Sexual abuse of children and adolescents is an alarming problem that has been brought to the public awareness through the news media, television documentaries, and books written by victims of sexual abuse and the professionals providing services to them. Both DeFrancis and Finkelhor, national authorities in the field of child abuse, have concluded that the greatest threat of sexual abuse may very well come from within the family, particularly from fathers and stepfathers. 1 Adolescent females have the highest incidence of sexual involvement and half of all abused girls are 11 years old or younger. Victims struggle alone with inner turmoil, develop self-esteem problems, and have difficulty forming trusting relationships. l
Intra-family sexual abuse is a complex phenomenon that raises numerous psychological, social, and moral questions. Accounts of sexual abuse by adult victims generally indicate that sexual encounters experienced in childhood were unpleasant and traumatic for them. Finkelhor states that "studies among populations of prostitutes, drug abusers, and adolescent runaways suggest that a high proportion of such people have a history of sexual abuse."1 Case studies of adjudicated youth described by Wooden also indicate a high incidence of physical and sexual abuse.2 Because of the youngster's personal anguish and social implications of abuse, it becomes imperative for the pediatrician to become knowledgeable about sexual abuse.
Intra-iamily sexual abuse and the surrounding issues evoke conflicts for most people, including professionals. Physicians have been reluctant to deal with this emotionally charged problem, in part because physical findings or symptoms are often absent or undetected. However, pediatricians are viewed by most children and adolescents as "helpful" adults. As adolescents begin to distinguish that incest is not normal, they may confide their problem to their physician if given the opportunity. Pediatricians need to know their legal responsibility in dealing with this situation, as well as the physical and behavioral indicators of sexual abuse. Knowledge about the family dynamics of incestuous families will facilitate the pediatrician in counseling the adolescent as she shares her experiences.
LEGAL ASPECTS AND DEFINITIONS
Every state has a statute providing for mandatory reporting of abuse to a designated authority. This responsibility is specifically directed to professional health care providers, as well as others. Abuse does not need to be "proved" before being reported. The agency designated to receive and investigate the report must confirm or disprove the suspicion. The pediatrician's findings are seriously considered in establishing if sexual abuse has taken place. In the role of mandated reporters, pediatricians and other professionals are afforded legal immunity for such reports. In most states, a civil or criminal penalty for failure to report can result.3 Because of the complexities of sexual abuse, a comprehensive definition is helpful. Henry Kempe defined sexual abuse as "the involvement of dependent, developmental Iy immature children and adolescents in sexual activities that they do not fully comprehend, to which they are unable to give informed consent, or that violate the social taboo of family role. "4 This definition takes into account molestation, voyeurism, and exhibitionism, as well as vaginal, oral, or anal intercourse.
PHYSICAL INDICATORS OF ADOLESCENT SEXUAL ABUSE
A complete history and examination are essential in delineating the possibility, extent, and nature of sexual abuse. A pediatrician knowledgeable about the physical and behavioral indicators can enable the adolescent to share her experiences by sensitive and perceptive inquiry. An adolescent who is coming to terms with the social taboo against incest, combined with the ability to examine relationships differently, may become so uncomfortable that she must divulge "the family secret." The sense of personal shame and guilt is further exacerbated by the need to be disloyal to the family and share this information. The pediatrician must be especially sensitive to the adolescent's love for family and at no time present «him or herself as condemning or judgmental. The physician's ability to listen actively to what the adolescent is sharing is essential, as well as the ability to provide emotional support. The adolescent will need specific information about what she can expect from the pediatrician, other professionals, and her family. The physician must be prepared to report the information acquired; refraining from doing so can imply that he or she condones the incestuous relationship and leaves the adolescent exposed and unprotected.
Physical indicators include5,6: gonococcal infection, particularly in children under 13 years of age, which may be in the pharynx, urethra, rectum, or vagina; syphilis; genital herpes; trichomonas; nonspecific vaginitis; candidiasis; condylomata; lax rectal tone; pregnancy, especially in girls under 12 years of age; recurrent somatic complaints unsubstantiated by physical examination or laboratory studies; complaints localized to genitourinary, gynecologic, or gastrointestinal symptoms; and chest pains.5,6 Behavioral indicators include: school problems and truancy; runaway behavior; depression; anxiety; phobias; sexual problems, including homosexuality and frigidity; provocative dress and seductive behavior; sophisticated sexual behavior or knowledge; sexual acting out; and self-destructive behavior.
Runaways can benefit from specific information about the realistic problems of being self-supportive with limited skills, making them prey to other exploitative adults. Counseling about social agencies available to them, such as runaway houses, can enable them to seek refuge instead of running away. The adolescent may find referral to protective services and other social agencies frightening, particularly as she considers the prospect of leaving her family. The pediatrician's knowledge about incestuous families may facilitate him in helping the patient to understand why it may be in her best interest (and that of her siblings) to confront this problem actively. In addition, her insights about her particular family may make this decision possible for her.
FAMILY DYNAMICS OF INCESTUOUS FAMILIES
Meiselman's analysis of the incestuous family,6 based on her research, revealed that most incest situations involving parent and child were "brewing" for years before they actually took place. Both parents usually had a background of emotional deprivation, which may have included physical and emotional abuse. The father often had left home early, and either lived alone or in an institutional setting, and the absence of a parent figure at an early age may account for his disregard of the incest taboo. He generally had an ambivalent relationship with his father, who may have been harsh and authoritative or deserted when the family was young. The mother often had a relationship of conflict with her mother, characterized by rejection and hostility. She often did not have the opportunity to learn the "mothering" role.
