) referred to the need for greater clarity regarding their specific roles where police investigations were in progress. Possible delays in accessing therapeutic intervention for children undergoing criminal investigations were among one of the concerns revealed. Another major concern which was consistently expressed by managers and social workers was the reliability and sustainability of voluntary sectors which provided direct therapeutic interventions following disclosure by sexually abused children. Participants spoke about prolonged waiting periods and limited availability of relevant services surprisingly for children with disabilities, teenagers, and belonging to minority ethnic groups. Similarly, based on the findings of this research, there appears to be having lengthy waiting periods for continuous therapeutic interventions (if at all such continuous interventions are available) necessary for sexually abused children. These children reported that they received an initial session only following disclosure, and more frequently follow-up and additional counselling sessions failed to occur. Based on the available literature, sexually abused children require structured and continuous therapy to assist them in successfully dealing with the trauma sustained from such an abuse. As such, it is recommended that local agencies currently providing such interventions acquire sufficient staff and resources, so that they are equipped to deliver interventions on a more reliable and sustainable basis.
Johnson and Worme-Charles (2016) examined the topic of child abuse and advocated for the necessity of an integrated multi-agency approach between police and other child protection organizations to effectively manage reported cases of child abuse. The above-mentioned paper further calls for clearly defined roles between agencies and service providers responsible for dealing with child abuse. Kwhali et al. (2016) stated that children experience anxiety as it pertains to giving evidence in court and talking to law enforcement officials, coupled with the fact that limited information could exacerbate the impact of abuse, resulting in increased distress for the child. A child-centered approach is recommended. This would entail agreements between social workers and police officers and the equality of working relationships between agencies. Children in Trinidad and Tobago also expressed fear when interacting with local law enforcement officials attached to the child protection unit. For necessary interventions to be attained, greater efforts regarding inter-agency collaborations are required. A memorandum of understanding (MoU) between the Children’s Authority of Trinidad and Tobago and the child protection unit is required so that both agencies can work closely to ensure the safety and protection of children and the prosecution of offenders while having a clear and guided understanding of the roles of each agency.
The study was designed to explore the effects of sexual abuse on children in Trinidad and Tobago and to determine whether children are in fact safe. Based on the data collected and analyzed as well as the prevailing theories and previous works on the subject, we deduced that children in Trinidad and Tobago are not safe and continue to be at risk of being abused sexually. Revictimization appeared to be a harsh reality for children who have endured sexual abuse. One could speculate that this might be due to the lack of structured, professional, and continuous therapy, which is a necessary factor in assisting children to recover from this type of trauma. Cultural practices within the Caribbean region could also be a significant factor when talking about the issue of therapy. The scores of all respondents on administration of the CRIES suggested a very high probability that they were suffering from PTSD because of enduring sexual abuse. This raised significant concerns regarding the type of therapeutic intervention available and administered to these vulnerable children as well as the severity of psychological distress these children were forced to deal with. This study would be a vital tool for the following:
Assisting in early detection of the effects of sexual abuse among children in Trinidad and Tobago and other Caribbean countries.
Ensuring greater sensitization and increased public awareness to this crucial but often uncomfortable topic.
The study would inevitably assist in preventing the perpetuation of such heinous crimes on society’s most vulnerable segment.
Protecting society’s most valuable assets for the future, that is, nation’s children and, by extension, its human capital.
Research as stated above, indicates that sexually abused children often develop maladaptive coping strategies and social development which can lead to long-term psychological disorders. Therefore, it is imperative that these children receive specific therapeutic interventions which are based on the techniques that have been proved effective in treating this population. The findings of this study revealed some major themes, where most participants reported several factors that were in agreement with the literature and could be utilized to identify the effects of child sexual abuse. Respondents disclosed as becoming isolated or withdrawn, a decline in academic performance, and losing interest in playing, some form of emotional scarring or mal adaptation and disruption in sleep and eating patterns. These findings are supported by the literature and could be used in developing sensitization campaigns or courses aimed at providing education to teachers, caregivers, and other persons who work with children.
The data from this study were retrieved from children who were abused sexually and highlighted some of the main effects of sexual abuse on children. Promotion of public awareness so that people could be equipped to identify the signs of child sexual abuse could be a crucial factor in combating this crime. This has been strongly supported in literature on the subject, specifically in the research conducted by Shafe and Hutchinson (2015). Furthermore, feedback from the sampling seems to suggest that policies for agencies that respond to child sexual abuse may require reviewing and updating. Certainly, the way such policies are implemented by respective agencies requires revisiting. This study found that participants generally had a scary experience with law enforcement officials. As such, advanced training designed to educate officers on effective approach to intervene with sexually abused children could be beneficial. Additionally, agencies that are tasked with providing intervention in such cases, particularly first responders, should have their policies reviewed and receive necessary funding so that they could be adequately staffed and equipped with the tools that are necessary to execute their mandate.
Some of these agencies in Trinidad include the Emergency Response Team, which functions under the Children’s Authority, the Child Protection Unit, which functions under the Trinidad and Tobago Police Service, and the Victim & Witness Support Unit, which also functions under the Trinidad and Tobago Police Service. Further large-scale scientific enquiries surrounding child sexual abuse in Trinidad and Tobago and the Caribbean region should be conducted so that the data gathered from such studies could be used as a guide for policy review and amendment. Studies conducted in the Eastern Caribbean, Barbados, and Trinidad and Tobago indicate that the rate of child sexual abuse is distressing. These studies revealed that 70–80% of child sexual abuse victims are girls, and in 50% of these cases the perpetrators live with the victims (Perrault, 2011).
The data are immensely alarming and emphasize the necessity of parents and primary care givers, teachers, school personnel, and the public to be enlightened. This could be possible by attending training seminars or by reading the material available through print and social media and designed to sensitize them on the observable effects of child sexual abuse. This could be a vital weapon in society’s arsenal for combating the underreporting, which often ensures an ideal environment for this crime to continue. Training should be devised to equip key personnel with the knowledge necessary to recognize whether child/children are victims of sexual abuse and the necessary steps to be initiated in cases of suspected abuse. Furthermore, everyone needs to be more vigilant regarding the people who are allowed access to children, particularly parents who leave children alone in the care of a family friend or acquaintance. Although not the intended subject matter of this study, the authors are compelled to note that if the prevalence of child sexual abuse is as high as shown by the statistics available in the public domain, then its large-scale effects do not paint a promising picture for the future of Trinidad and Tobago and may even be key indicators to many of the present problems faced by the country. On a national scale, it would appear that Trinidad and Tobago is building the future of socially damaged adults who are unable to perform at their fullest potential or form meaningful relationships without professional intervention. The effect on the country’s most valuable asset—its human potential—is therefore unquantifiable. The observable effects of child sexual abuse thus present vital indicators that children are not safe in Trinidad and Tobago. Moreover, these observable effects could be used as key indicators to combat the scourge of underreporting, which seems to dominate this country’s culture, thereby offering a ray of hope to those who need it most.
The authors have no conflicts of interest in this study.
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