Introduction
Reproductive and sexual health is not only the complete physical, mental, and social well-being of the functioning of the reproductive system but also the absence of any disease or disability in this system [1]. Having a healthy reproductive system and sexual behavior is imperative in many aspects [2]. One of the important causes of sexual injuries is the lack of abilities and skills required in the sexual management of children and adolescents [3]. Today, many children or teenagers are enticed to cyberspace for games and entertainment. Their presence in this space may have harmful and irreparable effects on morality, growth and development, and social identity [4]. The COVID-19 pandemic has intensified this trend toward cyberspace [5]. Children and adolescents react more to threats and tend to show maladaptive and risky coping behaviors [6]. One of the dangers that threaten children-teenagers in cyberspace is getting to know people with sexual deviance and starting subsequent dangerous and traumatic relationships, unhealthy friendships, to be exposed to emotional and sexual abuse, and finally, endangering their health, i.e., the possibility of suicide and other physical and mental disorders that can remain in the victim until the end of life [7]. 
According to the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition DSM-5, paraphilia refers to “non-normophilic” interest, in other words, any strong and persistent sexual interest other than normal human partners. Pathological paraphilia (paraphilic disorder) is when a person’s behavior is illegal or associated with discomfort or significant clinical disorder in the social environment [8]. According to DSM-5 and from a social point of view, paraphilia is known as a deviation from acceptable forms of sexual arousal [9]; the affected person engages in some sexual acts and fantasies that cause severe discomfort or interpersonal, social, and occupational problems or other important functional areas in society [10, 11]. Sexual abuse includes unwanted sexual movements, behavior, and actions, from annoying looks and nasty behaviors (verbal, non-verbal, and physical) to sexual assault. Therefore, the behavior of people with paraphilia causes sexual abuse in the victim [12]. One of the existing challenges is the high prevalence of these sexual abuses, which due to the lack of self-reporting by the victims, accurate statistics are not available [13]. Nahavandi et al. (2010) in Iran mentioned that the prevalence rates of sexual abuse were as follows: nasty words, 92.5%; touching, 42.5%; and annoying looks, 77.5% [14].
Despite limited research, official reports show that not only is there a high rate of committing these acts, but each perpetrator has a large number of victims, too [15]. One of the most vulnerable target groups of victims of sexual deviance is children-teenagers. This issue has raised many concerns at the global level due to the increase in child abuse cases [16]. Child sexual abuse has become a social problem because it has destructive consequences on various aspects of the personality of children-teenagers [17]. Therefore, sexual education of children is necessary to prevent such crimes [18]. According to the latest definition of the World Health Organization (WHO), sexual education refers to all actions that are carried out from the early stages of a person’s life to develop balanced and appropriate sexual instincts, and its goals include sexual information, help develop appropriate sexual behaviors, to perform properly sexual duties, survive the generation, and reach peace [19]. Also, sexual education is one of the issues considered by Islam religion in its field of education [20]. In Iran, sex education faces many problems because of ambiguities, theoretical misunderstandings, and practical obstacles. These issues have caused many social problems, as well as behavioral and sexual deviations [21]. Considering the attractiveness of cyberspace for children and teenagers, who constitute a significant population in the country, the vulnerability of this group due to the insufficient ability to understand the dangers of the negative consequences of cyberspace, and the high prevalence of paraphilia in cyberspace and everyday life, this review study investigated reproductive and sexual health consequences in victims of child-adolescent sexual abuse and preventive strategies.
Materials and Method
In this review study, the electronic databases, such as PubMed, CINAHL, Web of Science, Google Scholar, , ScienceDirect, Scopus, Magiran, and SID were investigated using the keywords of “sexual deviation,” “consequence,” “victim,” and “reproductive and sexual health.” Initially, 189 articles were reviewed in English and Persian language journals, and after the initial review, 46 articles were removed based on their irrelevant abstracts and titles in the first stage. Then, 143 articles were evaluated, of which 28 were removed due to lack of evidence, and finally, 115 full-text articles were reviewed. The search strategy was carried out using the prisma flowchart, which is mentioned in diagram Figure 1. Results
The findings of this stduy including the different types of sexual deviation and its consequences on child and adolescent victims, and the prevention strategies are summarized in Table 1.


