The paediatrician and the sexually abused child

Sexual abuse is an aspect of cruelty to children which merits greater scientific attention. It has potential for damaging the mental health of the victim and intergenerational cycles of this behaviour pattern may develop. The paediatrician is in a position to detect children at risk and may be able to intervene. Three types of sexual abuse are described (i) single sexual attacks which may be accompanied by physical violence: (ii) sexual exploitation of children for financial gain, and (iii) longstanding sexual relationships, generally between girls and father figures; these are far the most common. Although it is hard to separate the effects of premature sexual experience from other adverse environmental influences. the child victim of longstanding sexual abuse emerges immature, with considerable confusion as to her role in the family, and with constricted personality development. Her primary motivation is attention seeking, and she adopts sexual activity with an adult as a means of survival in often deplorable conditions. The sensitivity of management following the assault being made public is an important factor in determining eventual adjustment.     

Predictors of attributions of self-blame and internalizing behavior problems in sexually abused children

BACKGROUND: The purpose of the present study was to identify predictors of two potential sequelae of child sexual abuse, self-blame attributions and internalizing behavior problems. METHODS: In the study, detailed information was collected on 218 victims of sexual abuse aged 4 to 17, involved in criminal cases, about their background, the abuse, and their mother's reaction following discovery of the abuse. RESULTS: Increased attributions of self-blame were predicted by the child having a close relationship with the perpetrator, experiencing severe sexual abuse (e.g., long-lasting abuse that involved penetration), perceiving the abuse as disgusting, and coping with the abuse by pretending it was not happening. Similar factors did not emerge as predictors of internalizing behavior problems. CONCLUSIONS: Results suggest that different child and abuse characteristics predict the two sequelae often associated with childhood sexual abuse. Thus, although self-blame attributions and behavior problems are often considered similar consequences of sexual abuse, there appears a need to distinguish the two types of outcomes following sexual victimization in childhood.     

Common Conditions That Mimic Findings of Sexual Abuse

Sexual abuse is a problem of epidemic proportions in our society. Given the prevalence of sexual abuse, it is vital for medical providers, including pediatric nurse practitioners, to recognize sexual abuse in their patients and respond appropriately. Failing to recognize sexual abuse can leave children at risk for continued abuse and potentially lead to the sexual abuse of additional children. Serious ramifications also can arise when sexual abuse is diagnosed erroneously. Children can be removed from their homes and placed in foster care. An innocent person can be prosecuted. It is important for pediatric nurse practitioners to understand that the majority of children who are sexually abused will have a normal or nonspecific ano-genital examination. However, physical findings of sexual abuse are noted in approximately 4% of children who give a history of sexual abuse. Certain clinical findings can mimic sexual abuse. This article will discuss some of the more common findings mistaken for sexual abuse and assist the pediatric nurse practitioner in correctly recognizing these findings and responding appropriately.     

Vulnerability or resilience to intergenerational sexual abuse: the role of maternal factors

This study examined vulnerability or resilience to intergenerational sexual abuse. The sample included 196 African American mothers and their children of which 96 were sexually abused and 100 had no reported incidents of abuse. Four groups were formed based on maternal report of a history of childhood sexual abuse and the child's abuse status: (a) sexually abused mothers of children who were not sexually abused, (b) sexually abused mothers whose child was sexually abused, (c) mothers with no history of sexual abuse whose children had no history of sexual abuse, and (d) mothers with no history of sexual abuse who had a sexually abused child. The findings indicate that mothers who break the cycle of abuse were functioning as well as the nonsexually abused mothers in the study. Furthermore, sexually abused mothers with abused children evidenced significantly more disturbed functioning than the other three groups of mothers, particularly in their attachment relationships.     

