Clinical practice: recognizing child sexual abuse-what makes it so difficult?

Advances in diagnostic codes to document sexual assault in health care service

OBJECTIVE

To explore trends in documented sexual abuse/assault (SA) related episodes in California hospitals and emergency departments (ED), including the impact of a change in health care service reporting codification (from ICD-9-CM to ICD-10-CM) that more clearly defined SA in October 2015.

DATA SOURCES

Hospital and ED data were drawn from California's Office of Statewide Health Planning and Development (OSHPD).

STUDY DESIGN

Descriptive and trend analyses of SA-related hospital and ED records (including patients' demographic information) were conducted to determine whether changes in ICD codification had an impact on documented SA-related episodes.

DATA COLLECTION

All SA-related episodes (ICD-9-CM codes 995.83, 995.53; ICD-10-CM codes T74.21-T74.22, T76.21-T76.22) in California hospitals and EDs for the last decade of available data (2008-2017) were analyzed (n = 20,215).

PRINCIPAL FINDINGS

An abrupt increase in documented SA episodes in hospitals and EDs began in October 2015, when specific ICD10 codes for suspected cases of SA were created. Documented SA-related episodes doubled in 1 month (164 vs. 385 episodes in September 2015 and October 2015, respectively). More than half (58.2%) of all SA-related episodes documented in Oct 2015 were coded as suspicious. The number of documented SA-related episodes continued increasing to the end of the time series (December 2017). Overall, the annual number of documented SA-related episodes increased by over 700% in only 4 years (900 vs. 6441 in 2013 and 2017, respectively), suggesting high rates of prior under-reporting and the need to introduce the new codes. African Americans were disproportionally impacted; however, the highest increases in age-adjusted rates between the ICD-9-CM and the ICD-10 codification period were found among the White population (2.46 vs. 16.53 per 100,000 inhabitants).

CONCLUSIONS

SA episodes in the clinical population have been underestimated for many decades. Identifying SA victims and measuring SA-related health care utilization is a real challenge that needs further investigation.

Child sexual abuse in Kaduna State, Northwestern Nigeria: A review of 420 police-reported cases

Child sexual abuse affects millions of children globally but in Nigeria, hospital-based studies continue to report few cases, making it difficult to assess the magnitude and quality of care. This study aimed to overcome this challenge by reviewing police medical reports instead of hospital records. A total of 420 reports were retrieved from one police area command in Kaduna State, Northwestern Nigeria, between 2018 and 2021. The majority of the victims were females (65.5%), 5-14 years (70.2%), and familiar with their assailants (71.4%). Most of the assailants were men (99.0%), 20-40 years (29.1%), who acted alone (86.7%). Most of the reports contained history (79.3%), physical examination (49.6%), and laboratory results (>90%). Among female victims, the commonest genital findings were absent hymen (25.6%) and normal findings (17.6%). Among male victims, the commonest anal findings were normal findings (41.7%) and anal dilatation (23.6%). The victims tested positive for HIV (0.5%), hepatitis B (4.7%), hepatitis C (1.0%), and syphilis (0.8%). Higher positivity rates were noted among assailants. Treatments offered to the victims included antibiotics (30.2%), analgesics (11.9%), emergency contraception (6.7%), and psychotherapy (67.4%). The review calls for improved reporting, use of comprehensive treatment guideline, and training of service providers to improve the quality of care.

Child and adolescent victims of sexual violence: aspects of physical and emotional development

OBJECTIVE

to identify the multidisciplinary health team's perception on aspects of the physical and emotional development of children and adolescents who have suffered sexual violence.

METHODS

a qualitative study, carried out with 30 health professionals in a hospital in Bahia, Brazil, between June and July 2019. Data were collected from an interview guided by a semi-structured questionnaire. The results were interpreted according to Symbolic Interactionism.

RESULTS

some sexually violated children were under five years old and healthy, others had physical/mental disabilities. Victimized adolescents were in the pre-pubertal phase, with fragile body structure, not emotionally mature and unaware of sexuality.

