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Indicators Of Child Sexual Abuse
Sexual abuse may result in physical or behavioral manifestations. It is important that professionals and the public know what these are because they signal possible sexual abuse. However, very few manifestations (e.g., gonorrhea of the throat in a young child) are conclusive of sexual abuse. Most manifestations require careful investigation or assessment.
Unfortunately, early efforts at cataloging indicators of sexual abuse were problematic. They included extremely rare findings, such as blood in a child's underpants and signs that could be indicative of many problems or no problem at all, such as "comes early to school and leaves late." Recent efforts to designate signs of sexual abuse are more helpful.
- They differentiate between physical indicators and psychosocial indicators. Although physical indicators may be noted by many people, a definitive determination is generally made by a medical professional. Similarly, anyone may observe psychosocial indicators; however, often but not always, a mental health professional is responsible for forming an opinion that the symptoms are indicative of sexual abuse.
- A differentiation is made between higher and lower probability indicators. That is, some indicators are diagnostic of sexual abuse, whereas others may be consistent with or suggestive of sexual abuse but could indicate other circumstances or conditions as well.
In this chapter, higher probability findings and lower probability physical indicators are discussed first. A comparable discussion of psychosocial indicators will follow. It should not be surprising that the indicators specified in this chapter are similar to the effects described in the previous chapter since indicators are to a large extent the effects of sexual abuse before disclosure. Therefore, these indicators should become a focus of treatment and not simply used to support or rule out an allegation of sexual abuse.
Medical Indicators of Child Sexual Abuse
Significant progress has been made in the medical field in the determination of sexual abuse. Medical professionals are no longer limited to the presence or absence of a hymen as the indicator of possible sexual abuse. A variety of types of genital findings have been documented. In addition, notable progress has been made in identifying anal findings. Moreover, physicians are able to describe the effects of different kinds of sexual activity, and subtle findings can be documented using magnification (a colposcope or otoscope).
However, this progress is not without its controversies. Knowledgeable and conscientious physicians may differ regarding conclusions about certain physical findings. This difference of opinion is primarily due to the fact that data collection regarding the physical signs of sexual abuse has preceded careful documentation of characteristics of genitalia and anal anatomy of children who have not been sexually abused and of variations among normal children. These legitimate differences of opinion have been augmented by challenges to the medical documentation from defense attorneys, their expert witnesses, and alleged offenders.
It is also important to appreciate that for the majority of sexually abused children there are no physical findings. These findings, particularly vaginal ones, are most useful with prepubertal victims. As children become older, the possibility of consensual sexual activity needs to be considered. Further, changes that occur with puberty render insignificant some symptoms that have great significance in young children.
Two High-Probability Physical Indicators
Despite the progress noted above, the highest probability indicators are ones identified over 10 years ago. They are:
- pregnancy in a child and
- venereal disease in a child.
The reason these findings are high probability is because there is little dispute over the fact that they require sexual activity.
Some professionals assume that pregnancy in a child less than age 12 signals abuse although others designate the age of 13 or 14. Of course, not all situations in which children of these ages become pregnant are abusive, and pregnancy in older adolescents can be a consequence of sexual abuse.
Venereal disease may be located in the mucosa of the vagina, penis, anus, or mouth. The upper age limits for venereal disease raising concern about sexual abuse are similar to those for pregnancy. In addition, there is a lower age limit, usually of 1 or 2 months, because infants may be born with venereal disease acquired congenitally if the mother has the disease.