A Novel Scale to Communicate Perceived Likelihood of Child Sexual Abuse

Background and ObjectiveChild abuse pediatricians (CAPs) are often asked to determine the likelihood that a particular child has been sexually abused. These determinations affect medical and legal interventions, and are important for multisite research. No widely accepted scale is available to communicate perceived sexual abuse likelihood. In this study, we measure intra- and inter-rater reliability of a 5-point scale to communicate child sexual abuse likelihood.MethodsWe developed a 5-point scale of perceived likelihood of child sexual abuse with example cases and medical-legal language for each risk category. We then surveyed CAPs who regularly perform sexual abuse evaluations using the abstracted facts of 15 actual cases with concern for sexual abuse. A subset of participants rated the same vignettes again, 1 month later.ResultsOf 512 invited participants, 240 (46.7%) responded, with 145 (28.3%) indicating that they regularly perform sexual abuse evaluations, 116 initially completing all 15 vignettes, and 36 completing repeat ratings at least 1 month later. The scale showed consistent stepwise increase in mean perceived likelihood of abuse and intention to report for each increase in scale rating. Inter-rater agreement was substantial (Fleiss’ weighted kappa 0.64) and test-retest reliability among 36 participants was almost perfect (Cohen's kappa = 0.81).ConclusionsWe introduce a scale of perceived sexual abuse likelihood that appears to reflect CAPs’ perceptions and intention to report. This scale may be a reasonable metric for use in multicenter studies. CAPs demonstrated substantial inter- and intrarater reliability when evaluating sexual abuse likelihood in case vignettes. While this scale may improve communication of sexual abuse likelihood among experts, its examples should not be used as a legal standard or a clinical criterion for sexual abuse diagnosis.     

Sexual anxiety and eroticism predict the development of sexual problems in youth with a history of sexual abuse

Youth with confirmed histories of sexual abuse (N = 118) were followed longitudinally to examine associations between their initial sexual reactions to abuse and subsequent sexual functioning. Participants were interviewed at abuse discovery (ages 8 through 15) and again 1 and 6 years later. Eroticism and sexual anxiety emerged as distinct indices of abuse-specific sexual reactions and predicted subsequent sexual functioning. Eroticism was associated with indicators of heightened sexuality, including more sexual risk behavior and views of sexual intimacy focused on partners' needs. Sexual anxiety was associated with indicators of diminished sexuality, including few sexual partners and avoidant views of sexual intimacy. Age at abuse discovery moderated some associations, suggesting that the timing of abuse-specific reactions affects trajectories of sexual development. Findings point to the need for a developmental approach to understanding how abuse-specific sexual reactions disrupt sexual development and the need for early interventions promoting healthy sexual development.     

Child maltreatment and women's adult sexual risk behavior: childhood sexual abuse as a unique risk factor

This study investigated (a) whether childhood sexual abuse (CSA) was uniquely associated with adult sexual risk behavior, after controlling for other types of childhood maltreatment and (b) whether there were additive or interactive effects of different types of maltreatment on adult sexual risk behavior. Participants were 414 women (M age = 28 years) attending a publicly funded STD clinic. All women completed a computerized survey assessing childhood maltreatment (sexual, physical, psychological abuse, and neglect) and sexual risk behavior. Analyses showed that sexual abuse, physical abuse, psychological abuse, and neglect were associated with adult sexual risk behavior. Multivariate analyses that controlled for all other forms of child maltreatment showed that only CSA was uniquely associated with adult sexual risk behavior (i.e., percentage of episodes of unprotected sex in the past 3 months and number of lifetime partners). The authors found little support for an additive or an interactive model of the effects of different types of childhood maltreatment on adult sexual risk behavior; CSA alone was the best predictor of adult sexual risk behavior. Sexual risk reduction interventions are needed for women who were sexually abused as children. Continued research on the effects of multitype maltreatment on adult sexual risk behavior is needed.     

Evidence for sexual transmission of genital herpes in children.

