Sexual Assault: Victimization Across the Life Span — A Clinical Guide

Overview of Child Sexual Abuse

John Loiselle, MD
Marla J. Friedman, DO

Historical Perspective

The sexual abuse of children has been discussed in writings dating back to the late 19th century. Freud (1961) publicly noted in 1896 that many of his patients with hysterical illnesses had a history of a sexual experience in their childhood. He thus theorized that hysteria was a direct result of childhood seduction. Unfortunately, he supported this seduction theory for only a short time, and by 1905 his belief had shifted. He renounced his previous views and stated that the sexual events recalled by his patients were unconscious fantasies rather than real events. He claimed that his patients’ memories of sexual abuse were merely projections of their own desire for the parent of the opposite sex. Freud’s adoption of this oedipal theory was a setback to the widespread acceptance of child sexual abuse because it caused others to question the existence of the problem as well as its psychologic effects (Cosentino & Collins, 1996; Whetsell-Mitchell, 1995b).

Over the next sixty years, child sexual abuse did receive occasional mention but almost always as it related to incest. Most of Freud’s followers questioned the impact of sexual experiences on children as well as the role the children played in these activities. Between 1920 and 1950, investigators conceded that family members did sometimes involve children in sexual activities but that this contact did not have a damaging effect on the children (Cosentino & Collins, 1996; Whetsell-Mitchell, 1995a). Furthermore, some proposed that these experiences may even have had a beneficial effect on the children involved. Children were characterized as active participants in the sexual activities, often being labeled as the initiators of their own seduction (Bender & Blau, 1937).

In 1953 Kinsey et al. published the results of their study, which revealed that sexual abuse was indeed common in childhood. Even though they showed that almost 10% of women admitted to being sexually abused before age 18 years, their results received little attention (Whetsell-Mitchell, 1995a). It was not until the release of the landmark paper of “The Battered Child Syndrome,” in 1962 that the medical profession began to take notice (Kempe et al., 1962). In 1971 the first child sexual abuse program was opened in San Jose, California. The Child Protective Movement began to campaign for legislation that would confront the problem of child sexual abuse on a national level. In 1974 the Child Abuse Prevention and Treatment Act was passed, which “mandated mental health professionals and educators to assist in the detection and reporting of child sexual abuse” (Cosentino & Collins, 1996; Whetsell-Mitchell, 1995b).

The publication of “Sexual Abuse, Another Hidden Pediatric Problem” by C. Henry Kempe (1978) forced the healthcare community to address the importance of the diagnosis and treatment of child sexual abuse. Works in the early 1980s focused on the child as the victim and the offender as the initiator.

was put on the offender, not the child (Sgroi et al., 1982). At the same time, the publication of books by survivors of child sexual abuse and the release of television movies on the topic brought the issue of child sexual abuse to the public forefront (Whetsell-Mitchell, 1995b).

Definition

The characterization of child sexual abuse is subject to interpretation on multiple levels. Institutional, societal, medical, and legal terminology all differ in their definition or emphasis. It is impossible to find a single universally accepted definition. Child sexual abuse encompasses a wide spectrum of activities ranging from the less serious to the more serious. Sexually abusive actions may or may not involve direct contact with the child. Kempe defined sexual abuse as “the involvement of dependent, developmentally 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 taboos of family roles” (Kempe, 1978). Most legal definitions emphasize certain elements such as the age of the perpetrator and victim, description of specific acts or categories of sexual abuse, and who is considered a mandated reporter. The Child Abuse Prevention and Treatment Act (CAPTA) of 1974 provided a federal legal standard that all states were mandated to follow to be eligible for funds for child abuse programs. This act defined sexual abuse as “the employment, use, persuasion, inducement, enticement, or coercion of any child to engage in, or assist any other person to engage in, any sexually explicit conduct or simulation of such conduct for the purpose of producing a visual depiction of such conduct” (Child Abuse Prevention and Treatment Act, 1974). All 50 states have written statutes regarding sexual abuse based on this standard, but many differ in the specific wording. A child, in almost all instances, is defined as a person under age 18 years. Exceptions are made when that person is married. Certain laws are more specific with regard to the age of the perpetrator and victim when specific sexual acts are involved. Most statutes emphasize the discrepancy between the ages of the perpetrator and the victim. These laws also take into consideration the developmental level of the abused child. For purposes of reporting and involving specific legal agencies, laws distinguish who is considered a caretaker or guardian of the child. The involvement of a caretaker in the abuse necessitates the involvement of the local child protective services agency, as well as law enforcement. When the alleged perpetrator is considered a child, intervention may be limited to child protective services alone. When the assailant is unknown, unrelated, or not considered to be someone involved in the care of that child, the abuse may be a purely criminal case.