Types of Sexual Deviations in Humans 
Pedophilia
Pedophilia refers to a strong recurring sexual desire for children 13 years old and below that exists for at least six months; affected people are at least 16 years old and at least five years older than the victims [22, 23]. Pedophilia is a subset of various disciplines, including psychology, psychiatry, criminology, and sexual ethics [24]. Between 100000 and 500000 children are sexually abused in the United States each year. Overlooking child abuse and pedophilia and treating it can have serious and long-term consequences for innocent victims and continued abuse for the perpetrator. Many pedophiles can benefit from proper treatment. The main key to reducing the frequency of sexual abuse of children is primary prevention [25]. The sexually-abused Children and adolescents develop mental health disorders and adjustment problems in addition to physical consequences, which continue until adulthood [26].
The cause of pedophilia is generally related to psycho-social factors and is not biological. For example, they may have been abused in childhood [27]. However, recently, biological factors, such as IQ and poor memory, less white matter in the brain, low testosterone, hormones, and problems in the brain, have also been proposed as possible causes of pedophilia [28].
Voyeurism
Voyeurism is an exaggerated desire to see people’s private situations, such as having sex with others, naked bodies, and seeing people in situations, such as defecating and so on [29]. A person with such a strong desire feels compelled to look. People with sexual spectatorship disorder usually do not approach the victim and do not intend to have sex with her. Therefore, these people are often not dangerous and do not physically harm the victim. They enjoy secretly looking at others and violating their privacy while the victims are unaware of this issue [30].
Exhibitionism
Exhibitionism is a type of sexual deviance in which a man strongly desires to show his penis to others [30]. It is one of the types of sexual abuse that is considered a crime, but its punishment is not clearly defined in Islamic societies [31].
Clinical experiences show that visible private parts have four characteristics: abnormal erotic preferences, self-gratification, physical contact with the victim, strong tendency to choose relative strangers as targets for sexual activity [32, 33]. A study on 238 cases of exhibitionism showed that more than two-thirds (68.1%) preferred to choose the victim from among unknown people [34]. Also, one-third of affected people choose this act as an alternative to intercourse with the target person, and one-third intend to sexually stimulate the target person [35]. Marshall et al. reported that cognitive treatments and reconstruction, strengthening relationships and interpersonal skills, and improving awareness and monitoring to prevent recurrence could effectively treat this sexual deviation [36].
Frotteurism
According to the DSM-5, frotteurism is a rare paraphilia characterized by frequent, intense, usually masculine sexual arousal from touching or rubbing. The problem must at least be present for at least six months. This sexual deviance is considered a form of sexual abuse for the victims and a crime [37]. The victims are usually women whose body parts are usually touched and rubbed in public places without consent [38, 39]. Frotteuring behaviors are usually performed between the ages of 15 and 25, and after 25 years, the frequency of such behavior usually decreases [40]. The cause of this sexual deviation is exposure to emotional stressors during childhood. It is also reported that this disorder may be associated with bipolar disorder, child abuse, temporal lobe epilepsy, and schizophrenia [38, 41]. Due to the lack of research, the prevalence of frotteurism, especially in women, is unknown. However, according to a systematic review, the prevalence of frotteurism in men ranges from 35% in the United States to 7.9% in Japan [38]. The prevalence of this disease in Iran has not been determined; due to cultural factors, most people with frotteurism in Iran do not seek professional help in clinical centers. As mentioned earlier, most of the affected people are male, and most of the victims are female. However, the reverse is also possible [42, 43]. Stephanie showed that victims reported several negative outcomes due to being victimized, including feeling violated, changes in behavior, and even long-term mental disorders and anxiety [44].
Sexual Sadism
Sexual sadism means causing physical and mental suffering in another person and enjoying seeing the suffering of the victim [45, 46]. The WHO has a diagnostic system called the international classification of diseases-10th revision (ICD-10), in which sadism and masochism are combined in one category [47]. Some studies have mentioned sexual sadists with other titles, such as criminals, lust killers, serial sex killers, and people who commit crimes [48]. Almost all available studies focus exclusively on male offenders, but some females also have sexual sadistic deviance [49].
Consequences of child sexual abuse from the point of view of reproductive and sexual health
The impact of COVID-19 on child sexual abuse
The spread of infectious diseases like COVID-19 and social distancing has profoundly affected the rate of various crimes [50]. One of the effects of the COVID-19 pandemic and its restrictions is the increase in sexual abuse and violence against children and adolescents. On the other hand, child sexual abuse is often done by relatives when quarantine days make children-teenagers, and close relatives stay together for a long time [51]. On the other hand, the closure of schools, the impossibility of being with friends, and the lack of entertainment to fill free time lead to turning to cyberspace and sexual curiosities and friendship with unknown people, which can lead to trouble in the catch of pedophilic people [7]. The progress of science and technology has affected sexual health and fertility. One of the issues that have accompanied the progress of science and technology related to reproductive and sexual health is the use of cyberspace, which has received much attention, especially during the COVID-19 pandemic [52].