INTRODUCTION: Genital herpes in a prepubertal child presents a child protection clinician with a difficult problem: how likely is it that transmission occurred as a consequence of sexual abuse? Published guidelines on the management of sexually transmitted infections in children provide varying recommendations and refer to a limited literature. OBJECTIVE: To review the evidence for the likelihood of sexual transmission in a child with proven genital herpes. METHODS: Structured literature search for reports of series of children presenting with genital herpes where an assessment for possible sexual transmission or child sexual abuse had been made. RESULTS: Five suitable papers were identified. Although just over half of reported cases of genital herpes in children had evidence suggestive of a sexual mode of transmission, the quality of assessment of possible sexual abuse was too weak to enable any reliable estimation of its likelihood. Sexual transmission is reported more commonly in older children (aged > or =5 years), in children presenting with genital lesions alone and where type 2 herpes simplex virus is isolated. CONCLUSIONS: Child protection clinicians should be aware of the weakness of the evidence on the likelihood of sexual transmission of genital herpes in prepubertal children. The US guidance that child sexual abuse is "suspicious" reflects the evidence better than the UK guidance that it is "probable". A larger, more up-to-date, methodologically sound, population based study is required.     

Sexual abuse of human immunodeficiency virus-positive children. Outcomes for perpetrators and evaluation of other household children.

OBJECTIVE--To obtain the following data that pertain to programs for the prevention of sexual abuse and sexual transmission of human immunodeficiency virus (HIV) to children: (1) to determine the prevalence of sexual abuse among siblings and other children cohabiting with sexually abused HIV-positive children, and (2) to determine if programs designed to restrain identified perpetrators from further acts of child sexual abuse were instituted. DESIGN--Case series. SETTING--Households of previously described sexually abused HIV-infected children. PATIENTS AND OTHER PARTICIPANTS--Twenty-two siblings or other children who lived in the homes of 14 previously described HIV-infected sexually abused children. Eight perpetrators of the abuse were identified. MAIN OUTCOME MEASURES--Sexual abuse of cohabiting children was confirmed with disclosure interviews, witness by other persons, diagnosis of another sexually transmitted disease, or an abnormal physical examination result that was highly suggestive of sexual abuse. Telephone contact with the Department of Social Services, county sheriff or police, and district attorney provided data regarding reports, criminal indictments, trials, convictions, and plea-bargain arrangements for the identified perpetrators. RESULTS--Eleven (50%) of the 22 cohabiting children were confirmed to have been sexually abused and four (18%) were suspected of having been sexually abused. Seven (32%) of the cohabiting children could not be examined and it was not known if they had been sexually abused. No assailant was tried for a criminal offense, required to participate in offender therapy, or prohibited from unsupervised visitation of children. CONCLUSION--Programs for the prevention of sexual abuse and sexual transmission of HIV to children require means of ensuring the safety of children exposed to perpetrators and require adequate supervision of perpetrators and their adherence to therapy.     

Child abuse and domestic violence in families of children seen for suspected sexual abuse

We surveyed families of children seen in a sexual abuse evaluation clinic regarding domestic violence in the child's home and physical and sexual abuse during childhood among the mothers. Domestic violence occurred in 54% (216/402) of the children's homes; 28% (111/392) of mothers reported childhood physical abuse, and 42% (167/395) reported sexual abuse. There were no differences in the rates of domestic violence (chi 2 = 0.42, 2 df, p = 0.8), maternal physical abuse (chi 2 = 2.40, 2 df, p = 0.3), or maternal sexual abuse (chi 2 = 2.11, 2 df, p = 0.3) based on whether our current, patient was at high, medium, or low risk for having actually experienced sexual abuse. Neither domestic violence in the child's home nor the mother's childhood experience of abuse was increased if the child's perpetrator was a relative or lived in the home. Domestic violence in the child's home was more frequent if the mother had experienced physical abuse during childhood (65% 70/107) than if she had not (48%, 130/271; chi 2 = 8.69, p < 0.01). Child sexual abuse is part of a global pattern of victimization, and clinicians must address other forms of family violence when evaluating a child for allegations of sexual abuse.     

Child Sexual Abuse: Consequences and Implications

Sexual abuse is a problem of epidemic proportions in the United States. Given the sheer numbers of sexually abused children, it is vital for pediatric nurse practitioners to understand both short-term and long-term consequences of sexual abuse. Understanding consequences of sexual abuse can assist the pediatric nurse practitioner in anticipating the physical and mental health needs of patients and also may assist in the identification of sexual abuse victims. Sexual abuse typically does not occur in isolation. Implications for practice will be discussed.     

