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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
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
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. KendallTackett, 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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