Medical advances in child sexual abuse

This volume is the first of a two-part special issue detailing state of the art practice in medical issues around child sexual abuse. The six articles in this issue explore methods for medical history evaluation, the rationale for when sexual examinations should take place, specific hymenal findings that suggest a child has been sexually abused, the healing of genital injuries, approaches to interpretation of medical findings, and the neurological harm of sexual abuse. From the initial history to the process of the medical examination, the mechanics of what a genital examination might show, and the neurobiological consequences, it is demonstrated that the harm of sexual abuse is has more effect on the brain than the genital area.     

The Relationship between Knowledge and Child and Caregiver Distress during the Medical Examination for Child Sexual Abuse

When child sexual abuse is suspected, a child sexual abuse–related medical examination is recommended to ensure the child's well-being. While the extant research has sought to identify factors influencing child distress during this examination, only recently have studies began examining variables that may be directly associated with the child or with the medical setting. Knowledge of the child sexual abuse–related medical examination is one medical-related variable that has been implicated in child and caregiver distress during the examination. The current study contributes to the existing literature by investigating associations among examination knowledge in relation to caregiver and child anxiety at the time of a child sexual abuse–related medical examination, taking into account ethnicity, past child abuse, injury to child as result of abuse, and caregiver response to disclosure. Sixty-eight children and their nonoffending caregiver were assessed. Results indicated that understanding of the examination and caregiver response to disclosure were significantly associated with caregiver and child anxiety.     

The role of the medical provider in the evaluation of sexually abused children and adolescents

It was only 30 years ago that the medical community began to develop an increased awareness of child sexual abuse, and the role of the medical provider in the evaluation of sexually abused children has evolved significantly. As clinicians worldwide develop a greater understanding of the impact of the sexual abuse evaluation on the child, the roles of the physician and nurse have changed. In the United States, current practice often uses a multidisciplinary assessment involving skilled forensic interviewing of the child and a medical examination done by a medical provider with specialized training in sexual abuse. In order to minimize child interviews, these assessments are frequently held in settings such as child advocacy centers, where forensic interviewers and medical clinicians, child protective service workers, and police and district attorneys can work jointly to address the legal and protective issues in a coordinated fashion.     

Health Professionals' Responses to Disclosure of Child Sexual Abuse History: Female Child Sexual Abuse Survivors' Experiences

This study reports on a postal questionnaire, conducted in 2004, with female survivors of historic child sexual abuse. The questionnaire explored their experiences of health professionals' responsiveness to disclosure of child sexual abuse history. Of 61 participants, aged between 22 and 65, 69% had disclosed to health professionals. Those who had not disclosed reported that they would have liked to but were not asked about child sexual abuse. Thirty-five percent of participants suggested routine questioning about child sexual abuse. Most participants related a fear of common medical examination procedures to their experience of child sexual abuse, and 64% said this stopped them from attending regular health checks. The current study suggests the development of guidelines for dealing with possible child sexual abuse survivors would be useful for health professionals.     

Medical evaluation of suspected child sexual abuse: 2011 update

The medical evaluation of children with suspected sexual abuse includes more than just the physical examination of the child. The importance of taking a detailed medical history from the parents and a history from the child about physical sensations following sexual contact has been emphasized in other articles in the medical literature. The examination is important, however, and medical providers who examine children need to be aware of published research on findings in nonabused children, studies of healing of injuries, and studies documenting the association between sexual contact and the diagnosis of sexually transmissible infections in children. This article reviews the current approach to interpreting findings in children who may have been sexually abused and why additional research is needed.     

Sexual abuse: giving help to the children: A practical guide for concerned proiessionals

SUMMARY. This paper has been written for those professional workers who may have to deal with situations involving child sexual abuse, while having only limited knowledge and training. There are two sections. The first examines some of the key issues needed to increase understanding, and includes a preliminary discussion on the emotional impact of sexual abuse on Professional workers. Following a clarification of definitions, family aspects and incidence, this section focuses first on the child victims and then on the perpetrator. Finally, there is an examination of the consequences of child sexual abuse. The second section gives guidance on how a professional worker might respond if confronted with a case—from recognising the signs to facilitating disclosure. Suggestions are made about supporting the child during the investigation and heaving the child afterwards.     

