Psychiatric Annals

Child Abuse 

Evaluating Suspected Cases of Child Sexual Abuse

Domeena C Renshaw, MD

Abstract

Medical or psychiatric texts provide few guidelines lor the clinician confronted with a case of suspected child sexual abuse. However, with a federal mandate to report such a situation for further investigation by legal authorities, an essential immediate role shift must occur. The health professional must uhi ft from his/her customary role of offering confidentiality to the roJe of forensic evaluator who must report sexual abuse. This role shift is necessary because a possible criminal charge could be filed against the alleged teen or adult participant in order to protect the child or children and the professional could be held liable lor failing to report.1

Three types of presentation are noted:

* Crisis cases;

* Incidental cases;

* Special Search cases.

These presentation categories are summarized in Figure I.

Medical literature must lake care to use terminology accurately and avoid prejudicial legal language such as "victim/perpetrator." and include "alleged" when recording a verbatim statement unless a criminal trial has occurred and a guilty verdict substantiated. This is an important awareness to preclude observer bias that may so easilv lead to condemnation by the clinician rather than to an objective examination. Physicians have in the past been criticized for under-reporting child sexual abuse. In the early 1980s the American Medical Association responded through great efforts in journals, newspapers, symposia, highway billborads, etc. to educate physicians in practice as well as associated health professionals and the public to recognize and report this problem. Media coverage since then has been extensive and persistent.

Teachers, nurses, and social workers now listen attentively to children who mention sexual abuse, who use precocious sexual language, or display behavior that appears sexually inappropriate. However, it must not be forgotten that today (here is also a glut of erotic magazines that children may obtain from peers or in neighbor's garages. X-rated videos and cable TV are in the home where curious children often watch unsupervised by parents. They may mimic or discuss these to lest adults and to get instant attention from peers. In addition, there are numerous lay and professional articles now that erroneously list every ''generic" symptom of" childhood distress as pathognomonic ot sex abuse, for example, bedwetling after a weekend visit with a divorced father, withdrawal, daydreaming, sleeping in class, gym refusal, aggression, reading porn magazines, scratching genitals, masturbation, using obscene language, poor grades, etc. These have been frequent causes for referral from schools for a child evaluation for possible sexual abuse.

Concerned parents may also present their child for a check after an education campaign to see if there was or was not sexual molestation at school or elsewhere. With increasing frequency in the past three years (one, sometimes both), divorced parents will accuse the other of sexually abusing the child whom they then present for an evaluation, preliminary to demanding solo custody. Lawyers and judges are becoming more alert to the unscrupulous manipulation of a child in a vendetta against a former spouse. Children do not divorce parents and may show persistent and prolonged distress at the life changes due to the divorce. They may desperately try to please each parent and long to restore the marriage. Some will lie if a parent tells them to. A few will not. Either group may develop distress symptoms. Which truth is the truth may be difficult to distinguish by the time the case is presented. Unfortunately, even lie detectors lie.3

Neither deductions nor assumptions are appropriate for the examining physician who must maintain objectivity in what is always a highly emotional interaction. All adults claim they wish to protect the child. The physician's task is…

Medical or psychiatric texts provide few guidelines lor the clinician confronted with a case of suspected child sexual abuse. However, with a federal mandate to report such a situation for further investigation by legal authorities, an essential immediate role shift must occur. The health professional must uhi ft from his/her customary role of offering confidentiality to the roJe of forensic evaluator who must report sexual abuse. This role shift is necessary because a possible criminal charge could be filed against the alleged teen or adult participant in order to protect the child or children and the professional could be held liable lor failing to report.1

Three types of presentation are noted:

* Crisis cases;

* Incidental cases;

* Special Search cases.

These presentation categories are summarized in Figure I.

Medical literature must lake care to use terminology accurately and avoid prejudicial legal language such as "victim/perpetrator." and include "alleged" when recording a verbatim statement unless a criminal trial has occurred and a guilty verdict substantiated. This is an important awareness to preclude observer bias that may so easilv lead to condemnation by the clinician rather than to an objective examination. Physicians have in the past been criticized for under-reporting child sexual abuse. In the early 1980s the American Medical Association responded through great efforts in journals, newspapers, symposia, highway billborads, etc. to educate physicians in practice as well as associated health professionals and the public to recognize and report this problem. Media coverage since then has been extensive and persistent.

