Examining the Realities of Child Sexual Abuse in Ghana

Child Sexual Abuse (CSA) is a global public health concern. It is considered a crime in most countries in the world. CSA has a devastating and long-term adverse effect on the child, family, community, and the nation. Child sexual abuse involves any kind of sexual activity to which children are subjected, especially by someone who is responsible for them or has power or control over them, and who they should be able to trust. The statistics of CSA are alarming and vary across countries. In Ghana, there is evidence that CSA is on the increase, despite several efforts by Governmental and Civil Society Organizations to address this menace. The paper undertakes a contextual analysis of the realities of CSA, with a special focus on socio-cultural, legal, and health perspectives to obtain a comprehensive understanding of the situation of CSA in Ghana. The paper concludes that an appropriate understanding of the complexities and realities of CSA could contribute to a stronger stakeholder collaboration for comprehensive and multi-sectorial intervention strategies to address the problem of CSA in Ghana.


INTRODUCTION
Child sexual abuse (CSA) is a sin and a crime. It has devastating and long-term adverse effects on the child, family, community, and nation. 1 According to the World Health Organisation (WHO), CSA is "the involvement of a child in sexual activity that he or she does not fully comprehend, is unable to give informed consent to, or for which the child is not developmentally prepared and cannot give consent, or still that violates the laws or social taboos of society." 2 Although this definition is comprehensive and also considers the social taboos, others have argued that it does not account for the psychosocial and emotional effects on the victims later in life. 3 Additionally, the United Nations Global Study on Violence against Children (UNVAC) defines CSA as "any kind of sexual activity to which children are subjected, especially by someone who is responsible for them or has power or control over them, and who they should be able to trust." 4 indicated that the number of cases officially reported had increased from 1,128 in 2002 to more than 1,600 in 2009. The report further indicated that the incidence of CSA is significantly higher than what is formally reported to the Ghana Police Service. 14 Additionally, it was reported that between 2010 and 2014, a total of 5,752 children were sexually abused in Ghana,with 342, constituting about 17% of the cases perpetrated by members of the victims' families. 15 With reference to data from the DOVVSU of the Ghana Police Service, the report further indicated that 1,298 cases were reported in 2014, a total number of 1,230 in 2013, and cases reported in 2012 stood at 1,097. Those recorded in 2011 were 1,159 and in 2010, a total of 968 cases were recorded.
A critical analysis of the report from DOVVSU between 2010 and 2014 reveals a steady rise in sexual violence against children over the years. In 2015, the reported cases of defilement were 1198. Although there was a slight decrease from 1,298 in 2014 to 1,198 in 2015, it is important to recognise that the problem of CSA is still a reality in Ghana. In addition, there is evidence, that the reported cases of CSA are below the actual situation due to the cultural factors that discourage the disclosure and reporting of CSA in Ghana. 16 Although it is difficult to obtain current national data on the prevalence of CSA in Ghana, earlier studies provide some pointers. For instance, a national survey by the Institute of Statistical, Social and Economic Research (ISSER), revealed that 6.3% of women and 5.3% of men reported they had engaged in sexual intercourse before the age of 15 (ISSER, 2011). This data is similar to an older national survey of 3,041 participants, in which, 6% indicated they had experienced sexual abuse before the age of 15. 17 Böhm reported that a 2015 study showed that 27% and 11% of girls and boys of the 823 participants have experienced sexual abuse in Ghana. 18 Some studies have also focused on examining CSA among school children. For instance, a 2009 study conducted in selected schools by an NGO reports that 53% of sexual abuse cases occurred in the school environment, while 47% happened at home. The report further states that 67% of the victims of CSA are in senior high school, 28% in junior high school, and 5% in primary school. 19 Similarly, in a descriptive and exploratory survey, information collected from 490 school children, 116 parents, and 49 headteachers from 4 out of the 110 districts in the country, showed the incidence of CSA in Ghanaian public schools. About 11.2% of the children who participated in the study had been victims of either rape or defilement. 20 Further, the data suggested that gender plays a role in the severity, as the incidence showed that 92% of the victims were females.