Pregnancy complications for children and teenagers
Children and adolescents who are victims of rape may face the problem of unwanted pregnancy [53]. Pregnant teenagers under 15 are more exposed to adverse pregnancy and childbirth outcomes [54]. These consequences include preeclampsia, eclampsia, premature birth, fetal-maternal deaths, postpartum depression, and neonatal consequences [55]. According to the statistics from the WHO, the risk of death during childbirth in girls under 15 is five times that of older girls [56]. Also, following the pregnancy caused by rape in children and adolescents, the number of abortions in adolescents has increased, especially illegal and unsanitary abortions [57].
Children and teenagers affected by rape and sexually transmitted diseases
Another consequence of sexual assault in children and teenagers is contracting sexually transmitted diseases [58]. According to the statistics reported in 2018, the prevalence and incidence of sexually transmitted infections in America were more than 67 million and 26 million people, respectively [59]. The most common infections are gonorrhea, syphilis, chlamydia, genital herpes, genital warts, HIV, hepatitis, and trichomonas [60]. Therefore, if the aggressor suffers from these diseases, she or he can transmit the disease to the victim. Most of these diseases have serious long-term complications for these victims in the future, among which complications such as pelvic inflammatory diseases, infertility, ectopic pregnancy, and genital tract cancer can be mentioned [61].
Reluctance to marry and have children
Pedophilic people target both girls and boys [62]. Children-adolescent victims, especially girls, may imagine they have limited possibilities in front of men and their violence, and they become suspicious and afraid of men [63]. Pessimism and fear [63], feelings of inferiority and insecurity [64], and mistrust of the opposite sex [65] are possible reasons for reluctance to marry and have children in the future of these children.
Posttraumatic stress disorder
Posttraumatic stress disorder (PTSD) is one of the mental disorders caused by the rape of children and teenagers. After sexual and physical abuse, the child experiences severe psychological symptoms. These symptoms include anxiety, depression, aggression, thoughts of suicide or suicide, feelings of shame and guilt, pessimistic thoughts, Stockholm syndrome, eating disorders, dropping out of school, turning to drug abuse, risky sexual behaviors, and suffering from various sexual deviations [27, 66, 67, 68, 69]. Almost all rape victims show symptoms of PTSD in the days after the event [70], and about 40% within 3 months after that event [71].
Sexual Dysfunction in Adulthood
According to Firouzi et al. (2016), the experience of childhood abuse in married women is associated with sexual dysfunction and leads to a negative self-image and a decrease in sexual performance [72].
The effect of abuse on the psychological, emotional, and behavioral dimensions of children and teenagers
Child abuse is not only limited to physical harm to children-teenagers but also includes sexual and mental harm and neglect. Its complications and consequences appear in different types and the long term and even lifelong. Children-adolescents who face sexual abuse may experience maladaptive emotional, social, cognitive, and physical behaviors [17, 73]; especially if child abuse is long-term, children-adolescents are prone to becoming violent in the future. Also, these children or teenagers may suffer from communication disorders and the inability to establish intimate relationships. The possibility of pedophilia also increases in these people [74]. Notably, they may be completely isolated, and when they grow up, more serious symptoms, such as suicide, may threaten them [75].
The effect of abuse on the cognitive dimension of children and adolescents
Various brain injuries are caused by sexual abuse, which leads to cognitive changes in a person. If sexual abuse happens between the ages of one and three years, it may cause trauma, reduce growth and change parts of the brain, which results in a negative effect on memory, emotions, and basic movements [17, 76]. 
The effect of abuse on the emotional dimension of children and adolescents
Negative effects on the emotional dimension create a kind of unstable and insecure attachment in children-teenagers. This condition results in their being rejected by their friends and losing their friendships. They mostly feel hatred toward others [77], and they are very sensitive to anger [78]. Other emotional problems include self-blame and guilt and difficulty regulating emotions. These people do not know to which situation each emotional reaction is related. Interestingly they can describe the feelings of others, but they are unable to describe their feelings [17, 79].
