Practical Strategies
Evaluations of child sexual abuse: Recognition of overt and latent family concerns
As medical examiners in a busy child sexual abuse clinic, we strive to provide a high standard of care to children who are suspected of having been sexually abused. To this end, we employ evidence-based standards and rely on peer review.
In addition, with over 50 years of cumulative experience in this role among us, we recognize that we have developed an approach to our usual medical tasks of taking histories and performing physical examinations that reflects an understanding of the particular concerns common to our patient population. As part of our ongoing peer review process, we endeavor to identify what each of us has come to understand about our patients and their families and to share what we have learned with one another. We believe that this process has improved and continues to improve our collective and individual practice. For this reason, we offer the following article as part of the Practical Strategies section. Our goal in doing so is to complement what we know about examining children with the wisdom, derived from clinical experience, about what we feel most concerns the children and families we see and how best to address these concerns.
In this article, we focus on the overt and latent clinical issues that frequently arise during such an evaluation, but often are not addressed because the major focus of the evaluation is on the forensic issues: what the child is able to report in the forensic interview about the sexual abuse and what the physical examination shows about possible forensic medical evidence. While the interview and exam provide essential information to the investigation of a case of suspected sexual abuse, both the allegations of sexual abuse and the evaluation raise important issues for the nonoffending parent(s) and child, and these need to be addressed.
In this article, we describe 10 major concerns that are listed inTable 1(6 of parents and 4 of children). In addition, we offer suggestions regarding a clinical approach to helping parents and children in the context of five critical variables that can affect how families respond: (1) the age of the child, (2) intra- vs. extra-familial sexual abuse, (3) a parent's own experience of sexual abuse, (4) how supportive the nonoffending parents are to the child, and (5) the family's strengths and weaknesses and previous involvement with Child Protective Services.
Concerns of the parents
In the US, because of the rapid response to allegations of child sexual abuse, once a case is reported to Child Protective Services (CPS), a CPS social worker and police usually begin the investigation within 24 hours of the report, and the forensic interview and exam may occur within days of the report. Thus, parents are quickly faced with two obvious and immediate concerns: (1) should we believe our child and (2) has our child been hurt or damaged physically?
Believing the child's statements can seem straightforward to clinicians; clinicians understand that children who disclose their experience of sexual abuse often do so because of their upset at what has been happening to them, and clinicians recognize that children may not tell their family all the details. For parents, of course, deciding whether to believe their child can be more complicated. Parents' beliefs can be on the spectrum from definitely believing to definitely not believing, and their location on the spectrum can depend on a variety of factors, such as what the child said in the initial disclosure and to whom the child told first, whether the accusation is about someone inside the immediate or extended family or outside, whether the child has delayed in telling someone about the abuse, whether the child is perceived as a "child who tells stories," what the parents' relationships are with the child, and whether the parents' have their own histories concerning sexual abuse. Each parent may also differ in the extent to which they believe the child. We have found that many parents are facing conflicting loyalties to a child and to another family or household member who has been accused of abusing the child. When parents express feeling conflicted, or express concern for the suspected perpetrator, the degree of this conflict should be explored and addressed and, if parents are thought to be unable to support and believe a child, this information should be fed back to CPS.
Parental beliefs about the child's truthfulness also may change over time, as new information is provided. For example, a parent might directly approach the alleged perpetrator who might be the child's uncle (and mother's brother) and ask that person if anything has happened. If the brother denies that anything has happened, the mother is then faced with the dilemma of believing her daughter versus believing her brother. Since both persons cannot be telling the truth, the mother faces a difficult decision. When there is a delay in the child's disclosure and/or the child's first disclosure is not to a parent, parents may have doubts about the child's truthfulness. "She talks to me every night before she goes to bed and never said a word about it." Sometimes, we remind parents that a delay in disclosure does not mean the child lied and explain the potential reasons for the delay.
Another particularly challenging situation for parents can occur when the child has made a clear statement to a parent, but provides little information at the forensic interview such that the police and/or CPS indicate that they cannot do much about the situation. Thus, parents may be left with two conflicting pieces of data: information from their child indicating that something has occurred and information from investigators indicating that not much can be done about the situation.
The absence of a clear statement by a child at a forensic interview may not be completely surprising to clinicians, but it can be problematic for the family. Should the parents still believe the child and not let the grandfather visit? In this situation, we encourage parents to focus on the child's initial statement and ensure the child's safety.