Ghana launched a Child Welfare and Family Policy in 2015 as part of reforms in her child protection efforts. This policy calls on all stakeholders to institute evidence-based measures to respond to child abuse in the country. In line with this, the Ministry of Health through the Ghana Health Service (GHS), with support from UNICEF conducted a study to ascertain the capacity and gaps in the health sector's response to child abuse. The study was carried out in six (out of the then ten) regions of Ghana; Upper West, Northern, Ashanti, Western, Volta, and Greater Accra Regions. In order to obtain nationwide and relevant data for effective decision-making, the study lead engaged in discussions with strategic partners in child protection including government, NGOs, UN agencies, health professional training institutions, and other relevant stakeholders in health and child protection at the national and sub-national levels. 21 That particular study represents perhaps the most recent and comprehensive research on child abuse in Ghana. Consequently, it is extensively cited in this section of this study. In the first place, the study revealed that CSA is a serious public health problem in the regions where the study was conducted in Ghana. 22 The study further indicated that child marriage is another form of CSA, and it was common in all the study areas. It was observed that girls as early as nine years are betrothed, and given out to such men, who engage in sexual activities with them. 23 The research team obtained narratives from the communities visited on sexual abuse and defilement of girls by men and older boys. The situation of child abuse in Ghana extends beyond the abuse of only girls. Some studies also cited the abuse of boys as well. It was noted that boys were also sexually abused by other boys and men, especially, in boarding schools. 24

Sociocultural Realities
In an effort to understand CSA from the Ghanaian context, it is imperative to reflect on the circumstances under which CSA occurs in Ghana. That is, undertaking an exploration of the sociocultural factors that influence CSA in the context of Ghana. This is because there is clear evidence that the multi-factorial nature of CSA implies that socio-cultural factors can contribute to the occurrence of CSA on one hand, and on the other hand, it can influence interventions or programs aimed at responding to the menace. It is argued that perspectives about the concept and cause of CSA are rooted in sociocultural factors, and these perspectives influence what is considered appropriate intervention approaches for both victims and perpetrators. 25 It is observed that although CSA is a global phenomenon, it is deeply rooted in the socio-cultural and economic factors of the context in which it occurs. 26 A recent study in Ghana observed that sociocultural and economic factors have contributed to the sexual violence against children, as well as their inability to come out of such abuse. The study found that the majority of the respondents "agreed that the culture of the victims and perpetrators accounted for domestic violence against women and children." 27 In the first place, the societal perception of what constitutes CSA is key in defining the problem, as well as instituting measures to address it. In Ghana, it is recognised that there is a difference between what is regarded as CSA among professionals and lay people. 28 Whiles professionals define CSA in legal terms, lay people examine it in the light of whether the abuse is associated with violence and or whether there are possibilities of gains or financial compensation. The layperson's concept could be derived from the perception of the girls involved or their families. Some children may not consider their experiences as abuse when violence is not associated with the sexual encounter, and in other cases when there are financial gains or support from perpetrators. 29 Other studies revealed that sexual exploitation such as prostitution of young girls is seen as a moral failure on the part of girls and their families. It is not considered child abuse because of material gains such as money, mobile phones, food, and shelter. 30 In addition, a Child Research and Resource Centre reported from their survey that younger children may consider sexual abuse as normal. 31 Some children also hold this view because they were stigmatised for disclosing the abuse, and in some cases, nothing was done to the perpetrators. This situation of gaps in the concept of CSA among stakeholders such as professionals, families, and children calls for great concern. It was observed that this phenomenon has resulted in significant differences between what is legally accepted and what is socially accepted as CSA in Ghana. 32 Consequently, a significant number of cases of CSA occur without the appropriate legal redress and societal response. 33 When Agu et.al., investigated the perception of school children about actions taken by school authorities against perpetrators of CSA, it was reported that more than half of the participants (52.7%) were dissatisfied with the actions taken by authorities. 34 The report further indicates that 29.8% of the children cited that no action was taken by authorities whilst 22.9% could not tell whether or not the incident was reported by the school authorities to the law enforcement agencies. This perception could partly contribute to the fact that some children may not consider the abuse as a problem, thereby may not disclose it.