The sexual relationship of the incestuous father with his wife often has masochistic-sadistic colorings. He may become abusive in order to impose his will. She is often passive and dependent. She loses sexual interest in her husband and unconsciously moves her daughter into the "little mother" role. The daughter is encouraged to assume responsibility for household tasks and in time also assumes a sexual relationship with her father. While denying the possibility of such a relationship, the mother may be relieved that her husband is no longer sexually demanding of her.
There is a high incidence of sexual abuse by stepfathers or their friends. Often the mother does not pick up on clues the girl gives, or if she does, does not protect her. The girl thus becomes confused by the mother's hostile response when she becomes self-assertive or presents behavioral problems.
Father-son incest is considered as a psychological problem of the father rather than one of the family. He generally has homosexual impulses, and usually witnessed or experienced incest within his family of origin. It is normal for the son to be curious about sex and want to please his father; however, when he develops misgivings and insists that it stop, it generally does.
Mother-son incest has been considered as rare, but this may be attributable to lack of reporting. Because the "mothering" role is nurturing and protective, the mother's seduction of her son is considered to be in conflict with her role and psychotic. She is generally found to be a dependent woman whose need for a man in her life supersedes her maternal instincts.
Brother-sister incest is a more common form of sexual abuse and often takes place when youngsters are exploring sexuality and are not closely supervised. Ill effects are contingent on how the youngsters experienced the act. If a child or young adolescent was degraded or belittled, long-term ill effects can be expected. Sensitive handling of such a situation is necessary. 6 Rarents need help in coming to terms with their anger and guilt, as well as help in structuring their children's time.
Because of the complex family dynamics, as well as the conflicting and ambivalent emotions of the sexually abused adolescent, she or he should be interviewed without the parent present and with a great deal of sensitivity and emotional support. The young patient should be apprised that a report must be sent to the appropriate authorities, both for the patient's protection and because it is required by law. It is helpful to explain that the parent is a troubled individual who needs help in stopping this behavior and that treatment resources are available to him and the family. The adolescent should be supported for sharing information about the incest, but he or she should also be prepared to expect angry responses from family members as they come to terms with the family pathology and what that means to them individually.
If possible, the parents should be interviewed by a social worker experienced in working with abusive parents. Their perspective of the patient's presenting problem must be obtained, as well as a family history. The parents too must be informed of the adolescent's allegation, and that the authorities will be involved. Even if the mother acknowledges that she suspected her husband was abusing her child, it must be ascertained if she has the desire and means to protect her youngster. It must be remembered that dependent, passive women are easily intimidated, and it is recommended that the protective service worker be present to assess the situation and make placement plans if necessary.
All data acquired should be carefully recorded. Even though the interview should not have the quality of an interrogation, specific information, including dates of events and physical findings, will be required for the report. The findings of the physical examination are important, including the pediatrician's impression of the patient's account. If the adolescent has been recently assaulted by his or her father, specimens should be collected as is customary in rape cases.
All states have protective services available, and these agencies are mandated to offer assistance in these cases. They are prepared to make emergency placement plans for the adolescent and to investigate allegations. Their task is to prepare a report for legal action. They will rely heavily on the evidence as well as the professional opinion of the pediatrician, who may be asked to testify in court. They are knowledgeable of community resources such as Parents Anonymous, other self-help groups, youth shelters, Families United, and Daughters United, which have been helpful to victims and their families.
Victims of intra-family sexual abuse and their families can benefit from therapy. Pediatricians can use their position to encourage the adolescent to seek counseling and to stick with it even when it becomes especially painful. They can also act as the adolescent's advocate with protective services and the judicial system. The "system" is known to move slowly, and it is not at all uncommon for months to go by before a case is processed by the appropriate authorities. Thus, the pediatrician can become the adult who shows a consistent concern for the patient and ensures that referrai to a mental health professional is made. The pediatrician's continued interest can play an important role in helping the adolescent feel that someone believes she or he is of worth and is intent in helping to resolve conflicts about him or herself and family. If the adolescent is a male who was molested by a male relative, the pediatrician can assure the adolescent that he himself is not homosexual just because he was molested by a male. Open dialogue about sexuality and the adolescent's questions and concerns can alleviate a great deal of turmoil and faulty coping mechanisms.
Working with the sexually abused adolescent is emotionally draining, time consuming, and often painful, and this contributes to the professional's reluctance to become involved. However, pediatricians are called upon to help adolescents. They are also in a strategic position to raise public awareness of this prevalent problem and to participate in developing programs for children and adults who are victims and need protection and long-term treatment. They can encourage prevention by endorsing programs that teach children and adolescents about sexual abuse and the appropriateness of disclosure. Because of the complexities of sexual abuse and the prevalence of the problem, it is essential that all professionals working with youth come together to develop strategies to combat this problem. The pediatrician can act as an impetus in this process.
1. Fmkelhor D: Child Sexual Abuse: Nevt Theory and Research. New York, The Free Press, 1984. pp 1-4.
2. Wooden K: Wequng m the Pìayomeaf Others. New York, McGraw-Hill Book Company. 1976.
3. US Department of Health and Human Services, Health Resources and US Services Administration: Child Abuse/Neglect/Saual Abuse; ? Guide for Pieuennon. Detection, Treatment and FaUovt-ufi in BHCDA Programs and Protects- 1985. p 3.
4. Kempe CH: Sexual abuse, another hidden pediatrie problem. Pediatrics 1978; 62:382.
5. AMA Diagnostic and Treatment Guidelines Concerning Child Abuse and Neglect. JAMA 1985; 251(6):798.
6. Meiseltnan KC: Incisi: A Psychological Study of Causes and Effects with Treatment Recommendations. San Francisco, Jossey-Bass Publishers, 1978.