FINAL CONSIDERATIONS

children's physical and emotional aspects make children vulnerable to sexual victimization, as they facilitate the control and dominion that offenders need to have over them. As a protection strategy, it is recommended using sexual and health education linked to greater surveillance of family members, multidisciplinary team and educators.

Child sexual abuse detection in the pediatric emergency room

BACKGROUND

Children who report sexual abuse are often first evaluated in a Pediatric Emergency Room (ER).

OBJECTIVE

This study aims to describe clinical characteristics and management among these children.

PARTICIPANTS AND METHODS

A retrospective review of child sexual abuse (CSA) cases in the ER of a tertiary hospital in Madrid over a 9-year period (January 2011 to April 2020) was conducted. 213 children up to 16 years old were included. Descriptive statistics were performed.

RESULTS

An 83% of victims were girls, of whom 97.7% reported physical contact. The mean age was 8.5 ± 4.4 years, with two peaks of incidence at ages of 3 and 13. Aggressors were known by the victim in 77.8% of cases. Anogenital lesions were present in 39.9% of children who described physical contact, of which 31.7% were suspicious or specific of CSA. We obtained positive microbiological samples in 41 patients, with 14.6% specific findings for sexually transmitted infections (STIs). 23,9% received prophylaxis for bacterial STIs and 13.6% against HIV. 59.6% were followed-up in outpatient clinics. Since our protocol renovation in 2019, we observe a statistically significant increase in microbiological detection (p < .005) and outpatient follow-up (p < .001).

CONCLUSIONS

STIs screening should always be done when physical contact is reported for eventual treatment and perpetrator prosecution, as physical lesions are frequently not found. The optimal treatment of CSA requires the use of renewed specific protocols and the involvement of multidisciplinary trained teams to ensure adequate medical and personal care.

Health care providers' responses to sexually abused children and adolescents: a systematic review

Background

Sexual abuse of children and adolescents is a significant health concern worldwide. Appropriate and timely health services for victims can prevent severe and long-term consequences. This study identified and categorized diagnostic and treatment services needed for sexually abused children and adolescents.

Methods

Several databases, including MEDLINE, Web of Science, Scopus, Science Direct, ProQuest, and Google Scholar, were searched to retrieve studies on the topic and clinical guidelines in English covering the literature from 2010 to 2020 using search terms. Primary studies and guidelines were reviewed to identify treatment strategies and medical interventions related to sexually abused children and adolescents.

Results

Twenty-one studies and guidelines were selected and analyzed narratively. The quality of evidence was relatively good. We identified that effective health care systems for sexually abused children include the following: interview and obtain medical history, physical and anogenital examination, collecting forensic and DNA evidence, documenting all the findings, prevention and termination of pregnancy, diagnostic tests, prophylaxis for HIV and other STIs, vaccinations, and psychological intervention.

Conclusions

This review provides up-to-date evidence about adequate health care services for children and adolescent victims of sexual abuse. We conclude that recent studies have focused more on prophylaxis against HIV and other STIs, studies on vaccinating against HPV for victims are still limited, and future research in this area is needed.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07814-9.

Child Abuse: Recognition, Reporting, and Response

ABSTRACT

Because child abuse occurs across all genders, ethnicities, and socioeconomic groups, nurses working with pediatric patients and their families need keen observation and assessment skills. The purpose of this article is to discuss the recognition, reporting, and appropriate response to child abuse. Caring for children who have been abused and their families is challenging yet presents the opportunity to demonstrate Christ's compassion. Awareness of one's own emotional responses requires meaningful self-care strategies that are also discussed.