Teachers, nurses, and social workers now listen attentively to children who mention sexual abuse, who use precocious sexual language, or display behavior that appears sexually inappropriate. However, it must not be forgotten that today (here is also a glut of erotic magazines that children may obtain from peers or in neighbor's garages. X-rated videos and cable TV are in the home where curious children often watch unsupervised by parents. They may mimic or discuss these to lest adults and to get instant attention from peers. In addition, there are numerous lay and professional articles now that erroneously list every ''generic" symptom of" childhood distress as pathognomonic ot sex abuse, for example, bedwetling after a weekend visit with a divorced father, withdrawal, daydreaming, sleeping in class, gym refusal, aggression, reading porn magazines, scratching genitals, masturbation, using obscene language, poor grades, etc. These have been frequent causes for referral from schools for a child evaluation for possible sexual abuse.

Concerned parents may also present their child for a check after an education campaign to see if there was or was not sexual molestation at school or elsewhere. With increasing frequency in the past three years (one, sometimes both), divorced parents will accuse the other of sexually abusing the child whom they then present for an evaluation, preliminary to demanding solo custody. Lawyers and judges are becoming more alert to the unscrupulous manipulation of a child in a vendetta against a former spouse. Children do not divorce parents and may show persistent and prolonged distress at the life changes due to the divorce. They may desperately try to please each parent and long to restore the marriage. Some will lie if a parent tells them to. A few will not. Either group may develop distress symptoms. Which truth is the truth may be difficult to distinguish by the time the case is presented. Unfortunately, even lie detectors lie.3

Neither deductions nor assumptions are appropriate for the examining physician who must maintain objectivity in what is always a highly emotional interaction. All adults claim they wish to protect the child. The physician's task is twofold: to conduct a physical examination and to obtain a history of what allegedly occurred. The child's age, development, intellectual understanding of the words and questions used, information recall, and emotions must all be considered. Investigation of both physical and psychogenic elements must be carefully, objectively, and factually recorded, without options or unfounded statements, for example, "As seen today, this examination revealed no genital injury. The child denied any sexual contact," must be recorded by the evaluating physician.

Unfortunately, what may happen is that a physician eager to protect the best interest of the child (who showed a completely normal physical and genital exam) may then follow the objective negative finding by stating: "exam consistent with sex abuse." Such an ambiguous, subjective, unfounded deduction may later become destructive beyond the physician's comprehension. The child's home may immediately be regarded as unsafe and a father or mother named as a "perpetrator" and arrested by authorities. The family may be disrupted, the child or all the children placed in fostercare for days, weeks, or many months pending the court trial. Separation anxiety from the loss of mother, father, siblings, friends, school, and basic security may follow. Other traumata include:

* Physical and genital examinations;

* Repeated questioning by many strangers;

* Fear of the new placement;

* Shame;

* A great helplessness;

* Not being believed;

* Longing for kin, comfort, and home;

* Demoralization and depression. This syndrome may then be attributed wrongly to alleged sexual abuse when in fact it is due Io the chain of losses that followed a false or erroneous report of child abuse.

Table

FIGURE 1Types of Presentation of Cases of Child Sexual Abuse

FIGURE 1

Types of Presentation of Cases of Child Sexual Abuse

If the allegation is indeed accurate, most citizens and professionals feel that such dramatic life changes are justified and use the legal and medical systems to protect the child and aid long-range growth and adjustment.

Evaluation is, therefore, important. History-taking can be assisted by understanding some key elements involved in sexual exploitation (Table). In a disturbed or fragmented family there may be little protection or education about sexuality or values.7,8

Teachers, fosterparents, babysitters, or ministers in some cases may molest a child instead of protecting. For different reasons, learned sexual controls are noi operative when one partner (A) exploits another unequal, uninformed, non-resistive partner (B). Therefore, in the process of evaluating the child partner (B), the evaluator's task is to understand the child's general and sexual knowledge, values, resistance (self-protection), negative physical responses such as pain, infection, or bleeding, or negative emotional responses. Al times the child experiences quite natural sexual arousal and orgasmic responses from the sexual contact. These may be pleasing, confusing, or upsetting. Ii such response is elicited, the clinician can explain to the child that these were quite natural reactions, but lhat the partner was not appropriate and breaks the law by such behavior.

