RECOGNIZING SEXUAL ABUSE

Child sexual abuse involves the coercion of a dependent, developmentally immature person to commit a sexual act with someone older. For example, an adult may sexually abuse a child or adolescent, or an older child or adolescent may abuse a younger child. A perpetrator does not have to be an adult in order to sexually abuse a child (RAINN, 2021).

The fact that sexual abuse may be carried out by a family member or friend further increases the child’s reluctance to disclose the abuse, as does shame and guilt plus the fear of not being believed. The child may fear being hurt or even killed for telling the truth and may keep the abuse secret rather than risk the consequences of disclosure. Very young children may not have sufficient language skills or vocabulary to describe what happened (Clermont County CPS, 2021; RAINN, 2021).

Child sexual abuse is found in every race, culture, and class throughout society. Girls are sexually abused more often than boys; however, this may be due to boys’—and later, men’s—tendency not to report their victimization.

Most perpetrators of child sexual abuse are people who are known to the victim. As many as 93% of children who are sexually abused under the age of 18 know the abuser. There is no particular profile of a child molester or of the typical victim. Even someone highly respected in the community—the parish priest, a teacher, or coach—may be guilty of child sexual abuse. Anyone, including parents, can be a perpetrator, and most are male.

Negative effects of sexual abuse vary from person to person and range from mild to severe in both the short and long term. Victims may exhibit anxiety, difficulty concentrating, and depression. They may develop eating disorders, self-injury behaviors, substance abuse, or suicide. The effects of childhood sexual abuse often persist into adulthood (Clermont County CPS, 2021; RAINN, 2021).

Physical Indicators of Sexual Abuse

Physical evidence of sexual abuse may not be present or may be overlooked. Victims of child sexual abuse are seldom injured due to the nature of the acts. Most perpetrators of child sexual abuse go to great lengths to “groom” the children by rewarding them with gifts and attention and try to avoid causing them pain in order to ensure that the relationship will continue.

If physical indicators occur, they may include:

  • Symptoms of sexually transmitted diseases, including oral infections, especially in preteens
  • Difficulty in walking or sitting
  • Torn, stained, or bloody underwear
  • Pain, itching, bruising, or bleeding in the genital or anal area
  • Bruises to the hard or soft palate
  • Pregnancy, especially in early adolescence
  • Painful discharge of urine and/or repeated urinary infections
  • Foreign bodies in the vagina or rectum
  • Painful bowel movements
    (Clermont County CPS, 2021; RAINN, 2021)

Behavioral Indicators of Sexual Abuse

Children’s behavioral indicators of child sexual abuse include:

  • Unwillingness to change clothes for or participate in physical education activities
  • Withdrawal, fantasy, or regressive behavior, such as returning to bedwetting or thumb-sucking
  • Inappropriate, bizarre, suggestive, or promiscuous sexual behavior
  • Inappropriate sexual knowledge for age
  • Verbal disclosure of sexual assault
  • Involvement in commercial sexual exploitation
  • Forcing sexual acts on other children
  • Extreme fear of closeness or physical examination
  • Suicide attempts or other self-injurious behaviors
  • Layered or inappropriate clothing
  • Hiding clothing
  • Lack of interest or involvement in activities
    (Clermont County CPS, 2021; RAINN, 2021)

Sex Trafficking / Commercial Sexual Exploitation of Children

The crime of sex trafficking of children is a type of child abuse increasingly encountered in the healthcare setting. It is defined in the Trafficking Victims Protection Act (18 USC §1591) as “to recruit, entice, harbor, transport, provide, obtain, or maintain by any means a person, or to benefit financially from such action, knowing or in reckless disregard that the person has not attained the age of 18 years and will be caused to engage in a commercial sex act.”

The term child prostitution is misleading when used in the context of commercial sexual exploitation of children (CSEC). The children who are involved in commercial sex are victims. Traffickers may beat, rape, torture, and use drugs, alcohol, and emotional tactics to gain control over their child victims.

Commercially sexually exploited youth frequently suffer from injuries and other health issues. Physical issues may include:

  • Tuberculosis
  • Infections
  • Substance use, chemical dependency and withdrawal
  • Malnutrition
  • Physical injuries from violence
  • Sexually transmitted infections, including HIV
  • Pregnancy and pregnancy-related health issues
  • Urinary tract infections

Mental health issues may include:

  • Posttraumatic stress disorder (PTSD)
  • Depression
  • Suicidal ideation
  • Suicide attempts
  • Self-harm
  • Depression
  • Poor self-esteem
  • Feelings of hopelessness

(US DOJ, 2020; Hornor & Sherfield, 2018)

SCREENING FOR CSEC

Victims of sex trafficking seldom self-disclose, and many will resist disclosure because they have been threatened or feel shame, guilt, or loyalty to the trafficker. Some youth do not self-identify as victims. It is important for healthcare providers to ask about exploitation because 88% of adolescent victims of trafficking reported an encounter with a healthcare provider during the time that they were being exploited.

There are several validated screening tools for CSEC and a variety of known risk factors for victimization. Greenbaum and colleagues (2018) developed a short, six-question screening tool for CSEC that can be used effectively for youth in the healthcare setting. This short questionnaire also differentiates between victims of sex trafficking and youth who may have experienced sexual assault or abuse without sex trafficking. Each positive response is given a 1-point score. A cut-off score of 2 indicates a patient suspected for CSEC and indicates further questioning by someone trained in a trauma-informed approach.

  1. Is there a previous history of drug and/or alcohol use?
  2. Has the youth ever run away from home?
  3. Has the youth ever been involved with law enforcement?
  4. Has the youth ever broken a bone, had a traumatic loss of consciousness, or sustained a significant wound?
  5. Has the youth ever had a sexually transmitted infection?
  6. Does the youth have a history of sexual activity with more than five partners?
RESPONDING TO VICTIMS’ DISCLOSURES

It is difficult for young children to describe abuse. They may only disclose part of what happened, or they may make an indirect disclosure such as, “My stepdad keeps me up at night.” It is important not to rush the child and to listen to their concerns so that the child feels safe and supported. If a child discloses abuse, the following actions by the healthcare professional will help the child:

  • Avoid denying what the child discloses
  • Provide safety and reassurance
  • Listen without making assumptions
  • Do not interrogate
  • Limit questioning to only four queries:
    1. What happened?
    2. When did it happen?
    3. Where did it happen?
    4. Who did it? (How do you know them?)
  • Do not make promises
  • Document the child’s statements using exact quotes
  • Remain nonjudgmental and supportive
  • Understand the dynamics of abuse and neglect
  • Report suspicions to the authorities
    (Childhelp, 2021)

If a child or adolescent discloses sexual abuse to a trusted adult, or there is cause for the adult to suspect sexual abuse, the adult should not question the child further. They should instead contact Child Protective Services or, if the child is in imminent danger, the police. These professionals have protocols in place to interview the child by a child interview specialist while police, prosecutors, and caseworkers observe.

Such forensic interviewers are trained to communicate in an age- and developmentally appropriate manner. Coordination of services with a child forensic interviewer is essential, with the expectation that one interview rather than several by different concerned parties reduces the chances of traumatizing the child further (US DOJ, 2015).