Crianças e adolescentes vítimas de violência sexual: aspectos do desenvolvimento físico e emocional

RESUMO Objetivo: identificar a percepção da equipe multiprofissional de saúde sobre os aspectos do desenvolvimento físico e emocional de crianças e adolescentes que sofreram violência sexual. Métodos: estudo qualitativo, realizado com 30 profissionais de saúde em hospital da Bahia, Brasil, entre junho e julho de 2019. Os dados foram coletados a partir de entrevista norteada por questionário semiestruturado. Os resultados foram interpretados conforme o Interacionismo Simbólico. Resultados: algumas crianças violadas sexualmente tinham menos de cinco anos e aspecto saudável, outras portavam deficiências físicas/mentais. Adolescentes vitimizadas estavam em fase pré-púbere, com estrutura corporal frágil, pouco amadurecidas emocionalmente e desconheciam sobre sexualidade. Considerações finais: aspectos físicos e emocionais infantojuvenis vulnerabilizam crianças para a vitimização sexual, pois facilitam o controle e domínio que o agressor necessita ter sobre elas. Como estratégia de proteção, recomenda-se o uso da educação sexual e em saúde atreladas a maior vigilância de familiares, da equipe multiprofissional e educadores.

Child Maltreatment and Neglect

Emergency medicine clinicians are mandated reporters, legally, which obligates clinicians to report any behavior suspicious for child maltreatment to local authorities. Pediatric patients often present to the emergency department with concern for physical injury and other pervasive complaints. In some cases, these injuries are nonaccidental. To appropriately advocate and protect children from further physical and emotional trauma, it is important for clinicians to recognize the signs and symptoms of child maltreatment and sexual abuse.

How child health care physicians struggle from gut feelings to managing suspicions of child abuse

Aim

We examined how gut feelings of child health care physicians’ (CHCPs) contribute to the development of a suspicion of child abuse, how they act upon this suspicion and what barriers they experience in their management. To gain insight into the youth health care chain, we compared the diagnostic reasoning and management regarding this issue by CHCPs and family physicians (FPs).

Methods

Three focus groups, 20 CHCPs, thematic content analysis.

Results

A gut feeling acted as an early alert to look for the triggering cue(s), by observing more closely and asking relevant questions. CHCPs struggled to distinguish whether the situation involved child abuse or a lack of parenting skills, and how to communicate their concerns with parents. They tried to motivate parents to improve the situation, avoiding the term child abuse and considered involving the Child Abuse Counselling and Reporting Centre (CACRC) a measure of last resort only.

Conclusion

As with FPs, gut feelings support CHCPs in becoming attentive to child abuse and to situations which can lead to child abuse. The next step, discussing their suspicion with the parents, is a difficult one, and the CACRC might actually help to make this step easier.

Brazilian Protocol for Sexually Transmitted Infections 2020: sexual violence

This article addresses sexual violence, as part of the Clinical Protocol and Therapeutic Guidelines for Comprehensive Care for People with Sexually Transmitted Infections, published by the Brazilian Ministry of Health. Guidance is provided in programmatic and operational management, focusing on the service network for people in situation of sexual violence, recommendations to health staff about pregnancy and viral and non-viral sexually transmitted infections prophylactic measures, in addition to surveillance action strategies. Sexual violence is an encompassing issue that includes wider areas than the health field. It involves conceptual and programmatic challenges for health staff, at the forefront of care for affected people and also to the implementation of prevention strategies addressed to the whole society. Sexual violence is one of the principal forms of human rights violation, affecting the right to life, health, and bodily integrity.

Sexual Violence and Trauma in Childhood: A Case Report Based on Strategic Counseling