Another important socio-cultural issue in Ghana that influences CSA is the family system. In Ghana, children are defined in the context of a family as indicated by the Child and Family Welfare Policy. 35 This implies that what affects the family affects the children and vice versa. In Ghana, families function as extended systems, which widen the social protection network for children. On the contrary, it also widens the occurrences of CSA. This is because there is evidence that the majority of the cases of CSA in the Ghanaian context are perpetrated by family members, and also those in close relationships with children. 36 When sexual abuse of children is perpetrated by family members, it may go unnoticed by authorities for a very long time since it is a forbidden area for conversation. 37 Commenting on this scenario, Boakye observed that in the collectivistic nature of the Ghanaian culture, it is difficult to talk about intrafamilial sexual abuse of children because of what he described as "collective shame." 38 This implies that the entire family share in the shame of CSA when the issue is in the public domain. Consequently, there are two main choices for the family members with regard to CSA. Boakye indicated that on one hand, the family keeps abuse secret in order to prevent the child from stigmatisation and public ridicule. This is aimed at protecting the interest of the child. On the other hand, the family will keep the abuse secret to prevent shame that will be brought to the family. In this case, the interest of the family takes precedence over that of the child. This situation results in the possibility of families focusing on alternative ways of resolving the issue such as financial compensation from the perpetrator, and because of this, family members will not report the case to the police for redress. 39 With regard to family systems' influence on legal redress, a recent nationwide study on the gaps in the health sector response to CSA revealed that in some instances, even when CSA is reported, families may withdraw the case or abandon the case due to societal expectations. 40 The report further observed that "even in rape cases the victims' families sometimes agree with influential perpetrators to withdraw the case from the police." 41 Consequently, the family may never follow up on the case with the police, leading to complete abandonment and the perpetrators being free.
However, some families continue to pursue the case until justice is administered despite the police often slacking in their duties for several reasons such as bribery, and when the perpetrator is highly influential in society. For instance, a media report carried a sexual abuse story of a 14-year-old girl by three young men continuously for three days. The report indicated that the police arrested the men and later released them and advised the family to seek an out-of-court redress. However, the family of the victim insisted that justice would be pursued to the letter. The victim's father lamented "My daughter was raped by three young men. After we reported the incident to the police the boys were arrested and my daughter was admitted for five days at a health facility in the community. I was later told the young men have been released and the police are insisting we should do an out-of-court settlement. This was on my blind side; we will want the law to take its full course." 42 Another concern is the fact that in Ghanaian culture, maintaining the virginity of girls before marriage is the pride of families. 43 As a result, when sexual abuse occurs, families are more likely to remain silent in an attempt to protect their girls from being labeled as "bad girls". 44 Similarly, Boakye observed that girls who experience CSA may be labeled as 'damaged', and also blamed for acting in ways that attracted the attention of the perpetrator of the abuse. 45 Mansaray also noted that in some cases, the girl is "re-victimized by the stigma attached to her as the one who has brought disgrace on her family by virtue of her defloration outside of marriage." 46 The stigma or fear of the stigma of being a 'bad' girl may cause some victims to remain silent about the abuse. This implies that families will take steps to protect the honour of virginity and the risk of their girls being tagged as damaged, which also has implications for the marriage of the girls. Thus, CSA may be concealed in order to keep their girls as good candidates for marriage.
Further, the socialisation of girls in the Ghanaian culture has also been cited as a socio-cultural norm that creates an environment where girls are highly susceptible to CSA. Mansaray (2008) observed that children are socialised to esteem adults' instruction and carry it out without question, and the fact that "girls are socialized as helpers at home" gives easy access to children by potential perpetrators of CSA. 47 Quampah observed that although respect is expected to be reciprocal between adults and children, the traditional idea of the upbringing of children in Ghana is that children are socialised to be respectful and dutiful to adults irrespective of the treatment given to them. 48 Quampah argues that this orientation contributes to the alarming state of child abuse in the country. This societal norm may contribute to the reason CSA is usually perpetrated by adults in close relationships, and in the environment of children.
