**2. Child sexual abuse and emerging psychopathological syndromes in adulthood**

The prevalence of child sexual abuse (CSE) is close to one in 10 children worldwide [13]. In Mexico, more than 50,000 minors are victims per year [14] and less than 10% of what really happens in the country is reported [15]. There are several social reasons for not doing so, p.e., the authorities in charge of receiving the reports take a long time to start an investigation file, most people distrust authority, and the procedures are usually long hindering and even re-victimizing the person [16].

There are some other reasons regarding the victims. Boys and girls do not fully understand what happened, and it is difficult for them to communicate the event and usually, they simply know that it has caused them discomfort or has hurt them but do not know that is not something unacceptable but a crime [15, 17]. They also tend to keep it a secret out of fear, guilt, and shame. When CSE occurs, the word of an infant turns against that of an adult, and when there is insufficient evidence, most are not reported [18].

CSE is evidenced by sexual activity between a child and an adult or another child who by age or development is in a relationship of responsibility, trust, or power, with the intention to gratify or satisfy the needs of the other person and the child is unable to give informed consent to, or is not developmentally prepared and cannot give consent, or that violates the laws or social taboos of society [19]; that is, the minor is forced to have sexual contact and/or any sexual conduct, such as watching and listening to pornography or displaying the genitals [20]; it is considered one of the most severe forms of violence and a serious violation of the rights of children and adolescents, with devastating consequences for the victims, their family, and the community [15].

If these traumatic events occur early in the vulnerable and critical developmental period before the age of five [21, 22], they interfere with normative development, generating sequelae that impact mental health and well-being, emerging during adulthood and persisting throughout life in different ways [2, 6–10, 23, 24].

Sequelae associated with CSA refer to emotional problems [9, 25–27]; borderline personality disorder [28, 29]; antisocial behavior problems, increasing the risk of criminal behavior [30–32]; post-traumatic stress disorder (PTSD) [33–35]; personality disorders in adult life [36–38]; and a clear association with suicidal ideation, self-injurious behavior and suicide attempt in adulthood [39–45].

#### **2.1 Self-injurious behavior**

Self-injurious behavior (SIB) is considered any deliberate self-directed behavior that causes immediate destruction of body tissues, such as cuts, burns, bumps, and abrasions. SIB is low-lethality and socially unacceptable, used as a coping mechanism for disturbing emotions, with the aim of replacing overwhelming emotional pain with manageable physical pain. Drug overdoses or poisonings with suicidal intent are excluded [46–51].

The age onset is different. Since self-harm with suicidal intent rarely occurs before the age of 15, non-suicidal SIB tends to start at younger ages [46, 52–54]. Although this behavior occurs mostly in adolescence, there is still a significant group of young adults who maintain the behavior [55].

At present, there is a debate about whether self-injurious behavior has the intention of death. According to the Statistical and Diagnostic Manual of Mental Disorders, Fifth Edition [56], self-harm is formally known as a nonsuicidal selfinjury disorder (NSSID) as these self-destructive behaviors are carried out without any intention of suicide. Some researchers posit that SIB serves as a mechanism for self-relief and the release of tensions without the desire to die [57–59] Other surveyors emphasize the relationship between self-harm and suicide since data reveals that selfharm is the main risk factor for suicide attempts [60–62].

On this regard, in SIB with suicidal intent the individual seeks isolation, has little or no social interaction, and does not seek to belong or participate in a group; someone with non-suicidal SIB does seek to relate to others who understand and even share his or her feelings and behaviors and participating in groups that promote self-harm [63]. Two more aspects to consider are that SIB occurs more frequently in women than in men, with skin cuts being the most common method; and women also have a higher risk of suicide than men (3:1), associated with greater feelings of hopelessness and inability to resolve emotional problems [46, 64].

In a recent study, authors have tried to establish the differences between people who engage in NSSI and people who attempt suicide through algorithms, but the results were inconclusive to distinguish between groups with high accuracy [65]. So, more studies are needed particularly in psychological primitives—irreducible fundamental elements of the mind [66, 67]: internal stimuli, external stimuli, and conceptual knowledge, in this case, on emotions related to SIB and suicidal ideation [68].

#### **2.2 Suicide**

Far from being an isolated problem, suicide is also on the rise worldwide, with developing countries showing the highest rates (800,000 people per year) [69]. In Mexico (5.4 per 100,000 inhabitants) [70], and particularly in Nuevo Leon (in the first half of 2020, 152 suicides), suicide rates have been increasing [71].

It is important to consider two aspects that could lead people to act out their death wishes: the erroneous perception of burden that their existence harms and hinders others' lives, feeling emotionally and socially disconnected [44, 72–74], and an increase in suffering due to possible traumatic or painful events [75–77] that, for the sake of self-preservation, could live in a constant state of pain, either self-inflicted through self-injurious behaviors or mistreatment of others [74, 78, 79].

Likewise, it is important to keep in mind that people with a single suicide attempt are more likely than people with suicidal ideation to suffer from some type of disorder—depression, anxiety, post-traumatic stress, substance abuse—and usually were

exposed to some type of abuse, whether violent, psychological and/or sexual [80–82]. Similarly, people with multiple suicide attempts have a high rate of family suicide history [83, 84] and childhood emotional abuse, [76, 85, 86]; as well as psychopathological characteristics [87, 88], a higher degree of suicidal ideation [89, 90] and a higher proportion of psychiatric disorders [91, 92].
