IDENTIFICATION AND EVALUATION OF SUSPECTED SEXUAL ABUSE

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IDENTIFICATION AND EVALUATION OF SUSPECTED SEXUAL ABUSE

The District of Columbia Family Court

9

th

Annual Multidisciplinary Training Institute

Wendy

Gwirtzman

Lane, MD, MPH

Katherine

Deye

, MD

Objectives

Understand sexual abuse epidemiology

Distinguish normal sexual behavior from behavior suggestive of abuse

Understand the process of reporting and child advocacy center (CAC) evaluation

Become familiar with the medical evaluation, including the significance of medical findings

Case Presentation

You are appointed as Guardian ad Litem for 4 year-old Sara, because of possible parental neglect

Sara’s parents are no longer together. She lives with her mother, mother’s boyfriend, 2 sisters, ages 3 & 7, aunt, and 2 male cousins, ages 12 & 13

Sara sees dad infrequently. Paternal grandmother babysits twice a week

Case Presentation

You visit Sara for the first time. She is chatty and energetic when alone with you, but quiet when in the presence of her aunt and cousins.

While alone with her, Sara asks you, “Want to see me dance?” and proceeded to perform a very provocative dance.

Case Presentation

Sara’s mother is angry that CPS is involved with the family and is not very open with you.

While talking with mom, you observe Sara watching TV alone in the next room. She is sitting quietly, rubbing her vaginal area.

Case Presentation

You meet with Sara’s paternal grandmother the next day. She tells you that Sara always “looks red down there” and “her hole is too open.”

She expresses concern that mom’s boyfriend is abusing Sara.

Is Sara being sexually abused??What is sexual abuse??

Definition – CAPTA

“The employment, use, persuasion, inducement, enticement, or coercion of any child to engage in, or assist any other person to engage in, any sexually explicit conduct or simulation of such conduct for the purpose of producing a visual depiction of such conduct; or the rape, and in cases of caretaker or interfamilial relationships, statutory rape, molestation, prostitution, or other form of sexual exploitation of children, or incest with children.”

Definition

All sexual contact or conduct that is:

Unwanted by a child, or

Manipulative, exploitative, or

Outside developmentally appropriate play

By a parent, caregiver, household, or family member

Neither definition requires injury

Common Myths

Perpetrators are strangers in trench coats

Children always lie about abuse

Children never lie about abuse

Sexual abuse doesn’t occur in “nice” families

Historical Context

Late 1900’s – Freud initially tries to expose the problem. Later recants and attributes disclosures to child desires and fantasies.

Late 1960’s – Initial professional acceptance of existence of child maltreatment – Focus on physical abuse, “battered child syndrome”

Historical Context – 1970’s

1973 – 1

st

article on CSA listed in Index Medicus

1975 - Sgroi calls CSA “the last frontier in child abuse.” Tells physicians “in order to make the diagnosis of CSA, one must entertain the possibility that it occurs.”

Historical Context – 1980-on

1980’s -Increased acceptance of CSA by professionals & establishment of CAC’s

Late 80’s backlash against diagnosis

1990’s & beyond- gradual increase in knowledge, improvements in practice

Epidemiology

Reported cases are the tip of the iceberg

Level 1

Known to CPS

Level 2

Known to Other

Investigatory Agencies

Level 3

Known to Professionals in schools,

hospitals, and other major agencies

Level 4

Known to other agencies and individuals

Level 5

Known to no one

Known cases are just the tip of the iceberg

Epidemiology

PREVALENCE

19% of women

9% of men

abused as children

Perpetrator Characteristics

No typical profile

Many appear normal, successful & have no criminal record

Most are male

Most are familiar to the child many in position of trust, authority

20-40% adolescents

Many (not all) were abused themselves

Child Characteristics

About 85% female (cases known to system)

Peak ages:

Girls and boys – early school age 5-7 years

Girls – 14-15 years

Vulnerable, needy

Longitudinal Progression of Abuse (Sgroi, 1982)