Effective sexual education of children and teenagers 
School-centered sex education with the triangle of family-school-peer 
In peer training and sex education by schools, when the more comprehensive, principled, and logical methods and programs are used, better and more effective sex education is formed in the individual [80]. Continuous sex education in kindergartens and schools [81], use of special educational models by peers [82], and participation in sex education classes, seminars, and programs lead to a better understanding of sexual issues in the individual because the information and awareness of the individual increases, his understanding of sexual matters improve [83, 84]. Forming the triangle of family-school-peer is an effective way of preventive interventions.
Teaching parenting skills to parents
Parents are the best teachers of sexual education to their children, and in fact, one of the most important tasks of every parent is the sexual education of their children [85]. When the parents do the education, the feeling of intimacy and trust between the child and the parents increases, and a safe, emotional, and intimate environment is formed in the family where the children can easily share their issues and questions with the parents. Increasing parents’ awareness about child abuse and its prevention directly affects their children’s awareness [86]. Some education that all parents need to give to their children includes teaching the differences between the two sexes, sneaking into the parents’ bedroom, and teaching the concept of private parts of the body [87]. Some points that parents should follow in the family environment to educate children about sex include avoiding watching inappropriate sexual videos in front of their children, evading parents from crude and nasty jokes, gestures, and sexual innuendos [88], avoiding caressing, kissing, and flirting with each other in the presence of children, preventing sexual acts in front of children, avoiding touching the child’s genitals, and the separation of children from their siblings [87].
Using family-oriented sex education models
Effective communication between parents and children creates a right attitude towards gender issues and correct sexual behaviors that include improving adolescent reproductive health, increasing awareness of puberty and menstruation, pregnancy, emergency contraception methods, delay in starting sexual activity, and prevention of unwanted pregnancy. Family-oriented education is important in effective sexual education; it can prevent many sexual misconducts [89].
Promotion of Sexual Restraint in Adolescents Exposed to High-Risk Sexual Behavior
According to WHO (2010), the best way to ensure learning and choosing healthy and safe sexual behavior is to limit wrong and unsafe sexual behaviors [90]. Sexual abstinence leads to chastity and delaying sexual relations until marriage and prevents committing risky sexual behaviors [91].
Monitoring the impact of the media on child sexual education
The media play an important role in the practice, policy, and public understanding of sexual abuse of children [92]. Mass media can be beneficial, considering that they have been an effective tool in the field of public health to influence behavioral changes for the primary prevention of sexual abuse of children [93]. On the other hand, the person should be aware of the negative impact of some media in sexually assaulting children. Jimmy Sanderson et al. (2020) pointed to the impact of Snapchat [94] and Heydari et al. (2012) on the impact of satellite and the Internet [95] on the sexual abuse of children. Therefore, considering the COVID-19 pandemic and the directing of most children to cyberspace [7], there is a need to educate parents and schools to effectively monitor the interaction of children and adolescents in cyberspace [96]. Fajri et al. (2017) stated solutions to protect against the harm of cyberspace in their study, among which we can mention the planning and timing of the use of social networks by the child [96].
Early diagnosis of disorders such as depression or anxiety in children and parents
Psychological stress, anxiety, and depression following sexual assault are a great threat to raped victims [97]. Its symptoms include decreased energy, guilt, lack of concentration, anorexia, suicidal thoughts, decreased activity, academic failure, heart palpitations, sweating, headache, stomach upset, and restlessness [98]. Early recognition of these disorders, paying attention to warning vulnerability factors, and timely treatment can greatly help the victim to prevent further consequences, such as suicide, and so on [99].
Avoiding destructive parenting styles, such as controlling or extreme freedom
Destructive parenting styles can cause initial incompatibility schemas and the formation of inappropriate thoughts and emotions in children and adolescents [100]. The extreme control of parents over their children, although in the short term, informs the parents of their children’s activities and decisions. In the long term, it leads to serious damage, including the fact that children lose their trust in their parents [101]. On the other hand, some easy-going parents prefer too much freedom without restrictions, which causes neglect of children and adolescents [102]. Obedient and free children are more vulnerable to aggressors in ambush [103].
Teaching life skills to children and teenagers
One of these critical situations of childhood and adolescence is the risk of rape [104]. Problem-solving is one of the cognitive-behavioral processes in which a person learns to use a conscious, logical, and purposeful adaptation process to apply effective and adapted solutions in problematic situations of everyday life [105]. Also, teaching help-seeking, critical thinking, and the skills of saying no in the face of risky suggestions helps children and adolescents in facing dangerous situations of rape [105, 106].