Sexual abuse encompasses a large variety of actions. Whereas all states include a provision for rape or intercourse, some states use general terms in defining actions that constitute sexual abuse, while others are far more specific. The degree of detail can be crucial in certain cases; for example, medical and legal definitions do not require actual vaginal entry to occur for an act to be considered rape (Kempe, 1978). Genital fondling, oral-genital, genital-genital, and anal-genital contact are generally recognized forms of sexual abuse. The perpetrator does not need to have direct physical contact with the child for sexual abuse to occur. Exhibitionism, voyeurism, and viewing, producing, or distributing pornography are included under most definitions. Exposing a child to sexually explicit material or acts is also considered abuse. Laws making the use of computers and the Internet in producing, compiling, possessing, or disseminating child pornography a crime had been instituted by 27 states and the District of Columbia as of December 31, 1999. Violations are included under the heading of sexual abuse or sexual exploitation of children. Other laws address the use of computers to seduce or attract children with the intent of sexual misuse. The failure to protect a child is an important component of many definitions of child abuse and is relevant to sexual abuse when a caretaker is aware that such abuse is occurring and takes no action to stop or prevent it.

Evaluation of Child Sexual Abuse

Jacqueline M. Sugarman, MD

The evaluation of the child who may have been sexually abused is multifaceted, containing components such as obtaining a history; conducting a physical examination; initiating diagnostic and forensic testing when deemed necessary; and making appropriate referrals. This chapter primarily focuses on evaluation of the child who comes to medical attention in the acute medical setting (emergency department or physician’s office) because he or she has made a specific disclosure of developmentally inappropriate sexual contact (Hymel & Jenny, 1996). The chapter subsequently addresses the case of the child who has made no specific disclosure of sexual abuse but comes to medical attention because of either physical or behavioral symptoms about which a caregiver is concerned (Hymel & Jenny, 1996).

History

Physical evidence in child sexual abuse cases is often lacking because the majority of children who are sexually abused have normal examinations (Adams et al., 1994; Bays & Chadwick, 1993). When the examination is normal or nonspecific, the diagnosis of sexual abuse rests solely on the history, which is given by the child. Hence, obtaining and documenting an accurate account of what happened are crucial in diagnosing sexual abuse. If the child is deemed an ineffective witness, the state’s ability to protect him or her through the legal system may be undermined (Meyers,1986). The child’s recitation of the abusive event or events to a physician treating the patient may be admissible in court as an exception to the laws restricting hearsay testimony (Meyers, 1986). When this situation occurs, preservation of verbal evidence through the proper questioning of the child and documentation of the child’s history by the physician directly affects the state’s ability to take legal action on behalf of the child (Meyers, 1986). Not only does the interview detail for the examiner what happened, it also provides the examiner an opportunity to establish rapport with the child, assess the child’s developmental level and overall emotional status with regard to the abuse, and gauge how cooperative the child might be with further assessment (Faller, 1993; Poole & Lamb, 1998).