Some parents have made a decision not to believe their child's statement, and these parents can be particularly challenging for clinicians. Sometimes, it can be helpful to ask these parents to provide care as though they believe the child. Such care would involve keeping the child away from the alleged perpetrator and bringing the child to mental health counseling. Some parents can take on these tasks and yet continue to have doubts about the child's truthfulness; others cannot and require ongoing support and oversight, sometimes from CPS, to monitor the child's safety.
Worries about the child's body
The physical exam and sometimes the collection of forensic evidence, such as swabs for semen or laboratory data for sexually transmitted infections, focus the parents' attention on whether the child's body and, in particular, the child's genital and anal areas have been damaged. Since over 90% of children evaluated at specialty centers around the country have normal physical examinations, parents are usually greatly relieved to learn that the exam and laboratory tests are normal. Medical examiners regularly explain to parents (and children) that a "normal" medical exam does not mean that sexual abuse has not occurred.
In contrast, when there is an abnormal genital or anal exam, parents have very different concerns, including worries about their child's current and future health. Often unstated worries for parents of girls relate to whether the child is a "virgin," and whether she will be able to have normal sexual relations and have children. Clinicians often respond by reassuring parents that the abnormalities will have little or no effect on the child's future health; it sometimes helps to explain that the "abnormal" findings are small and can only be seen by a medical professional with a colposcope. No data, however, are available concerning whether parents find these reassurances helpful.
An alternative approach in which the clinician asks parents about their worries about the meaning of the exam findings can sometimes help to address what may be most troublesome for parents. Also, discussing the parents' ideas concerning "virginity" might help to address their worries, although the topic of virginity can be a complicated one because of its cultural and religious implications. It sometimes can be helpful to say to parents that losing one's virginity is not linked to sexual abuse, but rather to a person's first consensual sexual experience and that an abnormal medical finding will not be apparent to a future sexual partner.
Expressing emotions
Parents can be hurt, saddened, and furious because of what has happened to their child. Sometimes these emotions are openly expressed at the evaluation. Often, however, parents try desperately not to show these feelings in an effort not to lose control. Sometimes parents have not even talked to each other about their feelings. Asking about these feelings allows parents to express them: "Who at home has been most upset about what happened to your daughter?" Asking direct questions about sadness and anger (or upset) can sometimes be helpful. Information about feelings can also help when considering treatment for parents. Knowing about a parent's (particularly a father's) anger and rage can help prevent a parent from taking action against a perpetrator.
Another critical issue for parents relates to whether they should let their child see themselves be upset. Some parents report being very upset in their child's presence and we advise moderation, if possible. Other parents report that they have tried not to be upset or angry in the presence of their child. When they do show emotions, such as sadness, they sometimes will lie to the child by saying that the tears are "because something is in my eye." For these parents, we discuss what they might say to the child so that the child can learn about the expression of emotions. We remind parents that they can talk to their child about their own feelings without necessarily going into exhaustive details, but rather conveying in a straightforward manner that the parent is feeling sad or even angry about what happened to the child. Parents also may be guided to remind their child that being sad or angry does not mean they are "losing it" or that they will be unable to provide care to their child. We advise parents that talking to children about emotions as opposed to "something in one's eye" conveys at least three important messages: (1) it is okay for a parent to express an emotion, such as sadness in front of a child, (2) it is okay to have feelings of sadness or anger and having these feelings is not the same as losing control, and (3) it is okay to discuss these feelings with another person.
Why the child delayed in telling
Parents often wonder (as do clinicians) why children delay in telling about the sexual abuse, and parents can be upset, disappointed, and even hurt if the child told a nonparental figure first about the abuse. Sometimes, children sense or even know that it might be better not to tell a parent first. When a 6-year-old girl with gonorrhea, which she acquired from being sexually abused by her 16-year-old foster brother, was asked why she had not told her mother, the girl explained that her mother would have been "too upset." When the clinicians then explained to the mother how the girl had been infected, the mother fainted in the office; clearly, the 6-year-old knew about the risks of telling.
Clinicians have learned to understand why a child might not say anything about the sexual abuse for weeks or months or longer, but parents need help reconciling the delay with the view that "she tells her mother everything" or "I've taught her about good and bad touches." Sometimes, explaining to parents about how the alleged perpetrator prevented a child from telling can help parents understand about their child's dilemma and why the delay occurred. Sometimes, it helps to remind parents that at least now (even if after a delay of several months), the child has told so the abuse has stopped.