Impact of Uncertainty on Non-Medical Professionals' Estimates of Sexual Abuse Probability

ABSTRACT

The study assesses how an educational intervention describing uncertainty m child sexual abuse assessments affects estimates of sexual abuse probability by non-physician child abuse professionals (CAP). It evaluates whether CAP incorporate medical information into abuse estimates in concordance with Bayes' Theorem. Eighty-nine CAP estimated the abuse probability for a hypothetical preadolescent female: (1) randomly selected; (2) disclosing abuse; (3) with physical evidence of abuse; and (4) disclosing abuse but with a normal physical examination. CAP then attended a workshop that included discussion of uncertainty in abuse assessment. Post-lecture questionnaires, identical to pre-lecture questionnaires except for estimates of the examination sensitivity and specificity, were administered. Expected responses for post-lecture Scenarios (3) and (4) were generated using Bayes' Theorem and compared to actual responses. Respondents estimated a high abuse prevalence (average 32%, range 5 to 75%). Respondents incorporated medical information into their estimates in a Bayesian manner. However, they undervalued the medical exam findings relative to Bayes' Theorem. These findings suggest CAP had difficulty adjusting for medical uncertainty. Further research into approaches for more easily adopting Bayesian approaches to child abuse decisions may improve the quality of decisions made by child abuse professionals.     

Paediatric intervention in child protection

Since BASPCAN was founded 12 years ago an enormous amount has been achieved in both understanding and responding to the problems of child maltreatment. Paediatricians have played their part along with others, although the traditional view of medicine was that this was a social problem outside medical responsibility. Attitudes are changing and there is an increasing appreciation of the importance of maltreatment in many child health problems. It is also now accepted that doctors can only be effective if they work together in teams with other professionals. The consequences of child maltreatment present to paediatricians in many ways and symptoms and signs linked to abuse are common in clinical practice. Today the role of the paediatrician is much clearer and there is more guidance and information available about the diagnosis of sexual abuse. 1991 was the beginning of a new era in child protection where it will be seen whether the new insights acquired over the past decade can be applied for the welfare of children and families.     

Forensic, cultural, and systems issues in child sexual abuse cases--part 2: research and practitioner issues

This article introduces the second issue of the special double issue focusing on forensic, cultural, and systems issues in child sexual abuse cases. We briefly review the articles, which include a discussion of child sexual abuse myths, an empirical analysis of extended child sexual abuse evaluations, an article on the role of the medical provider in child sexual abuse evaluations, a study of satisfaction levels with multidisciplinary teams in child advocacy centers, and a commentary advocating for the credentialing of forensic interviewers. We call for further empirical examination of media related to child sexual abuse risk, research on appropriate models for extended sexual abuse interviews and evaluations, and optimal practices relevant to each member of multidisciplinary teams in a child advocacy center.     

Cross‐examination,sexual abuse and child witness identity

This paper presents extracts from cross‐examinations with child witnesses who are alleged victims of child sexual abuse. The manner in which cross‐examination may present a challenge to the child's identity as child, victim and witness is discussed. Specifically, the child may be portrayed as ‘unchildlike’, for example in their experience of sexual relationships or in their sexual knowledge. They may be portrayed as less than innocent, through references to previous contacts with social services or to other behaviours such as delinquency. Child witnesses may be depicted as instigators rather than victims, seducing the adult or seeking revenge through sexual allegations. Finally, children are easily accused of being poor witnesses, as being confused, untruthful and having fallible memories. The paper considers the dynamics and potential impact of such cross‐examination practice within Finkelhor's framework of four traumagenics of sexual abuse: traumatic sexualization, betrayal, powerlessness and stigmatization. The potential for poorly conducted cross‐examinations to create further problems for child witnesses, particularly in the area of identity, is highlighted, and it is suggested traumagenic factors in such cross‐examinations may resemble those of abuse. The paper discusses practice implications for cross‐examination, judicial intervention and witness support following implementation of the Youth Justice and Criminal Evidence Act 1999 in England and Wales. Copyright © 2002 John Wiley & Sons, Ltd.     