Every attempt should be made to interview the child separate from parents, guardians, or accompanying caregivers so that the presence of these individuals does not inhibit the child’s full disclosure of the events. It should not be assumed that the child’s caregiver believes the child and will protect the child from further abuse. Even a protective caregiver might inhibit a child’s disclosure if the child perceives that the information might upset the caregiver. Furthermore, the absence of a caregiver during the interview helps negate the argument that the child is merely repeating what the caregiver told the child to say or what the child perceives the caregiver wants to hear.

It is often easier to first interview the accompanying caregiver separate from the child (Giardino et al., 1992). This allows the examiner to obtain a history from the caregiver as well as a better understanding of the child’s world, which will aid in

communication with the child. The examiner should obtain from the caregiver the child’s names for his or her body parts, including genitalia. The examiner should try to ascertain how long ago the abuse took place and the possible extent of the abuse so as to be able to better tailor his examination. The examiner should discuss with the parent any unusual living situations (child lives at more than one home, child calls more than one person mom or dad) that might make the child’s version of the history confusing. The child’s past medical history should be addressed during the interview. Does the child have other medical problems that may mimic sexual abuse or make the diagnosis more suspicious? For example, lichen sclerosis is often misdiagnosed as sexual abuse. Genital warts can sometimes be acquired perinatally. Does the birth mother have a history of genital warts or abnormal PAP smears? Does the child have any physical signs and symptoms that are sometimes seen in children who are sexually abused, such as genital discharge or bleeding, recurrent urinary tract infections, chronic abdominal pain, sleep disturbances, bowel or bladder incontinence, or appetite disturbances (Jenny, 1996)? Has the child had any psychiatric or behavioral problems that might coincide with a history of ongoing abuse? For example, has the child been suicidal, socially withdrawn, depressed, or in trouble at school (Jenny, 1996)? Also suspicious would be a change in a child’s behavior, such as, a child who was a straight A student and is now failing (Jenny, 1996). Has the child been manifesting sexualized play, trying to sexually abuse other children, or been masturbating excessively (Jenny, 1996)? Has the child been evaluated for sexual abuse before?

If the examination is consistent with old injuries, it may be impossible to determine when the injuries occurred. The interviewer should be cognizant of common presenting complaints of sexually abused children (Jenny, 1996)(Table 3-1). Medications the child is taking should also be documented. Antibiotics, for example, could alter culture results.

Finally, the interviewer should form his own impression as to whether the caregiver is protective of the child and if the child is at risk for being abused in the future. Is the child safe going home with the caregiver? Does the perpetrator reside at the home where the child lives? Are there other children at risk? The latter three questions must be addressed and discussed with child protective services before the child is discharged.

Ideally, children should be interviewed in an unhurried manner and unthreatening environment. While some children may separate willingly, some may be more comfortable if an impartial third party, for example, a social worker, remains with the child when the parent leaves the room. It may be helpful if the parent remains for the beginning of the interview when the examiner is establishing rapport with the child but not asking questions directly related to the alleged abuse. The establishment of rapport, as well as the subsequent interview, must be tailored to the child’s developmental status. Appreciation of the developmental differences in children helps to achieve an optimal interview. Children as young as 2 years have been observed to give understandable information if properly questioned (Frasier, 1997). Very young children (age 0 to 3 years) have little or no ability to label time or sequence events; they may not even be able to identify body parts (Ludwig, 2000). Preschoolers have better language skills, and although they still cannot tell time, they may be able to

identify an event as occurring before or after another event or to sequence events. Interviewers must avoid long, complex questions, pronouns (instead use the name of the person), and be direct; for example, instead of “If you need to use the potty, let me know;” say, “Do you need to use the potty?” (Steward et al., 1993). School-age children may be uncomfortable about discussing their bodies, especially with strangers. The interviewer may want to give a reticent child a crayon or a pen so that he or she can draw or write what happened if verbalization is too difficult.