Poverty was considered a key socio-cultural factor that play a role in CSA. Poverty could be considered a 'double-edged sword' due to its role in contributing to the cause of violence against 40 GHS, "Capacity and gaps of Ghana health sector's response to child abuse," 80. 41 GHS, "Capacity and gaps of Ghana health sector's response to child abuse," 81. 42 H.K. Badu, "Family of a 14-year-old girl allegedly defiled by 3 men demands justice". Joy news 27 May 2020. (2020): Accessed June 12, 2021. https://www.myjoyonline.com/news/family-of-14-year-old-girl-allegedly-defiled-by-3-mendemands-justice/. 43 Mariama Ahmeda Mansaray, "Girl-Child Sexual Abuse as a Public Health Issue in Accra, Ghana" (2008). 44 Jolien Van der Geugten et al., "Virginity, Sex, Money and Desire: Premarital Sexual Behaviour of Youths in Bolgatanga Municipality, Ghana," African Journal of Reproductive Health 17, no. 4 (2013): 93-106. 45 Boakye, "Culture and Nondisclosure of Child Sexual Abuse in Ghana: A Theoretical and Empirical Exploration," 960. 46 Mansaray, "Girl-Child Sexual Abuse as a Public Health Issue in Accra, Ghana." 47 Mansaray, "Girl-Child Sexual Abuse as a Public Health Issue in Accra, Ghana". 48 Dela Quampah, Good Pastors, Bad Pastors: Pentecostal Ministerial Ethics in Ghana (Wipf and Stock Publishers, 2014), 37. children and also has implications for children seeking interventions. 49 It was noted that some of the perpetrators are often breadwinners since they are usually part of the child's family. 50 This implies that poverty can maintain the abuse since the victim may have no other option but to depend on the abuser for daily living. 51 Agu et.al., observed that poverty has significant implications for the contextual understanding of CSA and indicated that the rising nature of poverty could contribute to the increasing levels of CSA, especially, the sexual exploitation of children in the country. 52 It is estimated that 25% of the population in Ghana live in poverty, and this makes poverty a key issue in the understanding and strategic response to CSA. 53 For instance, reports from the Department of Social Welfare revealed that in 2009, out of the 10,000 cases dealt with, 49% were related to parents' inability to provide for the basic needs of children. Parents lack the financial ability to support the basic needs of their children. 54 Similarly, statistics from the DOVVSU also indicated that 67% were in the area of child maintenance. 55 The implications of poverty for the contextual analysis of CSA are enormous. Human Right Watch (2001) suggests that poverty could force children into offering sex in exchange for food, money, gifts, shelter, and protection. The poverty situation leads to some parents sending their children to sell after school, on weekends, and sometimes at night, in order to obtain income to support their families. 56 A report by Ghana GNCRC (2015:22) Ghana, 2016,21. https://defenceforchildren.org/study-violence-children-ghana-2/. 51  This implies that the endemic nature of poverty in Ghana contributes to the complexities of CSA in Ghana. Thus, poverty influences the cause of sexual violence, as well as intervention strategies. 58 Inadequate sex education is another sociocultural factor cited. Education on sexuality has been identified as a powerful tool in preventing CSA. 59 It is believed that comprehensive education on sexuality for children put them in a position to identify behaviours that can lead to CSA. 60 In Ghana, cultural factors consider sex education as a taboo, thereby making it difficult for parents and other adults to provide sex education to children. 61 In a recent qualitative study, data was collected from 19 children who are victims of CSA and from parents in the Greater Accra Region to investigate the role of sex education by parents in preventing CSA. It was observed that many of the parents were unable to provide sex education, and those who attempted rather gave strong warnings to their children about sex. 62 Further, the study reports that lack of adequate education on sexuality resulted in children relying on information from peers and the media, leading to an increase in the occurrences of CSA. According to a study by International Needs Ghana, inadequate knowledge of sexuality and reproductive health are key sociocultural factors that contribute to child sex tourism in Ghana. 63 The relationship between sociocultural factors and intervention strategies was considered in this contextual analysis. There is evidence that socio-cultural issues have also influenced interventions, especially, in the area of disclosure, and reporting of CSA to authorities. The WHO maintains that certain sociocultural factors and settings in society make sexual violence against children a sensitive topic. 64 As a result of this perspective, it is considered a taboo of talking about sex, especially among children. This may lead to several cases of CSA not being reported. Consequently, perpetrators may escape the punishment, which is supposed to serve as a deterrent to potential perpetrators. 65 The culture of 'collective shame' has also been identified as having a significant influence on the disclosure and reporting of CSA. 66 The notion of collective shame refers to "the tendency for individuals belonging to a particular group (family, clan, or lineage) to feel or express a strong sense of embarrassment following an undesirable attitude or behaviour by a member of the group, particularly those that are considered potentially damaging or threatening to the reputation of the group." 67 The culture of collective shame has two main implications. On one hand, the victim may not disclose the abuse due to fear of shame and stigma by her family, and on the other hand, the family may also not disclose the abuse to relevant authorities due to family sharing in the stigma and shame of the victim. 68 This implies that the shame CSA brings to the victim will be shared by all the family members. Consequently, family members are more likely to conceal the sexual abuse of children. This is even complicated in instances of intrafamilial abuse. It is important to note that when CSA is unreported, it often goes unpunished, and this phenomenon can contribute to the continuation of the abuse. In some cases, when the abuse is unreported, it also denies the victim access to a wide range of interventions such as medical, psychological, and legal services.