Interestingly, variations are found within the medical community regarding the certainty that sexual activity causes particular venereal diseases in children. Specifically, there is consensus that syphilis and gonorrhea cannot be contracted from toilet seats or bed sheets, but some differences of opinion exist about other venereal diseases (genital herpes, condyloma acuminata or venereal warts, trichomonas vaginalitis, and urogenital chlamydia), despite the conclusion that such infections are caused by sexual contact in adults.45 In a recent review of the research, Smith, Benton, Moore, and Runyan conclude that there is "strong evidence" that all of these venereal diseases are sexually transmitted, except for herpes, for which there is "probable evidence." They also review the evidence on human immunodeficiency virus (HIV) and conclude that there is strong evidence it is sexually transmitted as well, unless contracted pre- or perinatally.46
High-probability findings specific to the genitalia include the following:
- semen in the vagina of a child,
- torn or missing hymen,
- other vaginal injury or scarring,
- vaginal opening greater than 5 mm, and
- injury to the penis or scrotum.
Semen in the vagina is the highest probability finding, but it is uncommon.
Although there is a fair amount of variability among girl children in the extent, shape, and other characteristics of hymens,47 the complete absence of or a tear in the hymen of a young girl is indicative of sexual abuse. In older girls, it is important to determine whether other sexual activities may account for the absence or the tear. Conditions such as bumps, friability, and clefts in the hymen may be a result of sexual abuse, but they are also found in girls without a reported history of sexual abuse.48
Health care professionals document and describe injuries to or bleeding from the vaginal opening by likening it to a clock face, 12 o'clock being the anterior midline and 6 o'clock the posterior. Abrasions, tears, and bruises to the vagina between 3 and 9 o'clock, or to the posterior, are more likely to be the result of penile penetration, whereas injuries between 9 and 3 o'clock, or anteriorly, are more likely the consequence of digital manipulation or penetration.49
There is some controversy regarding what transverse diameter to use as a guideline for differentiating between girls with genital evidence consistent with penetration and those with no genital evidence, with measures ranging from 4 to 6 mm being advocated as indicative of sexual abuse.50 One factor that may affect findings is the age of the child, with the expectation that older girls will have larger vaginal openings. Heger, an expert in physical findings related to sexual abuse, discounts the importance of hymenal transverse diameter, noting that it varies in size depending on the position in which the child is examined.51 It is also important to note that not all girls who have a reported history of penetration evidence enlarged vaginal openings, tears, abrasions, or bruising.
Absent another explanation for an injury to the penis, which is consistent with the child's account of the abusive incident, the injury should be considered indicative of sexual abuse. Bite marks, abrasions, redness, "hickeys," scratches, or bruises may be found.
Lower probability genital findings are as follows:
- vaginal erythema,
- increased vascularity,
- labial adhesions,
- vulvovaginitis, and
- chronic urinary tract infections.
Erythema or redness and swelling might be caused by genital manipulation or intrusion perpetrated by a significantly older person. However, it might also be the result of poor hygiene, diaper rash, or perhaps the child's masturbation.52 Increased vascularity, synechiae, and labial adhesions may be a consequence of sexual abuse, but they are common findings in children with other genital complaints.53
Vulvovaginitis and chronic urinary tract infections can be sequelae of sexual abuse but also can be caused by other circumstances, such as poor hygiene, a bubble bath, or, in the case of urinary tract infections, taking antibiotics.
The following are high-probability findings:
- destruction of the anal sphincter,
- perianal bruising or abrasion,
- shortening or eversion of the anal canal,
- fissures to the anal opening,
- wasting of gluteal fat, and
Very occasionally there will be a finding of total absence of anal sphincter control, indicative of chronic anal penetration. If there has been forceful anal penetration, it may result in bruising and scrapes. A shortening or eversion of the anal canal has been found in very young children who have been chronically anally penetrated.54 Perianal fissures and scars from fissures are thought to be indicative of sexual abuse except when they occur at 12 o'clock and 6 o'clock,55 in which case they may be the result of a large stool. If the fissure is wider externally and narrows internally, this is consistent with object penetration of the anus. The converse finding is consistent with the passage of a large, firm stool.56 Funneling and wasting of the gluteal fat around the anal opening can occur from chronic anal penetration. This is a rare finding in children but may be found in male adolescent prostitutes. The following anal findings are lower probability:
- perianal erythema,
- increased perianal pigmentation,
- perianal venous engorgement, and
- reflex anal dilatation.
