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Introduction  

The growing body of literature and research on child sexual abuse that
we have witnessed in the latter part of this century was kindled primarily
by adult women speaking out about their childhood experiences of sexual
abuse. Despite significant numbers of documented cases and psychiatric
discourse at the end of the 19th century about child sexual abuse, the
issue was spoken about as a rare problem. The ‘Battered baby syndrome’
identified in the 1960’s by Kemp drew attention to the issue of child
physical abuse The Women’s Movement in the 1970s lobbied to place
the issue of child sexual abuse on the social, health and political agenda.
Retrospective studies of adults sexually abused as children revealed that
1:3-5 women have experienced sexual abuse in childhood. These
findings are well documented and has opened the door to a growing
awareness that child sexual abuse is a significant problem affecting the
lives of 1: 3-5 girls and generally about 1:6-7 boys by the age of 18 years
. In approximately 90% of cases, the offender is either a member of the
child’s family or is well known to the child and family.

Key points

• Kemp’s definition of ‘Battered baby syndrome’ in the 1960’s drew


attention to child abuse and in the 1970s there was public
awareness about child sexual abuse.

• 1 in 3-5 women and 1 in 6-7 men have experienced sexual


abuse in childhood.

• In 9 of 10 cases the offender is known to child and family.

Definition

Though the laws on child sexual abuse vary in different jurisdictions, child
sexual abuse is a crime, which occurs when an adult or older person uses
his/her power, authority or position to impose upon a child any sexual
activity.
Features of child sexual abuse may include the following:

• physical or psychological coercion which differentiates such


abuse from consensual peer sexual activity ( Child Protection
council 1997)

• the dependency and immaturity of children is exploited by adults


and adolescents who perpetrate child sexual abuse.

• the sexual activity may include sexual touching, masturbation


,sexual penetration, and non contact sexual acts such as
exposing a child to pornographic material , exhibitionism and
voyeurism.

• The child is coerced to keep the sexual activity secret in order to


prevent disclosure

• Offenders commonly employ tactics to make the child feel


responsible for the sexual activity

Key points

• Child sexual abuse is a crime irrespective in all jurisdictions.

Nature of child sexual abuse

B Prepubertal

• sexual gratification of the adult by the use of the child’s body

• commonly begins with touching of the genital area, making the


child touch the adult’s genitals and may eventually progress to
partial or full penetration

• commonly occurs over long period of time

• the offender commonly employs a range of tactics to engage a


child and involve the child in sexual activity e.g. favouritism,
bribery, tricks, threats, coercion

• child sexual abuse does not commonly present with concurrent


physical violence

• majority of offenders are a member of the child’s family or are


known to the child and its family

• disclosure rarely occurs following a single incident, unless the


offender is a stranger

Postpubertal

• may be continuation of prepubertal abuse with increasing level


of severity

• coercion may also involve the use of drugs, alcohol and peer
pressure

• may resemble adult rape involving a single episode with an


assailant of similar age to the victim
• commonly involves full penetration

• may involve violence

Key areas of consideration in managing a report of child sexual


abuse

Child protection and welfare considerations


Safety of the child from further sexual abuse is of the highest priority.
Notification to statutory authority vested with the legal responsibility of
ensuring the safety of children, to investigate the report is necessary to
ensure the protection and safety of the child.

Legal considerations
Child sexual abuse is a crime. Since children do not have the capacity to
consent to sexual contact, any person engaging in sexual activity with a
child has committed an offence. Investigation by police and charges being
laid are possible following a report. Medical Officers who receive a report
and/or provide medical examination may be called to provide expert
opinion on medical findings in criminal proceedings. Medical
examinations should be carried out within the particular protocols and
with an understanding of the interagency roles and policies.

Medical care and follow-up concerns


Physical trauma and medical needs, such as concerns about sexually
transmitted diseases and pregnancy must be addressed. Fears about
permanent damage following sexual abuse need to be assessed and the
child and non-offending parent reassured.

Therapeutic and support considerations


Psychological / emotional impact on the child and non-offending parent
needs to be considered and referral to specialist services where available
should be offered. The disclosure of child sexual abuse often precipitates
a crisis for which immediate counselling and support is strongly
recommended. This counselling addresses practical issues, emotional
impact and concerns, information and support through legal proceedings
if necessary.

Key points

• Psychological counselling for both child and non-offending


parent should be offered.
Responding to a report of child sexual abuse

Child sexual abuse requires an interagency approach that encompasses


all the considerations outlined above. The child’s future safety must
receive priority and cannot be assumed because a disclosure has been
made or the non-offending parent or offender gives assurances about the
child’s safety. It is crucial that child protection authorities are informed and
in many jurisdictions, medical officers are mandated notifiers of child
sexual abuse. Child Protection authorities, police, medical officers and
social workers all have a vital role to play in addressing the needs and
concerns of the child sexual abuse victim and their non-offending parent.
Only a Medical Officer who has received specific training should be
involved in the examination of a child where child sexual abuse is
reported or suspected. Such training must include the normal and
abnormal genital anatomy of children.

Key points

• The child’s future safety is paramount – appropriate authorities


should be notified.