In a nutshell, the examination of the socio-cultural realities revealed that socio-cultural perception of CSA influences the cause as well as the intervention strategies. In addition, sociocultural factors such as the family system, maintaining the virginity of girls, socialization of children, poverty and sex education influence the complexities of CSA in Ghana.

Legal Realities
This section explores the legal and policy framework of CSA in Ghana. The legal perspectives are critical aspects of the intervention strategies in Ghana. This is because CSA is considered a crime in the Ghanaian society. Ghana has laws, acts, protocols, ratified conventions, policies, and similar regulations that are supposed to protect children's rights and protect them from violence, exploitation, and abuse. Ghana's existing legal framework such as the acts, policies and regulations was informed by the United Nations Convention on the Rights of the Child (UNCRC) of 1989. 69 In 1990, Ghana ratified the UN Convention on the Rights of the Child, which tasked every country to institute appropriate measures to safeguard children. As a result, certain laws, and policies as well as institutions were established to undertake appropriate measures to protect children from physical, mental, and sexual violence. 70 The key components of the country's comprehensive legal framework which protects children from sexual abuse are the 1992 Constitution, the Children's Act 1998 (Act 560), the Criminal Code (Amendment) Act, 1998, (Act 554) and the Domestic Violence Act 2007 (Act 732). With regard to the 1992 Constitution, chapter 5 outlines the fundamental human rights and freedom and Article 28 spells out the rights of children under the Constitution. The Criminal Code (Amendment) Act, of 1998, (Act 554) describes different aspects of sexual offences such as rape, defilement, indecent assault, and incest as well as the punishment that those offences attract with various aspects of sexual offences. 71 Section 98 of the Criminal Code defines rape as "the carnal knowledge of a female of 16 years or above without her consent." Section 97 states: "Whoever commits rape shall be guilty of a first-degree felony and shall be liable on conviction to imprisonment for a term of not less than five years and not more than 25 years." Section 101, sub-section 1 defines defilement as "the natural or unnatural carnal knowledge of any child under 16 years of age." Sub-section 2 further states: "Whoever naturally or unnaturally carnally knows any child under 16 years of age, whether with or without his or her consent commits an offence and shall be liable, on summary conviction, to imprisonment for a term of not less than 7 years and not more than 25 years." The Children's Act 560 (1998) contains "reform and consolidate the law relating to children, to provide for the rights of the child, maintenance and adoption, regulate child labour and apprenticeship, for ancillary matters concerning children generally and to provide for related matters." This is a clear indication that there is a comprehensive legal framework that is expected to guide institutions and agencies to implement strategies to promote the welfare of children and protection from all forms of abuse.
The question as to whether these legal instruments are put to the best use in order to ensure a strong systemic approach to fighting child abuse is another issue for the ensuing discussion. In spite of this comprehensive nature of the legal framework, there is evidence that the implementation of these laws to ensure adequate protection has been poor, resulting in limited success in the country's efforts to deal with CSA. 72 Although Ghana has made some significant progress with regard to reforms in the child justice system, there are weaknesses in the policy frameworks that should guide the implementation of the delivery of justice to children (UNICEF 2011). 73  instruments paved the way for the establishment of agencies and institutions for the effective implementation of programmes and services to ensure the safeguarding of children in the communities of Ghana. Some of the key institutions are the DOVVSU of the Ghana Police Service; the Ministry of Gender, Children and Social Protection; the Department of Children; the Gender-based Violence Court; and the Girl Child Education Unit of the Ghana Education Service. 74 The DOVVSU is a department within the Ghana Police Service that deals with human rights abuses towards women and children. The DOVVSU plays a major role in protecting children from violence at the district, regional, and national levels. 75 Furthermore, certain policies and interventions were also introduced to provide guidelines to stakeholders and institutions in the implementation of child welfare and protection programmes and services in the country. Some of the policies and interventions include Free Compulsory Basic Education (1996); Livelihood Empowerment Against the Poor (2007) It is expected that these guidelines and policies will help consolidate the country's effort to address violence against children. However, it is recognised that in spite of this strong policy framework in place, the country is yet to make significant progress in the fight against CSA. In response to some of the gaps in the child protection system in the country, the government of Ghana through the Ministry of Gender, Children and Social Protection launched a Child and Family Welfare Policy in July 2015, with its prime focus on the establishment of a comprehensive and functional system of child protection in the country to meet the current global ideals for child and family welfare. The policy presents a "child and family welfare system that comprise of laws and policies, programmes, services, practices and structures designed to promote the well-being of children by ensuring safety and protection from harm; achieving permanency and strengthening families to care for their children successfully. This Policy understands that a child is an integral part of the family, as such, a child's welfare cannot be separated from that of the family." 76 This policy also calls on all stakeholders, including faith communities to institute measures to protect children. The government of Ghana is expected to provide adequate resources for the smooth functioning of Child and Family Welfare services at all levels.