Perianal erythema, increased pigmentation, and venous engorgement are all physical findings noted in children who have a history of anal penetration. However, these conditions also have been reported in substantial numbers of children with no reported history of sexual abuse, suggesting that they can be caused by other conditions.57 In the case of the first two findings, these conditions could be a consequence of poor hygiene.
A finding that is in some dispute is reflex anal dilatation, that is, gaping of the anus or the twitching of the anal sphincter at the time of physical exam. Some physicians believe that it is a consequence of anal penetration,58 but others have noted this finding in children whose lower bowel is full of stool. However, gaping of 20 mm or more is thought to be indicative of anal penetration.59
Generally oral sex leaves little physical evidence. The only physical findings that have been noted are the following:
- injury to the palate or
- pharyngeal gonorrhea.
Sometimes the child will sustain an injury to the soft or hard palate from being subjected to fellatio. This may cause bruising, especially pinpoint bruises called petechiae, or abrasions.60 Children may also contract pharyngeal gonorrhea as a consequence of oral sex, as described above.
Psychosocial Indicators of Child Sexual Abuse
Comparable efforts to identify the psychosocial indicators of child sexual abuse have been made by mental health professionals. In 1985, 100 national experts in sexual abuse met to develop criteria for the "Sexually Abused Child Disorder," in the hope that it would be included in the Diagnostic and Statistical Manual Three-Revised (DSMIII-R). It was not, but the effort remains important. The criteria of the "Sexually Abused Child Disorder" differentiate three levels of certainty (high, medium, and low) and vary by developmental stage. These criteria include both sexual and nonsexual indicators.61
The work of Friedrich focuses on sexualized behavior, indicators unlikely to be found in other traumatized or normal populations. His Child Sexual Behavior Inventory has been field-tested on 260 children between 2 to 12 years of age, who were alleged to have been sexually abused and 880 children not alleged to have been sexually abused. It was found to reliably differentiate the two types of children. However, a substantial proportion of children in Friedrich's research, determined sexually abused, are not reported to engage in sexualized behavior. Moreover, children who learn about sex from nonabusive experiences may engage in sexualized behavior.
In this manual, a two-category typology of behavioral indicators is proposed:
- sexual indicators, generally being higher probability indicators; and
- nonsexual behavioral indicators, usually considered lower probability.
Sexual indicators vary somewhat depending on the child's age. The discussion of these indicators will be divided into those likely to be found in younger sexually abused children (aged 10 or younger) and those likely to be found in older sexually abused children (older than age 10). However, this distinction is somewhat arbitrary, and within these two groups there are children at very different developmental stages. Finally, indicators that are important for children of all ages are noted.
Sexual Indicators Found in Younger Children
These behaviors are high-probability indicators because they represent sexual knowledge not ordinarily possessed by young children.
- Statements indicating precocious sexual knowledge, often made inadvertently.
- A child observes a couple kissing on television and says that "the man is going to put his finger in her wee wee."
- A child comments, "You know snot comes out of Uncle Joe's ding dong."
- Sexually explicit drawings (not open to interpretation).
- A child draws a picture of fellatio.
- Sexual interaction with other people.
- Sexual aggression toward younger or more naive children (represents an identification with the abuser).
- Sexual activity with peers (indicates the child probably experienced a degree of pleasure from the abusive activity).
- Sexual invitations or gestures to older persons (suggests the child expects and accepts sexual activity as a way of relating to adults).
- Sexual interactions involving animals or toys.
- A child may be observed sucking a dog's penis.
- A child makes "Barbie* dolls" engage in oral sex.
The reason sexual knowledge is more compelling when demonstrated by younger children than older ones is that the latter may acquire sexual knowledge from other sources, for example, from classes on sex education or from discussions with peers or older children. Even younger children may obtain knowledge from sources other than abuse. However, children are not likely to learn the intimate details of sexual activity nor for example, what semen tastes like and penetration feels like without direct experience.