Beyond sexual abuse: the impact of other maltreatment experiences on sexualized behaviors

This study sought to broaden research findings linking maltreatment to sexualized behaviors by investigating whether maltreatment experiences other than sexual abuse predict such behaviors. The sample included 690 children without reported sexual abuse histories who are participants in the LONGSCAN Consortium, a prospective multisite investigation of childhood maltreatment. Child Protective Service reports before age 8 years and caregiver reports on the Child Sexual Behavior Inventory-II at age 8 years were used to examine the relationship between maltreatment timing and type, and sexualized behaviors. Logistic regression analyses suggested that early (< 4) and late (4-8) reports of physical abuse were associated with more sexualized behaviors (odds ratios = 1.9-2.6). The pattern differed by gender, with physical abuse predicting sexual intrusiveness and displaying private parts in boys, and boundary problems in girls. Findings suggest that maltreatment other than sexual abuse, and the developmental periods in which it occurs, may be linked to the development of sexualized behaviors.     

A Normal Ano-genital Exam: Sexual Abuse or Not?

Sexual abuse is a problem of epidemic proportions in the United States. Pediatric nurse practitioners (PNPs) are at the forefront of providing care to children and families. The PNP is in a unique position to educate patients and families regarding sexual abuse and dispel common myths associated with sexual abuse. One such myth is that a normal ano-genital examination is synonymous with the absence of sexual abuse. This article will provide primary care providers, including PNPs, with a framework for understanding why a normal ano-genital examination does not negate the possibility of sexual abuse/assault. Normal ano-genital anatomy, changes that occur with puberty, and physical properties related to the genitalia and anus will be discussed. Photos will provide visualization of both normal variants of the pre-pubertal hymen and genitalia as well as changes that occur with puberty. Implications for practice for PNPs will be discussed.     

Repeated sexual abuse allegations: a problem for primary care providers.

Sexual abuse of children is a problem of epidemic proportions in the United States. Primary care providers, including pediatric nurse practitioners, are increasingly presented with the problem of alleged sexual abuse in their patients, and primary care providers typically find it difficult to perform medical evaluations of children for sexual abuse. Having a child present repeatedly with sexual abuse concerns that cannot be substantiated is a stressful and frustrating experience for primary care providers. A case study is presented that illustrates the complexity and difficulty of one such case. A review of the literature will discuss the impact of divorce and Munchausen syndrome by proxy on repeated allegations of sexual abuse. Implications for practice are discussed, and a plan that addresses repeated sexual allegations in primary care settings is outlined.     

From child victim to adult victim: a model for predicting sexual revictimization

Women with histories of child sexual abuse (N = 221) participated in a study designed to test a model for predicting adult/adolescent sexual revictimization and post-assault functioning. Participants completed anonymous questionnaires regarding their sexual victimization history, post-sexual assault symptoms and attributions, and consensual sexual behavior. Repeated victimization was defined as having experienced child sexual abuse and a separate incident of adolescent/adult victimization. Repeated victimization was associated with having experienced child sexual abuse involving physical contact, including intercourse and/or penetration. Women with repeated victimization engaged in more self-blame, reported higher levels of post-traumatic symptoms, and reported more high-risk sexual behavior. A path model was developed that indicated that the relationship between revictimization and child sexual abuse was mediated by self-blame, post-traumatic symptoms, and consensual sexual activity. The results suggest the need for further research on revictimization as well as suggesting areas for intervention to prevent sexual revictimization.     

Anal injury and fissure-in-ano from sexual abuse in children

Ano-rectal injuries in children are generally uncommon, and those caused by sexual abuse are rarely reported in our environment. This is a report of two children aged 5 and 12 years who sustained anal injuries following anal sexual abuse. Both presented late with fissure-in-ano and were managed conservatively. Though fissure-in-ano is not uncommon in children, it might be necessary to exclude sexual abuse and undertake appropriate evaluation and treatment. The child must be protected from further abuse.     