Medical role in child sexual abuse assessments

A child who has reported sexual abuse, because of the sensitive nature of
the material that needs to be explored needs to be treated with sensitivity
and respect. It is important that the doctor’s intervention is not perceived
by the child as a continuation of the abuse. Any examination that needs to
be performed must be explained to the child in age appropriate language
and must only be done with the consent and cooperation of the child.

The doctor has two major functions when involved in the assessment of a
child/young person who has disclosed sexual abuse or about whom there
is a suspicion of sexual abuse:

• to inform, medically manage and reassure the child and it’s


parents about any medical concerns that they have

• to document the assessment, including appropriate examination,


for any medico-legal purposes that may arise

Acute assessments
Children and young people who present within 72 hours of the reported
abusive event must be seen immediately so that both medical and
medico-legal issues can be dealt with. Because the possibility of
pregnancy can occur in post-pubertal girls if there has been ejaculation
near the genital area, the possibility of administering the ‘morning-after
pill’ must be considered. Children should be offered a medical
examination as soon as possible after their disclosure of sexual abuse so
the anxiety that they and their non-offending parents experience can be
addressed.

Forensic evidence
In the medical assessment of children who have reported sexual abuse
there may be forensic evidence to collect particularly if the assessment is
performed soon after the reported abuse.

The forensic evidence may consist of:

• physical evidence on the body of the child

• physical evidence on the clothing that the child was wearing

• physical evidence at the site of the sexual abuse such as stains


on bedclothes, towels etc

The physical evidence on the child’s body may be in the form of minor or
major injuries consistent with the history of abuse. These must be
documented on the body and genital diagrams of the child in the forensic
protocol.
The other evidence present on the child’s body may be the remains of
seminal fluid if the offender ejaculated. Forensic specimens are taken
from any parts of the body where traces of seminal fluid may remain and
these specimens are retained in secure circumstances for future forensic
examination.

The genital examination of young children who have been sexually


abused is usually normal due to the non-penetrative nature of the acts.
An article by Joyce Adams et al in ‘Pediatrics’ summarizes the physical
findings of 236 children with conviction of the perpetrator for sexual
abuse. The findings showed that there was clear evidence of abuse in
only 9% of the genital examination of females, and in 1% of males and
females where the abuse was reported to be anal.

Disclosure of sexual abuse often creates an acute emergency within the


family, even if the event occurred some time before and has occurred
over a long period of time. These children should also be seen urgently
so that assessment and reassurance can take place.

Investigation v. assessment

t is not the role of the doctor to investigate complaints of sexual abuse.


The decision on whether child sexual abuse has occurred is a legal
matter, which may be dealt with by a court. Depending on the
circumstances the investigation of the report of sexual abuse may be
done by the Police service or by the government department with the
responsibility for Child Protection issues. It is the role of the doctor to
assess, document findings and treat these children.

The doctor should obtain the history of sexual abuse from the adult
accompanying the child and from any referring agency. In the case of a
very young child, only sufficient detail to ensure an adequate examination
is necessary. The investigative interview with the child should be
conducted by the police and child protection services. If a young child
repeats the history to a large number of people, their evidence may
become contaminated and unable to be used in legal proceedings.

Impact of sexual abuse of children

Child sexual abuse has been extensively documented since it was


recognized as a significant clinical problem in the 1970’s. Kendall-Tackett
et al in their 1993 article reviewing 45 studies found that “sexually abused
children had more symptoms with abuse accounting for 15-45% of the
variants”. They also found that the following symptoms were most
common:

• Fears

• Posttraumatic stress disorder

• Behaviour problems

• Sexualized behaviours

• Poor self esteem

They also noted that approximately one third of children had no


symptoms, and that no one symptom characterized a majority of sexually
abused children. Factors which affected the degree of symptomatology
were:

• Penetration

• Duration and frequency of the abuse

• Force

• The relationship of the perpetrator to the child

• Maternal support

Mullen and Fleming, in their discussion of the long-term effects of child


sexual abuse noted that “ There is now an established body of knowledge
clearly linking a history of child sexual abuse with higher rates in adult life
of depressive symptoms, anxiety symptoms, substance abuse disorders,
eating disorders and posttraumatic stress disorders.”

Key points

• The long term impacts of sexual abuse in childhood include a


number of well recognized effects.

Conclusion

The doctor who first assesses the child who has reported sexual abuse
has a key role to play in the recovery process of this child and, by
engaging in a multidisciplinary response helps to ensure the child’s future
safety.

   
William Kemp

Goldman, Fleming, Finkelhor

Child Protection Council 1997

“Examination findings in legally

confirmed child sexual abuse: It’s

Normal to be Normal” Adams et. al.

PEDIATRICS Vol. 94 No.3 September

1994

“Impact of Sexual Abuse on Children :

A Review and Synthesis of Recent

Empirical Studies” Kathleen A. Kendall-

Tackett, Linda Meyer Williams and

David Finkelhor Psychological Bulletin

1993 Vol 113, No 1, 164-180


“ Long-term effects of child sexual

abuse” Paul E. Mullen and Jillian

Fleming Issues in Child Abuse

Prevention – Australian Institute of

Family studies No.9 Autumn 1998

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