Another indicator often cited is excessive masturbation. A limitation of this as an index of sexual abuse is that most children (and adults) masturbate at some time. Thus, it is developmentally normal behavior, which is only considered indicative of sexual abuse when "excessive." However, a determination that the masturbation is excessive may be highly subjective. The following guidelines may be helpful.
- Masturbation is indicative of possible sexual abuse if:
- Child masturbates to the point of injury.
- Child masturbates numerous times a day.
- Child cannot stop masturbating.
- Child inserts objects into vagina or anus.
- Child makes groaning or moaning sounds while masturbating.
- Child engages in thrusting motions while masturbating.
Sexual Indicators Found in Older Children
As children mature, they become aware of societal responses to their sexual activity, and therefore overt sexual interactions of the type cited above are less common. Moreover, some level of sexual activity is considered normal for adolescents. However, there are three sexual indicators that may signal sexual abuse.
- sexual promiscuity among girls,
- being sexually victimized by peers or nonfamily members among girls, and
- adolescent prostitution.
Of these three indicators, the last is most compelling. One study found that 90 percent of female adolescent prostitutes were sexually abused.62 Although there has not been comparable research on male adolescent prostitutes, there are clinical observations that they become involved in prostitution because of sexual abuse.63
A High-Probability Sexual Indicator for All Children
Finally, when children report to anyone they are being or have been sexually abused, there is a high probability they are telling the truth. Only in rare circumstances do children have any interest in making false accusations. False allegations by children represent between 1 and 5 percent of reports.64 Therefore, unless there is substantial evidence that the statement is false, it should be interpreted as a good indication that the child has, in fact, been sexually abused.
Nonsexual Behavioral Indicators of Possible Sexual Abuse
The reason that nonsexual behavioral symptoms are lower probability indicators of sexual abuse is because they can also be indicators of other types of trauma. For example, these symptoms can be a consequence of physical maltreatment, marital discord, emotional maltreatment, or familial substance abuse. Nonsexual behavioral indicators can arise because of the birth of a sibling, the death of a loved one, or parental loss of employment. Moreover, natural disasters such as floods or earthquakes can result in such symptomatic behavior.
As with sexual behaviors, it is useful to divide symptoms into those more characteristic of younger children and those found primarily in older children. However, there are also some symptoms found in both age groups.
Nonsexual Behavioral Indicators in Young Children
The following symptoms may be found in younger children:
- sleep disturbances;
- other regressive behavior (e.g., needing to take transitional object to school);
- self-destructive or risk-taking behavior;
- impulsivity, distractibility, difficulty concentrating (without a history of nonabusive etiology);
- refusal to be left alone;
- fear of the alleged offender;
- fear of people of a specific type or gender;
- firesetting (more characteristic of boy victims);
- cruelty to animals (more characteristic of boy victims); and
- role reversal in the family or pseudomaturity.
Nonsexual Behavioral Indicators in Older Children
- eating disturbances (bulimia and anorexia);
- running away;
- substance abuse;
- self-destructive behavior, e.g.,
- suicidal gestures, attempts, and successes and
- criminal activity; and
- depression and social withdrawal.
Nonsexual Behavioral Indicators in All Children
Three types of problems may be found in children of all ages:
- problems relating to peers,
- school difficulties, and
- sudden noticeable changes in behavior.
Sexually abused children may manifest a range of symptoms, which reflect the specifics of their abuse and how they are coping with it.
Suspicion is heightened when the child presents with several indicators, particularly when there is a combination of sexual and nonsexual indicators. For example, a common configuration in female adolescent victims is promiscuity, substance abuse, and suicidal behavior. Similarly, the presence of both behavioral and physical symptoms increases concern. However, the absence of a history of such indicators does not signal the absence of sexual abuse.
* Barbie is a registered trademark of Mattel, Inc.
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