As any criminal attorney knows, the stakes are high when evaluating cases that involve childhood sexual abuse. The review and analysis then needs to be done by an experienced forensic nurse (as in Integrity Legal Nurse Consulting PDX) to ensure that your client has the best chance in representation for their alleged crime.
This blog post provides a review of the literature for childhood sexual abuse. Our hope is that this provided information can assist you and your practice and improve the lives of those that you serve.
Identifying and Evaluating Sexual Abuse in Children
Sometimes the topics of the greatest importance are the ones we are most reluctant to talk about. However, using discomfort as an excuse to avoid these conversations only tends to make matters worse. One of these taboo topics is child sexual abuse. In order to prevent it, we must know how to identify and evaluate it, especially in legal settings where crucial precedents can be set and justice can be brought to this6 situations. Therefore, we will be looking, from a medical perspective, at child sexual abuse in this post to help raise awareness of this heart wrenching crime and possibly reducing its incidence.
Sexual abuse refers to a single or repeated occurrence of a child engaging in sexual activity that they cannot comprehend, they cannot give consent to, and/or is in violation of the law. This includes fondling and all forms of clothed or unclothed oral-genital, genital, or anal contact with the child, as well as non-touching abuses such as exhibitionism, voyeurism, and child pornography. Sexual abuse occurs when there is asymmetry in age or development among the victim and perpetrator, and is coercive.
Children often do not disclose that they have been sexually abused, and so it is up to the adults in their lives to recognize that something is wrong. Here are some signs, identified by the U.S. Department of Justice, that can indicate that a child has suffered sexual abuse:
- Frequent nightmares and sleep problems without explanation
- Distraction and acts distant at odd times
- Sudden change in eating habits
- Sudden mood swings
- New or unusual fear of certain people or places
- Refusal to talk about a secret shared with an adult or older child
- Writing, drawings, play, or dreams that feature sexual or frightening images
- Talk of a new older friend
- Sudden money, toy, or gifts appear without reason
- Self or body seen as repulsive, dirty, or bad
- Exhibition of adult-like sexual behavior, language, and knowledge
Interviewing the child
After identifying behavioral changes, the next step is typically to interview the child who is suspected of experiencing sexual abuse. Even when sexual abuse has been legally confirmed, most children do not exhibit physical abnormalities, making their personal disclosure critical. Investigative interviews should be performed by forensic interviewers if possible, and physicians should ask relevant medical questions as well. The child should be interviewed alone, a neutral tone of voice and manner should be used, and open-ended questions should be use whenever possible.
In acute sexual assault settings – within 72 hours – forensic evidence should be collected, but for all other cases, physicians should still conduct an examination to look for and document any lacerations, ecchymoses (bleeding beneath the skin caused by bruising), or petechiae (spots indicating broken capillary blood vessels). Physicians should maintain a gentle and calm demeanor and explain procedures and instruments to the child to help alleviate their fears.
About 80% of child victims of sexual abuse will be cleared “within normal limits” after the completion of a physical examination. This is because many forms of sexual abuse do not cause physical injury and because many victims do not seek medical care for weeks or months after the abuse. However, for those who do exhibit physical signs of trauma, findings that are diagnostic of penetrating trauma include acute laceration or ecchymosis of the hymen, absence of hymenal tissue in the posterior half, healed hymenal transaction or complete cleft, deep anal laceration, and pregnancy. Findings that are not diagnostic, but are concerning include notches or clefts in the posterior half of the hymen extending nearly to the vaginal floor, confirmed in all positions, condylomata acuminate in a child older than two, immediate, marked anal dilatation, and anal scarring.
Though it can be painful to think and talk about, knowing the kind of identification and examination processes required to determine child sexual abuse is critical. While we might want to ignore this social issue, knowledge is power when working with childhood sexual abuse.
 Bechtel, Kristen & Bennett, Berkeley, “Evaluation of sexual abuse in children and adolescents,” UpToDate, Oct. 8, 2017, https://www.uptodate.com/contents/evaluation-of-sexual-abuse-in-children-and-adolescents
 “Recognizing Sexual Abuse,” U.S. Department of Justice, n.d., https://www.nsopw.gov/en-US/Education/RecognizingSexualAbuse?AspxAutoDetectCookieSupport=1
 Lahoti, Sheela L., McClain, N., Girardet, Rebecca, McNeese, Margaret, & Kim Cheung, “Evaluating the Child for Sexual Abuse,” American Family Physician, Mar. 1, 2001, 63(5): 883
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