It is interesting to note that the comprehensive nature of the legal system for child protection, has resulted in the attainment of legal redress for a number of cases of violence against children, including CSA. 77 Also, the legal framework has paved the way for the establishment of relevant policies, institutions and agencies tasked with the welfare of children. Notwithstanding, this comprehensive legal framework in Ghana for the protection of children, some concerns have been raised with regard to effective implementation to ensure children are safeguarded in the various communities. 78 The Ghana Health Service (GHS), reported that community members believed that enforcement of the law on child protection will inject a responsibility on people. The report further argued that if perpetrators of child abuse are arrested and prosecuted, it will send a strong warning, and deterrence to others. 79 Another challenge in legal redress is the institutional bureaucracy. It was observed that sometimes, it might take two years or more to bring one case of CSA to a close. 80 As a result, sometimes, families and community members might lose interest in pursuing the case to a logical conclusion. Further, when a case of CSA is reported to the police, they may ask for money and other resources from the victim to carry out investigations. 81 Additionally, it was indicated that although CSA is a first-degree felony, sometimes, the police allow the case to be withdrawn for the purposes of settlement in the community. In some instances, whilst the law ensures the perpetrators are arrested, and prosecuted, it does not ensure that victims receive other essential services like medical and psychosocial support. Consequently, some victims' life situations may get worse despite the fact that the perpetrators are punished by law. 82 For example, GNCRC contains a report on the frustration of respondents from an NGO: "One of our projects seeks justice for children through the provision of support for victims of sexual abuse to report to DOVVSU. We have encountered so many challenges with the system and the process can be very frustrating, victims are expected to pay for the medical examination that proves the abuse to support the prosecution and the cost is enough to stop victims from reporting. Secondly, victims and their families are sometimes expected to bear the cost of transportation for the arrest of the suspect. This is further compounded by the cost of transportation throughout the investigation and to court as well. It took us almost 18 months of trial before the judgement was passed on one of the cases we supported. You can imagine how many people would be able to afford the cost and time to go through such a process. The reality is that sometimes the victims give up along the way truncating the entire process. Besides, a majority of the cases go unreported, and some offenders go on to abuse other children with all impunity. The laws are there beautifully couched but they cannot be enforced to the latter because the institutions with that mandate do not have what it takes to do so effectively." 83 The examination of the legal realities shows that Ghana has a comprehensive legal and policy framework to address CSA. In spite of the fact that some progress is being made in the prosecution of perpetrators of CSA, poor implementation of these legal and policy provisions has been identified as a major hindrance to the fight against CSA. It is evident that more effort is required on the part of the government and other stakeholders to ensure effective implementation of the legal and policy framework geared towards child protection in the country.