Engagement – development of relationship

Sexual Interaction – progressive

Secrecy – bribes, threats

Disclosure – accidental or purposeful

Suppression

Child Sexual Abuse Accommodation Syndrome

(Summit, 1983)

Secrecy

Helplessness

Entrapment & Accommodation

Unconvincing disclosure

Retraction

Helps explain delayed disclosure

Impact of Sexual Abuse –

Physical Health

Short term

Acute injuries

STD’s

Long term:

GI problems (irritable bowel)

Chronic pain (headache, abdominal, back, or pelvic pain)

Obesity, failure to thrive

Somatization

Impact of Sexual Abuse –

Mental Health

Behavioral problems – withdrawal, acting out, delinquency

Depression

PTSD & other anxiety disorders

Substance abuse

Eating disorders – anorexia, bulemia

School failure

Low self esteem, interpersonal difficulties

Ways Children May Be Identified

Physical signs: injury or infection

Child’s disclosure – to another child, parent, therapist, or trusted adult

Child sexually abuses another child

Child uses sexually explicit language, behavior beyond normal development

Developmental Considerations

in Disclosure

Ages 0-4

Often can’t give reliable disclosure

Diagnosis by medical evidence, reported symptoms of physical or emotional trauma

Ages 5-7

Give simplistic description of abuse

May see sexual acting out (in play and on others), sleep problems

Developmental Considerations

in Disclosure

Ages 8-11

Allegations clearer, more specific

Boys may be more reluctant to disclose

Self-blame

Ages 12-16

May see promiscuity, depression, withdrawal, suicide attempts

Physical maturity confused with emotional maturity – girls may not see abuse as such

Sexualized Behavior in Children

Possible causes:

Sexual abuse

Poor understanding of societal norms

E.g. child with mental retardation

Sexual curiosity/exploration

Exposure to explicit sexual activities

Witnessed activity in home, on TV, movies

Viewing pornography

May be inadvertent, neglectful, or abusive

Common Behaviors @ 2-9 years

(unlikely to be related to abuse)

Friedrich WN. Normative sexual behavior in chidren. Pediatrics. 1998; 101:e9

Boys

Touches sex parts at home

Touches breasts

Stands too close

Tries to look at other people when they are nude

Touches sex parts in public

Masturbates with hand

Girls

Touches sex parts at home

Touches breasts

Tries to look at other people when they are nude

Stands too close

Masturbates with hand

Touches sex parts in public

Common Behaviors @ 10-12

(unlikely to be related to abuse)

Friedrich WN. Normative sexual behavior in chidren. Pediatrics. 1998; 101:e9

Boys

Very interested in opposite sex

Wants to watch TV nudity

Tries to look at pictures of nude people

Knows more about sex

Talks about sex acts

Touches sex parts at home

Girls

Very interested in opposite sex

Knows more about sex

Stands too close

Wants to watch TV nudity

Touches sex parts at home

Talks about sex acts

Uncommon Behaviors @ 2-12

(more likely to be related to abuse)

Puts mouth on sex parts

Asks to engage in sex acts

Masturbates with object

Inserts objects in vagina/anus

5) Imitates intercourse

Makes sexual sounds

Tries to french kiss

Undresses other people

Asks to watch explicit TV

10) Imitates sexual behavior with dolls

Behaviors that Raise Concern

Excessive focus on sexuality, knowledge beyond normal development

Inappropriate behavior despite redirection

Sexual behavior/exploration/coercion with much older/younger children

Inflicts injury to own or other’s genitals

Disturbing toileting behavior

Drawings with genitals predominating

Sexual contact with animals

What to do if you observe…

Calm, non-judgemental questioning

“Where did you learn about that/how to do that?”

Don’t push child to answer

Back to Sara…

Based on your observations and interviews, you decide to:

Do nothing

Report to CPS

Report to Police

Provide information to grandmother about reporting

B and C

Back to Sara…

Grandmother decides to call CPS to report suspected sexual abuse

The report is accepted for investigation

Grandmother wants to take Sara to the local emergency department, “so the doctor can tell me if she’s been touched”

What do You Tell Grandma?