Table

TABLESexual Exploitation Model

TABLE

Sexual Exploitation Model

Also, how the child regards other family members must be explored.2 Who was approached by the child after the sexual contact and for what reason: contusion, anxiety, physical problems (such as bleeding, sexually transmitted disease, or pregnancy symptoms)? Details of divorce and stepfamily arrangements are also very important to prevent a charge of sexual abuse erroneously levelled (particularly in marital disputes) toward a stepfather when the sex contact was between step and natural siblings. Special care is needed in sexual history-taking as well as from the parent who presents. Clinician objectivity is not to be clouded by myths that children do not lie or that sexual knowledge is pathognomonic of sex abuse - gently get more details and still more.

Many video interviews of taking a child sex history seen in consultation go "straight for the groin." This is a mistake because leading questions seek to confirm observer assumptions or bias and may even be misleading or confusing to the child about the "safety" or legitimacy of this stranger designated as an authority. A suggestible child may say yes or nod to all questions to please an adult. A defensive child often will say "i don't know" to all questions. A child who wants to prolee! self or another may, despite a previously diagnosed venereal disease, deny any sexual activity, which may relate to a threat or to sanctions from the family such as "don't say anything."

Some children cover up well and are incredibly resistant. They may need more lime to build trust toward the examiner, to understand why the questions are being asked and what the possible consequences may be. For the examiner to say "it's not your fault" may be eorrect, but that does not mean that no harm will result from telling. That depends on who defines harm. Loss of home and family may be a terrible harm to the child, although may not seem so to the professional. To say schoolmates will not know may be an impossible promise when tomorrow's headlines report the story.

An audio or videotaping may help in many ways:

* Allow another professional to evaluate the direetiveness or challenge the skill and interpretations of the evaluator, who must be professionally accountable for conclusions drawn;

* Assess the child's non-verbal behavior in response to the questions:

* Review the evaluator's own voice tone (high pitched, encouraging, leading to a desired reply, firm or frightening, affirmatory in the absence of the child's affirmation, etc.) and cooing or congratulatory terms such as "good girl," "nice boy," etc. when certain replies are attained;

* Note and assess the general knowledge, developmental level. and mental status of the child from responses to family, school, as well as sexual history;

* Evaluate the accuracy of the information given to the child about why this interview was being done and what is to happen with the information;

* See the child's responses to the method used l'or the sexual history, eg, rag dolls, paper dolls, pipecleaner dolls, drawings, etc.;

* Get an overall picture of the child's informational recall (immediate, intermediate and long-term memory scaled down to the developmental level of the child);

* For use in the court hearing in some jurisdictions;

* For diagnostic or therapeutic use with the child should there be later "blocking" of the memory or change of' the story or for other reasons.

For those who work with children a sexual hisiory is now obligatory to mie out sexual abuse, which is reportüble by law in all states.0 Therefore, in the course of taking a medical or psychiatric history, a few standard screening questions could be: "Boys and girls learn about the private sexual parts of their body. Have you? Who helped you? How?" Further details should be obtained if indicated. This should be followed by. "Has anyone shown you, scared you, or touched private sex parts - theirs or yours? How? Who?" Again, further detail should be obtained i I indicated. If sexual abuse is suspected by the clinician, then a more complete series of sexual questions must be asked (Figure 2). These can be woven in with general family and school history to avoid undue locus or emphasis on sex as separate from the rest of existence. Cheek for understanding. Do not express disapproval of child or family member. Attempt to be as neutral and clinically objective as possible.

ETHICAL ISSUES

Several ethical issues remain regarding taking a child's sexual history.