Children and adolescents are too often victims of sexual abuse and harassment. According to the World Health Organization (WHO), approximately 150 million girls and 73 million children <18 have been victims of violence and sexual exploitation during their childhood. Data show that females are more likely to be a victim of abuse and violence than males (20% vs. 5–10%). Such abuses lead to long-term psychophysical and relational consequences and victims are often afraid of asking for support from both parents and professionals. This case report shows the story of a 17-year-old adolescent, Sara, involved by her mother in a strategic counseling process, to solve BDSM-type sexual addiction (slavery and discipline, domination and submission, sadism and masochism), self-aggressive behavior, and alcohol abuse issues. The strategic counseling process is structured in 15 sessions and was based on problem-solving techniques and corrective behavioral strategies. During the sessions, it emerged that Sara had been a victim of sexual violence at the age of 6 and that she had never talked about the rape with anyone. At the age of 12, she began to experience social anxiety and shame, feelings that led her to use alcohol and seek violent sexual partners and bondage relationships. During the counseling sessions, Sara elaborated on her trauma, becoming more aware of her resources and her desires, and she learned to manage the sense of guilt and shame associated with the violence suffered, through alternative strategies. At the end of the process, Sara normalized her relationship with sex and alcohol, regaining her identity.

[Brazilian Protocol for Sexually Transmitted Infections 2020: sexual violence]

This article addresses sexual violence, a topic that makes up the Clinical Protocol and Therapeutic Guidelines for Comprehensive Care for People with Sexually Transmitted Infections, published by the Ministry of Health of Brazil. Guidance is given to managers in programmatic and operational management with a focus on the service network for people in situations of sexual violence, recommendations to health professionals about prophylactic measures of pregnancy and viral and non-viral sexually transmitted infections, in addition to strategies for surveillance actions. Sexual violence is a broad problem that goes beyond the health field and involves conceptual and programmatic challenges for both health professionals, who are at the forefront of care for affected people, and for society, in terms of possible forms of prevention.

A Brief Depression and Anxiety Rating Scale for Sexual Violence Victims

OBJECTIVE

This study aimed to develop a brief self-report measure of depressive and anxiety symptoms in victims of sexual violence.

METHODS

The sample, which consisted of 215 victims and 255 healthy controls, was recruited between December 2016 and November 2018 from eight Sunflower Centers. Eligible items were selected from existing scales of depression (CES-DC and CES-D) and anxiety (SAI-C and BAI) symptoms by item-total correlation coefficients and item response theory (IRT) analysis. Internal consistency coefficients were computed and the receiver operating characteristics curve was inspected to assess the validity of the brief scale and determine optimal cutoff scores.

RESULTS

The brief scales showed high internal consistency across all age groups. The optimal cutoff score of brief depression scale was 1.5 for children, 2.5 for adolescents, and 2.5 for the adults. That of brief anxiety scale was 8.5, 6.5, and 3.5, respectively.

CONCLUSION

The results underscore the need for age-appropriate screening measures of depressive and anxiety symptoms in victims of sexual violence.

Impact of poor evidence management on DNA profiling in sexual assault and homicide: A case report

Increasing numbers of female victims of violent sexual assaults are being murdered with the aim of concealing the identity of the perpetrator. Proper handling and analysis of evidence is very important in gaining a conviction in many criminal cases. After evidence is collected, due precautions must be taken to ensure that the integrity of the sample is maintained, and chances of contamination are minimised. This paper presents a case study where improper handling of biological evidence led to loss of evidentiary value, and the semen could not be located on the vaginal swabs and victim's garments due to improper preservation of samples. However, the DNA from the nail of a decomposed finger helped identify the victim, and the suspect was apprehended based on the clues given by her family.

PERCEPTIONS OF A MULTIDISCIPLINARY TEAM ON THE PSYCHOLOGICAL REPERCUSSIONS OF SEXUAL VIOLENCE AGAINST CHILDREN AND ADOLESCENTS