Discussion
In the current research, the types of sexual deviations, their reproductive and sexual health consequences in child-adolescent victims, and preventive solutions were investigated. The results indicated that security in public spaces is one of the indicators of the quality of urban life [107]. The fear of violence in public spaces affects the quality of people’s daily lives [108] because people suffering from sexual deviance take action in public places through abnormal and unusual sexual behavior to reach orgasm [109] and cause severe discomfort or interpersonal and social, occupational or other important functional areas in society [10, 11]. Finally, they cause sexual harassment in the victim [110]. On the other hand, cyberspace security is very important these days following the spread of COVID-19 because people, especially children, and teenagers, are attracted to it more than before for playing and entertainment. Unfortunately, pedophilic people use this space to entrap their victims [7]. 
The consequences of sexual abuse of paraphilic people are more towards children and teenagers, and the negative consequences include suffering from various sexually transmitted diseases, unwanted pregnancy, obstetric complications, preeclampsia, postpartum depression, reluctance to marry and have children, posttraumatic stress syndrome, suicidal tendencies, violent behaviors, suffering from various sexual deviations and sexual dysfunction [27, 54, 58, 63, 64, 66, 67, 68, 72, 111]. It also negatively affects the child’s psychological, cognitive, and emotional aspects [17, 28, 73]. Shahidi et al. (2021) assessed the psychological consequences of sexual abuse of children under the title of psychological consequences of sexual abuse of children under 15 years of age in Tehran Province using the examples obtained from the social emergency [17]. Tabatabai et al. (2020) pointed out the negative effects of sexual deviations in the collapse of the family foundation [112]. These studies are in line with the present study in terms of examining the consequences of sexual deviation [17].
In Iran, sexual education is facing many problems, which has caused many social problems and behavioral and sexual deviations [21]. The findings showed that the following measures could be used for the effective sex education of children and teenagers: using basic education at schools [80], participation in educational classes [84], the use of family-oriented educational models [89, 113], strengthening self-control [91, 114], teaching parenting skills to parents [86, 87], early recognition of disorders, such as depression or anxiety in children and parents, avoiding destructive parenting styles, such as controlling or extreme freedom, teaching life skills, critical thinking, saying no and asking for help to children and adolescents, and promoting awareness of the influence of the media [92, 94, 96, 99, 103, 105, 106, 115]. Goldman et al. (2011) suggested sex education at schools [80], Sattari et al. (2020) considered promoting self-control to be effective [91], and Asgharian et al. (2021) suggested a family-oriented sex education model [113].
These studies align with the present study in terms of providing solutions to reduce sexual misconduct among children and adolescents. However, the review of studies showed that solutions, such as using special educational models by peers, teaching parenting skills to parents, adopting the correct parenting style, teaching life skills, critical thinking, the skill of saying no and asking for help from children-teenagers, effective monitoring of children teenagers contact with the cyberspace, and paying attention to the early diagnosis of disorders, such as depression or anxiety in children and parents had not been widely considered.
Conclusion
In conclusion, it can be acknowledged that currently, because most paraphiliacs do not go to medical centers and the lack of accurate statistics on its prevalence. Due to the threatening consequences for children and adolescents, there is a need to increase sexual literacy by taking preventive measures at the macro policy level to the operational level, such as family, kindergartens, schools, sex education through the creation of games and interesting related programs by mass media and wide social communication networks with the use of relevant experts, the training of child sex educators, for awareness and preventing sexual harassment.

Ethical Considerations
Compliance with ethical guidelines
Ethical issues, such as avoiding plagiarism, ensuring robustness in relevant data acquisition, preparedness, and submission of the data were all taken into consideration by the authors. The study has an ethical approval (Code: IR.SSU.RSI.REC.1401.001) .

Funding
This research was supported by the research project (No. 13118), Funded by the University of Shahid Sadoughi. 

Authors' contributions
Data collection: Fatemeh Zahra Mimar and Tahmina Farajkhoda; Data analysis: Fatemeh Zahra Memar and Tehmina Farajkhoda; Financial sources: Nursing and Midwifery Research Center of Shahid Sadoughi University of Yazd.

Conflict of interest
The authors declared no conflict of interest.

Acknowledgments
We are grateful to the Vice Chancellor for Research and Technology of Shahid Sadoughi University of Medical Sciences for their support and all participants in this study.

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