Is it possible to obtain "informed assent" from the child who is to give the history? To lei! the child, "We want to help you/your father/ mother, etc." may not begin to describe the major life changes that could result. Yet there must be some effort to explain. Even, "We have a law that says I have to ask you these sexual questions to protect or help you if you need it." is grossly inadequate, but it does with goodwill try to explain to the child why the sexual questions are to be asked.

How can confidentiality be promised to the child? Il is impossible. Sexual abuse is regarded as a reportable criminal offense and the evaluating professional temporarily becomes a criminal investigator whose "evidence" from the child will be reviewed by police and the law courts. A therapeutic alliance is, therefore, extraordinarily difficult. One way is to explain: "The law forces me to report the sexual problem so they can protect you." To go further with a promise of "help or treatment" for child or adult sex partner or family may be inaccurate when there may be no family funds. no treatment resources other than foster placement, and when the loss of home and parents - even non-protective ones - may not be perceived by the child as help.

How can the evaiuator justify keeping silent aboul the necessary law enforcement invasion of the sanctuary of the child's home to question family members under child protection laws?

How can there ever be restitution to a family and child for "wrongful rescue" or for an erroneous sexual abuse diagnosis?^ Is plea-bargaining to make a false confession of child sexual abuse justified or redeemable? Whieh professionals have returned to check their case reports and to measure the sequelae of false arrests?15

Table

FIGURE 2Renshaw Child Sex HistorySupplemental to routine medical/psychosocial history

FIGURE 2

Renshaw Child Sex History

Supplemental to routine medical/psychosocial history

Table

FIGURE 2Renshaw Child Sex HistorySupplemental to routine medical/psychosocial history

FIGURE 2

Renshaw Child Sex History

Supplemental to routine medical/psychosocial history

How can the courts accept "child workers," sometimes unlicensed, untrained, or only marginally trained in child development, pathology, and playtheory as adequate evalualors of whether child sexual abuse occurred in the absence of "hard signs" such as genital injury or sexually transmitted diseases? Two "anatomically correct" dolls, however expensive, do not make an instant child sex history-taking expert of the person who uses them. Incredible misinterpretations have resulted.

Some pitfalls in history taking are to be remembered by all who work in this difficult and highly emotional arena of child sexual abuse. Children try to please adults as part of their normal security-seeking behavior; therefore, it can be easy to mislead a child. This was well noted three quarters of a century ago Jn a significant study regarding child witnesses.9 Two classroom experiments were conducted. In the !irsi. 19. 7year-olds were asked "What color is Mr. B's (a familiar teacher) beard?" Sixteen said black. Two did not reply. In fact Mr. B had no beard. In a similar class experiment. 27. 8-yearolds had a male teacher talk to the class for five minutes and leave. Then they were asked "In which hand did Mr. A hold his hat?" Only three correctly replied he wore no hat; 17 children said the right hand, 7 children the IeIi hand.4

Another example of a misleading question is to point to the genitals of a doll or picture and ask: "Did Daddy touch you here?" That is how not to take a sexual history. Openended questions, such as, "What happened then?" or "Where were you touched?" or "Show me what happened?" are more likely to be accurate.

Deductive leaps are further pittalls. A child's intrigue and interest in the genitals of a doll or drawing are not necessarily abnormal nor per se evidence of sexual abuse, although they may be. A recent study was done with "anatomically correct" dolls in Canada with 17 daycare center children from age 2. 4 to 5. 2 years.11-' This is an important baseline study long overdue. The children in the study were not abused, but volunteers whose parents had agreed to the study. Eight types of behavior were noted in response to the dolls: including three children "fled", too shy to look further at the dolls; active handling of the dolls; concealing the sexual parts; unusual and overt interest in the dolls' genitals; identifying the anatomy correctly, etc.10 Such dolls have recently been regarded as "stock in trade" of almost every emergency room and child agency in the country. Fortunately, related problems are now being noted, studied, and published.

Some of the dolls are not anatomically correct:

* The genitals may be disproportionately enlarged;

* The girl doll may lack an anus therefore, when a 2-year-old girl pointed to the doll's solitary opening it was misinterpreted by a child worker as vaginal penetration by her grandfather, who had wiped the anus when changing her diaper;

* Genitals made to look like a human's may be sewn onto a bear or bunny toy. which is confusing, dehumanizing, and misleading to the child;

* Some 198b boy dolls allegedly come with the "latest," a velcro detachable penis for an interchangeable circumcised or uncircumsized one! What this will do to loster castration anxiety will await further study.

