By Santa J. Bartholomew M.D. FAAP, FCCM & Betsy Kastak, DNP, RN, C-PNP
The impact of sexual abuse on children is broad and complex. Studies provide evidence that child sexual abuse accounts for multiple long-term deleterious outcomes including psychiatric disorders, posttraumatic stress disorder and mood, anxiety, and substance use disorders in children, as well mixed evidence for personality disorders in adolescence and adulthood. While there are clear physical and psychological consequences to the child who has been abused, there are also shame and guilt among the adults responsible for the safety and well-being of the child who was sexually abused. Abuse can have far-reaching consequences that may leave a legacy of guilt, trauma, and mental illness for generations.
Sexual abuse is the sexual activity by a parent, caregiver, or responsible adult perpetrated on a child. Abuse can involve touching or non-touching.
Sexual abuse is the sexual activity by a parent, caregiver, or responsible adult perpetrated on a child. Abuse can involve touching or non-touching.
- Touching includes stroking a child’s genitals, making a child touch someone else’s genitals, rubbing one’s genitals against a child, playing sexual games, and putting objects or body parts inside the vulva or vagina, mouth, or in the anus of a child to realize sexual stimulation.
- Non-touching includes showing pornographic material to a child, photographing children in sexually provocative poses, trafficking or prostituting children, or encouraging a child to watch a sexual act in person or using video.
In the United States, statistics predict that approximately one in four adult women and one in six adult men report being abused sexually as children. The prevalence of childhood sexual abuse is unknown because many victims never share their history. Boys are much less likely to disclose abuse because of the fear that the abuse may reflect on their sexual identity or may be a threat to their “manliness.” Both boys and girls often fail to disclose abuse since it usually begins as a “fun” or “loving” relationship between a child and an adult that eventually devolves into a sexual interaction. Children are confused and afraid of hurting someone they love, their abuser.
Researchers suggest rates of child sexual abuse in the US may vary from 1% to as high as 35%. Most professionals agree that there will be 500,000 babies born in the United States this year who will experience childhood sexual abuse before they turn eighteen years old.
The American Academy of Child and Adolescent Psychiatry provides guidelines for what to say to a victim and what to do following disclosure of sexual abuse. This allegation requires a report to child protective services in all 50 states. Healthcare workers, such as primary care providers and nurses, who often initially encounter an allegation of child sexual abuse, are advised to determine the child’s immediate need for safety first. Then, in a private environment away from suspected abusers, collect more basic information.
It is strongly recommended that children not be interviewed in depth by anyone who has not been trained as a forensic interviewer. Leading statements can distort the story and will not be legally valuable in court. Disclosing abuse can be distressing, embarrassing, and shameful for the child. Reassuring the child that they have done the right thing by revealing the abuse and that they are not at fault often helps the interviewer to gather more information. It is also recommended that investigators use a non-judgmental and nonthreatening line of questioning toward suspected abusers and withhold expressing shock or disgust.
The Evaluation
When evaluating a child for sexual abuse, an extensive, general medical history must first be completed. This is the foundation of all medical evaluations, which help medical professionals plan how to navigate their physical exam. The healthcare provider should meet with the non-offending caregiver and then, if old enough, meet with the child and their chaperone to assess facts of which the caregiver may not be aware. This medical history must include the gastrointestinal and genitourological systems. It should also include factors like changes in sleep patterns, changes in appetite, increased stress level, changes in school performance if relevant, and symptoms of depression.
The Physical Examination
Parents, law enforcement officers, and CPS professionals understandably look forward to receiving a quick answer from the physical exam, which will confirm or invalidate allegations, but this is often not possible. Unless this is an acute event and/or life-threatening, an emergency room is the least appropriate setting for an exam. Sexual abuse exams should be done once by a person with significant experience and knowledge of child sexual abuse. This person should have time, privacy, and appropriate equipment available during the exam. Because children rarely disclose immediately after an event, the need for a rape kit and diagnosis of injury or STI are typically not of primary concern.
Exams should be scheduled in a calm setting, usually outpatient but depending on the age of the child a sedated exam may be required. The exam may additionally have a significant therapeutic value to the child, who may assume they have been injured. A normal anogenital exam in the abused child may greatly alleviate fears that have been building in the child for years. The exam aims to identify and treat any abnormality that may exist but also to reassure the child and family.
In very young children, vaginal or anal penetration with a penis, fingers, or a foreign body is possible but rare. Depending on the child’s size, forced penetration can cause internal lacerations and bleeding. In severe cases, it can cause damage to internal organs and, in some cases, death. Child sexual abuse may cause sexually transmitted infections. The extent of injury depends on multiple variables, the most significant of which is the degree of force and object used.
A physical exam on a child that includes a SA exam should only be done in the context of a complete physical exam so that the child knows their entire body is important. While the exam of the anogenital region will take the most time, it should not be first and should just be done as part of a complete exam. When formulating a conclusion based on examination AND history, the medical professional must consider not only medical history, and the disclosure, but also behavior reported by parents, teachers, and family, any symptoms related to sexual contact, as well as exam findings, and forensic details. Medical findings rarely stand on their own. Diagnosis will contain a combination of medical conclusions, forensic interview findings, and positive laboratory data. 95% of sexual exams alone are “negative” for signs of abuse even when a conclusion of sexual abuse is made based on all the available data.
In the past, much of the physical exam focused on the hymenal membrane orifice. Law enforcement, parents, and CPS workers would like to hear that the membrane is “intact.” However, any genital contact is inappropriate and considered sexual abuse in a minor child. Vulvar coitus, rubbing of the thighs, or gluteal coitus are common methods of abuse. All leave the hymenal orifice intact but impact the child psychologically.
The Psychological Well-being of the Child
Children who receive emotionally supportive responses following disclosure of sexual abuse may have fewer traumatic long-term symptoms. One study in Sweden identifies the level of family support as one of the most important predictors of the degree to which the child can adjust following the disclosure of child sexual abuse. Non-validating and otherwise non-supportive responses to disclosure by the child’s primary attachment figure may indicate a problem with the relationship predating the sexual abuse. This disordered relationship can remain a risk factor for the child’s long-term psychological well-being.
References:
Back, C., (2012). The Legal Process in Child Sexual Abuse, Difficulties in confirming evidence and providing support. Linköping University medical dissertations No. 1338
Berliner, L., & Elliott, D. M. (2002). Sexual abuse of children. In J. E. B. Myers, L. Berliner, J. Briere, C. T. Hendrix, C. Jenny, & T. A. Reid (Eds.), The APSAC handbook on child maltreatment (pp. 55–78). Sage Publications, Inc.
Vaskinn, A., Melle,I., Aas, M., Ottesen Berg, A. (2021) Sexual abuse and physical neglect in childhood are associated with affective theory of mind in adults with schizophrenia. Schizophrenia Research: Cognition Volume 23,
Child Sexual Abuse Definition & Facts | Prevent Child Abuse NC
Laskey, A. & Sirotnak, A. Child Abuse Medical Diagnosis, and Management 4th Edition. American Academy of Pediatrics Publishing 2020 (pp.309-476)