Explaining the forgetting and recovery of abuse and trauma memories: possible mechanisms

Much attention has been focused on memories of abuse that are allegedly forgotten or repressed then recovered. By retrospectively surveying more than 1,400 college women, the authors investigated (a) the frequency with which temporary forgetting is reported for child sexual abuse experiences as opposed to other childhood abuse and traumas and (b) exactly how victims characterize their forgetting experiences in terms of various competing cognitive mechanisms. Rates of forgetting were similar among victims who experienced sexual abuse, physical abuse, and multiple types of traumas. Victims of other types of childhood traumas (e.g., car accidents) reported less forgetting than victims of childhood sexual abuse or multiple types of trauma. Most victims' characterizations of their forgetting experiences were not indicative of repression in the classic Freudian sense but instead suggested other more common mechanisms, such as directed forgetting and relabeling. The implications of these findings for psychological theory, clinical practice, and law are discussed.     

Is it child sexual abuse? A general paediatrician's guide

Child sexual abuse (CSA) is more common than many professionals working with children imagine: it is estimated that contact-sexual abuse affects at least 1 in 20 children, and is equally as common as physical abuse. Although some children will make allegations of (disclose) abuse, others present with physical signs such as unexplained vaginal bleeding, or behavioural concerns such as sexualised behaviour. This paper aims to provide evidence-based guidance on the differential diagnosis for common presentations, enabling the general paediatrician to confidently refer and discussed at Strategy Meeting those case requiring specialist examination at the Sexual Assault Referral Centre (SARC), while avoiding unnecessary escalation though safeguarding pathways for those cases with a clear non-abuse cause for the presentation.     

The relevance of fecal soiling as an indicator of child sexual abuse: a preliminary analysis

Encopresis is typically characterized as resulting from chronic constipation with overflow soiling but has been portrayed as an indicator of sexual abuse. The predictive utility of fecal soiling as an indicator of sexual abuse status was examined. In a retrospective analysis of three comparison groups of 4-12 year olds, we studied 466 children documented and treated for sexual abuse; 429 psychiatrically referred children with externalizing problems and 641 normative children recruited from the community, with the latter two samples having abuse ruled out. Standardized parent report measures identified soiling status and sexual acting out behaviors. Multiple regression analysis was used to predict abuse status in each group. Reported soiling rates were 10.3% (abuse), 10.5% (psychiatric), and 2% (normative), respectively. The soiling rate in the abused group differed significantly from that of the normative group, but not from the psychiatric group. Similar rates of soiling were reported among abused children, with and without penetration, and the psychiatric sample. Rates of sexualized behavior were reported significantly more often by the abused group versus both the psychiatric and normative groups and were a better predictor of abuse status. The positive predictive value of soiling as an indicator of abuse was 45% versus 63% for sexual acting out. The psychiatric sample displayed significantly more dysregulated behavior than the sexually abused sample. The predictive utility of fecal soiling as an indicator of sexual abuse in children is not supported. Soiling seems to represent one of many stress-induced dysregulated behaviors. Clinicians should assume the symptom of soiling is most likely related to the typical pathology and treat accordingly.     

Child sexual abuse: psychosocial risk factors.

Child sexual abuse is a problem of epidemic proportions in the United States. Child sexual abuse has been recognized as a predictor of many physical and psychological problems. It is important that clinicians have the ability to recognize the psychosocial dynamics present in families in which child sexual abuse takes place. Studies have shown that early detection and treatment of child sexual abuse leads to better outcomes for the victims. The literature discusses psychosocial risk factors present in families of child sexual abuse victims. An understanding of these characteristics may enable professionals to identify children at risk for child sexual abuse and may lead to earlier detection, protection, and treatment for victims. A case study illustrates psychosocial characteristics present in the family of a sexual abuse victim. Implications for practice are discussed, and a plan to assess families for psychosocial risk factors and intervene appropriately is outlined.