Bridging the gap: Investigating the abuse of children with multiple disabilities

This is a summary of a series of practical papers written to help bridge the ‘gap’ between the fields of child protection and childhood disability, with a view to improving practice in child protection work with severely disabled children. Particular attention is paid to the needs of children using alternative communication systems. The theme of the paper is that disabled children are in most senses just like other children, but may have particular needs in relation to the investigation of abuse, as well as being particularly vulnerable to abuse. Issues around the assessment of suspicion, preparation for interviewing and the interview process are presented. The needs of the child, the accompanying adult and the child protection worker are considered. Guidelines and recommendations for practice at different stages of the investigation are given. The need to adapt the investigation to the particular needs of the child is emphasized throughout.     

Child abuse,child protection and disabled children: a review of recent research

This paper reports the results of a scoping study that reviewed research about child abuse, child protection and disabled children published in academic journals between 1996 and 2009. The review was conducted using a five stage method for scoping studies. Several studies have revealed a strong association between disability and child maltreatment, indicating that disabled children are significantly more likely to experience abuse than their non‐disabled peers. Those with particular impairments are at increased risk. There is evidence that the interaction of age, gender and/or socio‐cultural factors with impairment results in different patterns of abuse to those found among non‐disabled children although the reasons for this require further examination. It appears that therapeutic services and criminal justice systems often fail to take account of disabled children's needs and heightened vulnerability. In Britain, little is known about what happens to disabled children who have been abused and how well safeguarding services address their needs. Very few studies have sought disabled children's own accounts of abuse or safeguarding. Considerable development is required, at both policy and practice level, to ensure that disabled children's right to protection is upheld. The paper concludes by identifying a number of aspects of the topic requiring further investigation. Copyright © 2010 John Wiley & Sons, Ltd.     

Laughing Through This Pain: Medical Clowning During Examination of Sexually Abused Children: An Innovative Approach

This study examined the role of medical clowns during medical examinations of children who were sexually abused. Three case studies are described, illustrating diverse interactions among the victimized child, the medical clown, and the medical forensical examiner during medical forensic examinations held at the Tene Center for Sexually Abused Children, Poria-Pade Medical Center, Israel. The results indicated that medical clowns play a unique role both in lowering anxiety and fear among children before and during the unpleasant forensic examination as well as in mitigating potential retraumatization of the sexual abuse event resulting from the medical examination. The medical clown was found to assist in creating a pleasant and calm atmosphere, thus improving the child's cooperation during the examination.     

The Seven Pillars of Quality Care in a Statewide Pediatric Sexual Assault Nurse Examiner Program

This article describes a systematic approach used by a statewide pediatric sexual assault nurse examiner program to ensure the quality of forensic medical examinations it provides in child sexual abuse investigations. Seven strategies for enhancing quality are described: (a) hiring experienced professionals, (b) effective training, (c) comprehensive protocols, (d) ample support for pediatric sexual assault nurses, (e) management oversight, (f) a clinical coordinator to provide ongoing training and technical assistance, and (g) a quality assurance process in which expert child abuse pediatricians review each statewide pediatric sexual assault nurse examination. To show the evolution of quality care over time, the program's experience from 2004 to 2010 is reviewed, and quality assurance data are analyzed.     

Domestic violence: a priority in child protection in New South Wales,Australia?

Over the last several years there has been increasing awareness of the connection between domestic violence and child abuse, yet only minimal attention has been paid to the implications of this for child protection practice. This article begins to address this gap. Drawing on research undertaken in New South Wales (NSW), Australia, it examines child protection practice in relation to children and young people who have been exposed to domestic violence. The research involved analysis of the responses of the statutory child protection authority in NSW (the Department of Community Services or DoCS) to abuse allegations involving domestic violence. The data are drawn from observation and analysis of the initial responses to referrals to DoCS and the ‘tracking’ of a sample of these referrals over an 18 month period. From the data obtained, it is evident that domestic violence referrals are treated less seriously than other referrals, with more being confirmed as abuse but fewer resulting in follow up or intervention. The implications of this for child protection practice are teased out. Copyright © 2007 John Wiley & Sons, Ltd.     