ABSTRACT Objective: to understand the perceptions of a multidisciplinary health team in caring for hospitalized children and adolescents with psychological repercussions of sexual violence, in the light of Symbolic Interactionism Theory. Method: this is a qualitative study, carried out with 30 professionals from the multidisciplinary health team working in a general public hospital in Salvador, Bahia, Brazil. The interviews took place between June and July 2019, using a semi-structured questionnaire and, after being recorded, the reports were transcribed. In analysis, the data were categorized by similar themes following the steps: pre-analysis, material exploration, treatment of results and interpretation. The project was approved by an Institutional Review Board. Results: among the psychological disorders presented by children and adolescents are aggressiveness, mutism, eating disorders, infantilized behavior, hypersexualized behaviors, depressive disorders, anxiety disorders, psychotic episodes, and delusions. Conclusion: the study demonstrates the perceptions resulting from the interaction allowed in caring for the multidisciplinary team to children and adolescents who experienced sexual violence and developed psychological disorders. In this way, it raises warning signs for family members, health professionals, education, protective devices and the whole of society about the need to observe signs of these changes on a daily basis, seeking to investigate their possible relationship with sexual assault.

Piloting sexual assault care centres in Belgium: who do they reach and what care is offered?

BACKGROUND

Sexual assault (SA) is highly prevalent in Belgium. In order to mitigate the negative consequences for victims of acute SA, Sexual Assault Care Centres (SACCs) were piloted from October 2017 to October 2018 in three Belgian hospitals. SACCs offer medical and psychological care, forensic examination and the possibility to report to the police at the SACC.

OBJECTIVE

Aiming to improve SACC services, we quantitatively assessed the number and characteristics of victims attending the SACC, the SA they experienced, and the care they received over 12 months upon admission.

METHOD

Data on victims presenting at the SACC were routinely collected in electronic patient files by the SACC personnel between 25 October 2017 and 31 October 2019. These data were analysed in IBM SPSS Statistics 25.

RESULTS

Within the first year 931 victims attended the SACCs. Mean age was 24.5 years (SD = 12.8), and one-third were under 18. The majority were female (90.5%) and 63.1% presented for rape. About one-third of the victims were considered vulnerable due to previous SA (35.6%), prior psychiatric consultation (38.7%) or disability (8.5%). The assailant was known to the victim in 59.2% of the cases. Of all SACC presentations, 35.2% self-referred to the SACC while 40.9% were referred by the police. Two out of three victims attended the SACC within 72 h post-assault. Respectively 74.7% of victims received medical care, 60.6% a forensic examination, 50.2% psychological care, and 68.7% reported to the police.

CONCLUSION

Despite the absence of promotion campaigns, the SACCs received a high number of victims during the pilot year. Use of acute and follow-up services was high, although new approaches to offer more accessible psychological support should be explored. The big proportion of vulnerable victims warrants careful monitoring and adaptation of care pathways.

Survey evidence of the decline in child abuse in younger Canadian cohorts

Physical and sexual abuse in childhood is a worldwide phenomenon with potentially dramatic consequences of both a psychological and physical nature. Measures of primary prevention have been developed in some countries. In the USA, child protection services reports and research surveys indicate that child sexual abuse has been on the decline in recent decades. Results are less clear for physical and overall abuse. The aim of this study was to describe how childhood abuse has changed over the years in Canada through an analysis of the 2012 Canadian Community Health Survey: Mental Health Edition data. The sample comprised 22,775 respondents ages 20 and over who completed a child abuse questionnaire. Respondents born from 1983 to 1992 reported significantly less overall abuse, physical abuse, and sexual abuse than did older generations, with the exception of people born in 1942 or earlier. The decrease was observed among men and women and across all the regions of Canada.Conclusion: The results are encouraging in that they may have an impact on life expectancy, severity of various chronic disorders, and suicide in the population. They also support policies that have focused on improving the childhood environment in the 1990s. Results also underline the importance of using different kinds of data sources for evaluating child abuse. What is Known: • Physical and sexual abuse in childhood has been associated with lower life expectancy in connection with an array of chronic diseases, including mental disorders, and with suicide. • Measures of primary prevention have been developed in some countries, such as the USA and Canada. What is New: • Canadians born from 1983 to 1992 report significantly less overall abuse, physical abuse, and sexual abuse than older generations do. • These encouraging results support policies implemented in the 1990s focused on improving the childhood environment.