Immediate medical exam only necessary if:

Abuse occurred in past 72-96 hours

Child is having serious physical or psychological symptoms

Immediate exam generally needed to:

Document injury

Collect forensic evidence (saliva, blood, semen)

Exam should only be done by clinician trained to do sexual abuse evaluations!!!!

What Happens Next??

You successfully dissuade Grandma from bringing Sara to the ED.

The next day, an investigator from CPS contacts Sara’s mother.

She schedules an interview at the local child advocacy center

The Child Advocacy Center

Sara’s mother wants to know what is going to happen at her appointment

What do you tell her?

What Happens at the CAC?

Forensic interview

Sara is interviewed by trained professional.

May be CPS worker, other social worker, or psychologist

Interview may be taped, observed by camera or 1-way mirror

Medical evaluation (in 2011)

By physician or nurse with special training in child sexual abuse

Safe Shores (CAC in DC)

Bundy School

Art Therapy Room

Safe Shores/CNMC Medical Suite

Medical Suite &

Colposcope

Why does she need a specialist??

Little training in medical school & residency about examination of female anatomy

Many practitioners don’t routinely examine children’s genitals – not familiar with what’s normal & abnormal

Expert often has camera/colposcope to improve visualization, document findings

The Medical Evaluation

Interview with parent

Explain process

Possible questions about reason for visit

Obtain medical history

Elicit signs/symptoms that may indicate abuse

Interview with child

Explain exam in simple way “nose to toes check-up”, nothing that will hurt

Examination Techniques

Frog Leg Position

Supine Knee Chest Position

Myths About the Exam

The doctor can tell for sure if she’s been abused

The doctor can tell if she’s been penetrated

The doctor needs to look inside of her

If she has a hole in her hymen, she’s been abused

If the hole is too big, she’s been abused

The Medical Evaluation - Findings

“It’s normal to be normal”

More than 95% of referred children have normal exams

Why???

Abusive acts may leave no injury (e.g. fondling)

Causing injury increases risk of disclosure

Injuries often heal without scars before disclosure and medical evaluation

The Medical Evaluation – What’s Not Normal

Genital injury –

Acute - tears, bruises, bite marks

Sub-acute, chronic – healed hymenal tears, scars

Sexually transmitted diseases

Pregnancy

Forensic evidence – sperm, semen, etc.

Implications of Commonly Encountered STDs

STD Confirmed

Sexual Abuse

Suggested Action

Gonorrhea*

Diagnostic

Report

Syphilis*

Diagnostic

Report

HIV infection

Diagnostic

Report

C.

trachomatis

infection*

Diagnostic

Report

T.

vaginalis

infection

Highly suspicious

Report

HPV (

anogential

warts)

Suspicious

Report

Herpes simplex (genital location)

Suspicious

Report

Bacterial

vaginiosis

Inconclusive

Medical follow-up

*If not perinatally acquired and rare nonsexual transmission is

excluded

Adapted from Kellogg, N; AAP, Committee on Child Abuse & Neglect. Pediatrics. 2005; 116(2): 506-512

Sexually Transmitted Diseases

In infants & toddlers, need to consider possibility of transmission from mother during pregnancy, birth.

In adolescents, need to consider transmission via consensual sex

Diagnosis of gonorrhea, chlamydia, or syphilis make sexual abuse highly likely

If the doctor can’t give me an answer, why have an exam???

Document injuries, if present

Test for infection

PROVIDE REASSURANCE –

“Everything looks normal and healthy”

What is done with the information from the medical exam???

Findings provided to CPS worker, police.

Determination made based on combination of medical findings, child interview, and other available data

Substantiated – abuse occurred

Unsubstantiated – abuse may have occurred

Ruled-out – abuse did not occur

Questions???