Exploring the Relationship Between Adverse Childhood Experiences and Hope

ABSTRACT

To explore the relationship between adverse childhood experiences and hope, a convenience sample of caregivers bringing in children for medical investigation of child abuse at a regional child advocacy center were surveyed for adverse childhood experiences and dispositional hope. Hope in this sample had a significant negative correlation to the adverse childhood experiences subscale “abuse” (r = –.19; p < .05). The relationship between hope and the other adverse childhood experiences subscales “neglect” (r = –.14) and “dysfunctional family” (r = –.16) was not statistically significant. An analysis of variance was performed to determine if caregivers who have experienced both sexual and physical abuse (M = 29.67; SD = 15.96) have lower hope scores compared to those caregivers who have experienced neither physical nor sexual abuse (M = 42.64; SD = 18.44). This analysis (F (1, 84) = 5.28; p < 0.05) showed that caregivers who experienced both physical and sexual abuse scored significantly lower on hope compared to their counterparts who experienced no adverse events, with an estimated effect size of moderate strength (d = 0.70). Higher adverse childhood experiences scores are associated with lower hope. This result was especially true for those adult caregivers who reported experiencing both physical and sexual abuse when compared to adults who did not experience either form of child trauma. While the empirical literature continues to demonstrate the negative consequences of adverse childhood experiences across the life span, hope offers a compelling new line of inquiry in child maltreatment research especially for studies targeting prevention or intervention.     

Children's response to the medical visit for allegations of sexual abuse: maternal perceptions and predicting variables

This study examined maternal perceptions of their child's response to the medical evaluation for alleged sexual abuse. A total of 50 mothers were interviewed 6 months after a visit to a Child Protection Clinic for a medical evaluation of alleged sexual abuse. The mothers answered a questionnaire on their child's reactions to the medical visit. More than 60% of children were perceived as being reassured about physical integrity. The degree of psychological distress was independent of perpetrator's identity and severity of the abuse. Mothers considered that a hypothetical second visit would generate in their child a level of anxiety that increased with perceived intensity of fear of the examination and decreased with perceived kindness of the physician. These results suggest that the physician's behaviour during the medical evaluation for alleged sexual abuse has an influence on the child's degree of distress that is independent of type and severity of abuse. Copyright © 2001 John Wiley & Sons, Ltd.     

UK Paramedics Confidence in Identifying Child Sexual Abuse: A Mixed-Methods Investigation

United Kingdom (UK) paramedics are in a prime position to identify children and young people who are victims or at risk of sexual abuse. Paramedics have access, by phone, or in person, to unprepared homes and communities which other health professionals such as social workers may not. Little research exists however, investigating UK paramedic confidence in identifying child sexual abuse. This mixed-method explanatory sequential investigation used the self-reported confidence levels of 276 UK paramedics to inform the design of seven semi-structured focus groups with 25 UK paramedics from a large ambulance service with operating models similar to all UK services. Multiple factors contribute to a lack of confidence in identifying child sexual abuse, child sexual exploitation, and female genital mutilation, including a perceived lack of exposure to sexual abuse, the perceived hidden nature of sexual abuse, and the lack of physical symptoms and examination. An overarching lack of knowledge is the most significant contributor to a lack of confidence which in turn perpetuates misinformation surrounding prevalence, location, and the signs and symptoms of sexual abuse. These findings suggest a lack of sufficient training and a need for further research evaluating the content of current training and its method of delivery.     

Factors Related to Prosecution of Child Sexual Abuse Cases

ABSTRACT

This study explored how various factors regarding the victim, offender, abuse situation, and case evidence were related to prosecution decisions in child sexual abuse cases. Data were collected from records of 200 closed child sexual abuse cases served at a southwestern United States agency during 1989–1990. Results indicated that cases involving recently reported abuse and offenders who were charged with abusing multiple child victims were significantly more likely to be prosecuted than cases involving less recently reported abuse and offenders charged with abusing only one victim, respectively. In terms of the victim-offender relationship, prosecution was most likely for cases with offenders who were strangers, next most likely for acquaintances and step and extended family members, and least likely for biological nuclear family members. Also, cases with medical evidence of abuse were more likely to be prosecuted than cases without medical evidence only when serious abuse was involved. In addition, prosecution was significantly less likely for cases with younger victims than for cases with older victims. Seriousness of abuse, the presence of medical evidence, and recency of abuse did not account for this victim age-prosecution status relationship. Furthermore, no cases involving possible custody disputes were prosecuted. Implications are discussed concerning the need for focused and integrated efforts in responding to allegations of child sexual abuse.