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SEXUAL ABUSE 101

The following is information all physicians should have when they encounter children and families of sexual abuse.

A. Definition

Sexual abuse can be defined as the involvement of children in sexual activities they do not understand, to which they are unable to give informed consent, or that violate the social taboos of family roles. It may involve attempted intercourse. However, other sexual activities, such as fondling and exhibitionism, also constitute sexual abuse.

B. Child sexual abuse is common.

One in 3 to 4 adult women were sexually abused as children, as were one in 7 to 9 men. Approximately 650 children are evaluated at ACH each year for suspected sexual abuse. Most UAMS pediatric residents will evaluate 8 to 20 sexually abused children during their residency.

C.Legal requirement to report a suspicion

  • Arkansas Act 703 of 2007 states the following:

When any individual listed in subdivision (b)(4) of this section has

reasonable cause to suspect that a child has been subjected to child

maltreatment or has died as a result of child maltreatment or observes

a child being subjected to conditions or circumstances that would

reasonably result in child maltreatment, he or she shall immediately

notify the child abuse hotline by telephone call, facsimile transmission,

or online reporting.

  • Reporting is to the Arkansas Child Abuse Hotline, at 800-482-5964. This legal mandate to report applies to physicians, nurses, and almost all who have professional responsibilities involving children.
  • Legislative Act 1210 of 2001 defines child maltreatment to include physical, sexual and psychological abuse, neglect and abandonment. It also includes conduct creating a realistic and serious threat of death, permanent or temporary disfigurement, and impairment of any bodily organ.
  • Note that a suspicion (rather than certainty) must be reported. Failure to report a suspicion of maltreatment imposes a risk of civil suit and criminal charges. In addition, a child may subsequently be re-injured or die. The report must be made to the Hotline; it is not sufficient to call a law enforcement agency or the Arkansas Department of Human Services. If the call to the Hotline is delegated to a staff member, the physician is responsible for confirming that the report was made.
  • The investigating agency can “found” or “unfound” a suspicion, depending on the evidence uncovered. Some physicians have been concerned they may be liable for

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  • suit if a report is unfounded, but protection is included in legislation. No legislative protection for failure to report exists.

D. Some children are more likely to be sexually abused than others.

These risk factors are especially common:

  • presence of a step-father or other father figure in the home
  • living without the mother at some interval
  • lack of maternal high school education
  • lack of emotional closeness to the mother
  • sexually repressive mother
  • lack of physical affection from father
  • family income less that $10,000
  • spousal violence
  • child physical abuse
  • trusting/naïve child with little self-confidence and tendency to obey others

E. Most physical evaluations of sexually abused children are normal.

Recent studies have shown that 85% to 95% of children who have given clear histories of being sexually abused have normal or non-specific medical findings on examination, either because the injuries they sustained have healed completely by the time they are examined, or because the acts of abuse did not cause any physical injury to the child. Many children do not have a clear concept of vaginal intercourse; for them, a described insertion of an object may be a pushing against their external genitalia or penetration beyond the labia minora into the vestibule but not through the hymen. Penetration of the hymen in girls who are into puberty may not cause injury because of the ability of the tissues to stretch, or it may cause a minor injury that heals completely. Even pregnant teenage girls frequently have normal hymens. Penile penetration of the anus commonly produces no findings.

F. Sexual abuse causes family, behavioral, and psychological harm.

Children commonly display behavioral and psychological signs of the stress of maintaining the secret of sexual abuse. They often disclose first to other children before

telling an adult, because of fear of not being believed, being punished, or causing distress

in the family. The stress does not always improve with disclosure. Frequently, parents and others do not believe the child, the child undergoes multiple interviews, and examinations are insensitively performed. Siblings may become angry at a child for having disclosed when it results in a removal of an adult who is significant in the life or income of the family. Many sexually abused children recant their disclosure as a result.

The child who has been sexually abused is at increased risk of the following sequelae:

  • delinquency
  • running away
  • excessive alcohol and illicit drug use
  • teen pregnancy
  • becoming abusive parents
  • having difficulty forming stable relationships

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  • post-traumatic stress disorder
  • depression and other psychological sequelae
  • re-victimization (40% before age 18)

Therapy can moderate the risk of these occurrences.

G.Most sexual offenders are well-known to the child and family, and most are relatives or situated in the family like relatives. The vast majority of offenders are child molesters or people who have an abnormal attraction to children, rather than rapists. Child molesters frequently create situations in which they can become close to vulnerable children and establish a long term relationship with a child whom they consider unlikely to disclose. They gradually “groom” the child, as they increase the intensity of the sexual abuse acts. The offender's/child's “secret” is maintained through:

  • Threats of harm to the child or family
  • Pity (perpetrator would go to jail)
  • Blaming the child
  • Bribery
  • Misrepresentation of normal family behavior
  • Insisting no one will believe the child’s disclosure

Because the offender is commonly a family member, the non-offender parent often is conflicted as to whether to believe the child’s disclosure or the adult offender's denial.

H.Sexual assault (rape) is a different entity than sexual abuse. (See TABLES I and II following this section)

I. Sexual abuse forensic examiners can be divided into these levels based on their level of skills and experience.

Primary Examiner (often primary care or community hospital Emergency Department physicians)

  • Evaluates children and adolescents for evidence of acute injuries
  • Tests for STDs, performs a State Crime Lab Sexual Assault Kit collection if appropriate, and provides initial management
  • Refers children to a specialized center to assess for non-acute, healed injuries.
  • Refers children to the ACH Emergency Department or elsewhere to re-assess acute findings or obtain appropriate tests

(Note: Although only a single exam is desirable, not all facilities can have an experienced examiner able to assess for non-acute trauma.)

Secondary Examiner (most ACH Emergency Department attendings)

  • Evaluates children and adolescents for evidence of acute injuries
  • Tests for STDs
  • Recognizes hymenal findings that are clearly normal or normal variants
  • Provides appropriate initial management
  • Refers to a specialized center such as the UAMS Arkansas Children's House for confirmation that a healed injury may be present, if needed; otherwise, arranges other appropriate referrals (including mental health) and follow-up tests for STDs
  • Documents abnormal findings by photographs or videotapes

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Tertiary Examiner (UAMS Children’s House forensic examiners)

  • May see children only on appointment, utilizing criteria that must be met to give an appointment for a deferred examination (>72 hours post exposure, child is asymptomatic and safe, and the alleged perpetrator is not known to have a STD)
  • Provides colposcopic examinations and photo-documentation
  • Utilizes a comprehensive approach to management of the child and family, including crisis intervention, case review, counseling, follow-up tests for STDs, referrals, and interaction with the investigating agencies.

Unless residents complete a subspecialty elective in child maltreatment, they likely will be at the primary level upon completion of the residency.

J.Residents will participate in the examination of sexually abused children.

Pediatric and medicine-pediatric residents will examine boys and girls suspected of having been sexually abused. Most of these examinations will occur in the ACH Emergency Department and UAMS Children's House. The vast majority of children can have stress-free examinations in the supine and knee-chest positions if properly prepared and supported; Child Life can assist in the Emergency Department. Children should never be restrained.

An accurate examination is critical. Failure to recognize abnormal findings may result in lack of protection of a child or prosecution of a perpetrator. The interpretation of normal variants as abnormal may severely disrupt the life of a child and result in the arrest of an innocent person. All examinations in the ACH Emergency Department should be performed with an attending to enhance accuracy.