Medical and Psychological Health Realities
The health implication of CSA cannot be overemphasised. There is evidence that sexual abuse of children has an adverse effect on their health. Some studies revealed that CSA has been associated with mental health problems such as Post-Traumatic Stress disorder, depression, anxiety, and suicide. 84 Similarly, other studies also reported physical health implications of CSA such as autoimmune problems, sexually transmitted diseases, irritable bowel syndrome, asthma, fibromyalgia, and many others. 85 Due to the varied nature of the health needs of victims of sexual abuse, and the fact that most countries are unable to meet these needs, the WHO developed guidelines to ensure adequate response to the health needs of the victims. 86 In Ghana, the laws on sexual violence against children, and the Child and Family Welfare Policy make provisions for free healthcare services. In addition, the policy mandates the Ministry of Health and the Ghana Health Service to ensure comprehensive medical and psychological care, as well as support victims and their families to access other relevant services. 87 In a study conducted in Cape Coast, the Central Regional capital of Ghana, a situational analysis of the healthcare providers' response to sexual violence was assessed. Both qualitative and quantitative data obtained from the two health facilities indicated that supplies such as pre-packed rape kits, post-exposure HIV prophylaxis, and informational handouts on medications and support services for survivors were not available in both facilities. Also, the management and staff of the hospital did not receive any training on the clinical management for survivors of sexual violence, including providers' role in reporting sexual violence to authorities, medical forensic exams, reproductive and sexual health services, and referral for mental healthcare. Furthermore, stigma and structural barriers, such as the cost of medical supplies and lack of privacy within the healthcare facilities were cited as barriers to healthcare providers' response to sexual violence against children and women. 88 Although, the legal and policy framework that protects children in Ghana made provisions for free healthcare for victims of CSA, a recent study in six regions of Ghana to assess gaps and capacity of the Ghana Health Service found that there were no free health services in most cases. Furthermore, the expenses relating to transport to and from different locations, as well as healthcare providers' requests for laboratory investigations such as tests for HIV, Hepatitis, STDs, and other tests were catered for by the victim and family. 89 With regard to the initial standard protocol when CSA occurs, a report is made at the police station and a Police Medical Referral Form is obtained to be sent to health facilities. The form is filled and signed by a medical doctor after the examination of the victim. This report assists both healthcare providers and law enforcement agencies in handling the case. It was reported that in order for this protocol to be followed in instances of CSA, the victim should be prepared to compensate medical doctors for this service since the National Insurance Scheme does not cover the cost of these services relating to the medical examination and filling of the Police Medical Referral Form. 90 The implication of the current situation is that there is a significant gap between the legal and policy framework with regard to access to healthcare by victims of CSA in Ghana. This section points to the reality that CSA has both physical and psychological health implications for the child. It reveals that, although the legal and policy framework provides for free access to healthcare for victims of CSA, factors such as cost of medical care, lack of logistics, lack of privacy in health facilities, stigma, and inadequate training of health personnel were identified as barriers to access to care.

RECOMMENDATIONS
The following recommendations are made based on the realities of CSA in Ghana: 1. The Ghana Health Service should provide comprehensive regular training on the clinical management of survivors of child sexual violence. In addition, it must provide adequate logistics such as pre-packed rape kits and post-exposure HIV prophylaxis. There is also the need to incorporate appropriate psychological interventions such as counseling into the country's health delivery systems at all levels to help address psychosocial challenges associated with CSA. 2. Religious bodies in the country should prioritize the education of their members on the realities of CSA. This can be done by training all workers/volunteers who handle children as well as caregivers and the children themselves to become active partners in the fight against CSA. 3. The Ghana Education Service should include child protection in the training program of teachers and also in the curriculum of the Basic and Secondary schools. 4. The Department of Children, under the auspices of the Ministry of Gender, Children and Social Protection should initiate and sustain continuous engagement with relevant stakeholders such as religious bodies, traditional leaders, Ghana Health Service, Ghana Education Service, and the Ghana Psychology Council to find pragmatic and context-specific ways of reducing CSA in our communities. 5. Furthermore, future research should examine specific contributions the various relevant stakeholders can play in the context of Ghana to reduce the menace of CSA in the various communities.

CONCLUSION
The paper has pointed out that CSA is a public health concern with complex realities in Ghana. The study observes that the sociocultural perception of CSA is not consistent with the professional perspective. Sociocultural factors such as poverty, family systems, sex education, maintaining the virginity of girls, and collective shame in the family have influenced the construction of CSA with regard to both causes and intervention strategies. The legal realities showed that Ghana has a solid legal and policy framework to respond to CSA. However, there are several bottlenecks, resulting in poor implementation. Also, the examination of the medical and psychological complexities indicates that CSA could contribute to serious health implications for the victim. In spite of the fact that the policy framework provides for free access to healthcare, it was observed that lack of logistics and training of health personnel contribute to poor healthcare delivery to victims of CSA. The article concludes that the staggering statistics of CSA in Ghana, and the glaring multidimensional complexities of the problem should be a source of concern for all stakeholders. Consequently, the paper suggests the need for multi-sectorial dialogue by relevant stakeholders on the realities of CSA and the urgent call for more comprehensive intervention measures that address the sociocultural, legal, and health realities of CSA in Ghana.