The inner world of a child is different from that of the adult. For a child symbolism, fantasy, fusion and confusion, make-believe, and primitive thinking are pathways as they learn to incorporate daily experiences and information to make sense of the world around them. Sexual interest is normal from infancy onwards, so are arousal and orgasm, noted from the first months of life in both sexes, long before the vocabulary to describe them has evolved. Childhood sexplay and exploration are also natural phenomena, as is learning by watching and rehearsing Irò m dancing and singing to sexual movements so vividly portrayed in X-rated cable, videos, and explicit magazines around the home or neighborhood. It is a major clinical pitfall to disregard the cultural fact that we are in the era of the eroticized child. Therefore. "Where did you learn about lhal?" must be a followup question whenever relevant.

In the early 1980s newspapers headlined "U.S. child is sexually abused every two minutes," "Sex abuse up 600<fo," etc. Clinicians must ask: "Is that really true?" The answer, is "no." In 1982 the National Study of Child Abuse and Neglect revealed nationwide statistics: 62% of child abuse allegations were neglect; 24"V. physical abuse; 10% emotional abuse; 7'1O (65,0OU) sexual abuse, and 9% other. For the State of Illinois the ratios were very similar. Allegations of sex abuse rose by 38"-MIrOm 5. 170 reports in 1983) to 7.134 in 1984, a total of 6.7% of the total Child Abuse allegations. Of the reports, bO% reached a category "Indicated" and 40'V were dropped, although unclear whether it was before or after trial. These ligures. the best available today, do not resemble the "pandemic" loosely reported in the media.

The unfortunate backlash of the current "bad touch" teaching is that we now have "sex abuse hysteria." Some principals tell teachers never to be alone with a child without an adult chaperonc, and the same advice is being adopted by physicians who examine children.6 Fathers and grandfathers say lhey are nervous to hug, hold, or bathe their little ones. Needed caring affectionate touch expression is thus lost to every family member. Only in this century has scientific proof emerged of the va/ue of abundant touch for physical, mental, and emotional growth - from the cradle to the scnium. In the past, bumper stickers asked, "Have you hugged your kid today?" Leo Buscaglja has become a national "hug" idol, speaking to a universal hunger for his message. Meantime, common sense dictates that appropriate affectionate touch continue between family, trusted adults, peers, and our children because it is an essential exchange for general growth and weil being of young and old alike.

REFERENCES

1 . Renshaw DC: When you suspect child sex abuse: Takt the child's iexual history. Medical Aspects of Human Sexuality 1986; 20(6):19-27.

2. Renshaw DC: incest: Understanding and Treatment. Boston. Linie. Brown & Co. 1982.

3. Bok S: Lying. New York, Pantheon Books, 1978.

4. Faller CF: Is the child victim of sexual abuse telling the truth? Child Abuse and Neglect 1984; 8:473.

5. Joyner G: False accusations, uf child abuse - Could it happen to you? Woman's Day 1986; May: 30-42.

6. Renshaw DC: When sex abuse is falsely charged. Medical Aspects of Human Sexuality 1985; 19(71:116-124'

7. Renshaw DC: Sex Talk for a Safe Child. Chicago. American Medical Association, 1984.

8. Yates A: Sex Without Shame. New York. William Morrow, 1978.

9. Varendock J: Les teroignages d'en fants, dans un proce,s retenissant. Arch Psychol 1911; 11:129.

10. Gabriel F: Anatomically correct dolls in the diagnosis of ihe sexual abuses of children. Journal of the MeIu ine Klein Society 1985; 3(21:40-51.

FIGURE 1

Types of Presentation of Cases of Child Sexual Abuse

TABLE

Sexual Exploitation Model

FIGURE 2

Renshaw Child Sex History

Supplemental to routine medical/psychosocial history

FIGURE 2

Renshaw Child Sex History

Supplemental to routine medical/psychosocial history

10.3928/0048-5713-19870401-10

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