LAW ENFORCEMENT ISSUES

Patsy Rauton Lightle

Investigating sexual assault is a demanding task. No single group of individuals is immune to the possibility of sexual assault. When sexual abuse involves a child or the elderly, the investigative tasks become even more complex due to difficulties with language, cognitive skills, and physical and mental impairment that can hinder the interview process. It is imperative that law enforcement personnel be cognizant of the indicators of sexual abuse and understand that some techniques have proved useful in these investigations. The processes and techniques described in this chapter are largely based on the author’s field experience and subsequent design of several protocols, including the South Carolina Law Enforcement Division’s protocols and kits for Adult Sexual Assault Evidence Collection, Child Sexual Assault Evidence Collection, Chronic Sexual Assault Evidence Collection, Suspect Evidence Collection, and the Child Postmortem Evidence Collection. In addition, a few basic textbooks provide general background information (Fisher et al., 1987; Henry, 1979; Kinnee, 1994; Wicklander & Zulawski, 1993).

It is crucial that an investigator with the training and experience necessary to support successful prosecution be assigned to conduct the thorough and methodical investigation of sexual abuse crimes. The law enforcement officer must have a basic understanding and knowledge of sexual offenses and feel comfortable seeking outside expert advice when needed. In all cases the safety and well-being of the victim should be the first priority. Attention to details is a must. The case should be worked and closely monitored with prosecution as the final goal.

Processing the Scene and Collecting Evidence

Law enforcement personnel are usually the first responders once the crime is reported. The steps in the investigative process should be followed carefully; many of these are the same steps taken for any criminal assault. These steps are as follows:

1. Record exact time and location of the assault. 911 tapes and law enforcement dispatch tapes can be useful to confirm this information for court purposes.
2. While traveling to the scene, carefully note fleeing persons, vehicles, witnesses, etc.
3. If the first notification of the assault is received in person, detain this person for investigation and written statement. If unable to detain the person, obtain enough information to locate him or her at a later time. When a third party reports the assault, document identification information for follow-up interview(s). This person will be a crucial witness.
4. Record exact time of the arrival and notify communications that you are on the scene. Do not use a telephone at the crime scene to report your arrival. Use your mobile radio, hand-held radio, or agency-issued cell phone, but never a telephone at the scene. The suspect may have picked up the telephone at the scene to call someone or held it as he or she disconnected the telephone cord from the wall jack. The smooth surface of the telephone would be an excellent source for the suspect’s fingerprints. The use of the same telephone by a law enforcement officer at the scene contaminates the print by adding additional fingerprint ridge detail or by smearing the suspect’s fingerprint, thereby causing that print to be unsuitable for comparison.
5. If the victim is injured, request Emergency Medical Services (EMS) and provide first aid. Do not move seriously injured people unless it is to protect them from additional harm. Be sure to document if the emergency medical technician (EMT) moves or touches anything within the crime scene. Document what, when, and why the alterations were made and if any medications were given to the victim. Emergency medical staff or a law enforcement officer will take the victim to a licensed health care facility where a sexual assault evidence collection protocol is performed. This protocol provides a standardized and coordinated approach to the collection of information and forensic evidence, as well as treatment for injuries and prevention of sexually transmitted diseases and pregnancy. The victim will need to take an additional set of clothing because the clothing he or she is wearing will be collected for forensic evidence processing.
6. An initial incident report detailing information to support a crime should be taken. Record the names and addresses of all persons present when you arrive. Record the names of all officers present with you at the time of arrival, as well as officers who come later to assist.
7. Only one officer should enter the scene.
8. Isolate a large area around the assault scene to prevent loss of evidence. Establish a perimeter and secure it using crime scene tape, ropes, cones, barricades, etc. and at least one officer to provide security until evidence collection and documentation by the forensic crime scene unit and lead investigator are completed.
9. Consider the weather conditions for crimes occurring outside and protect the scene. Document weather conditions, persons present, and any nearby vehicle information, including license number, make, model, and color. Avoid discussion of the crime; the suspect may appear as a neighbor or an onlooker.
10. Once the scene is secured and the victim is safe and located away from the scene, a complete, thorough background investigation should be conducted. A crime scene log-in or sign-in sheet is kept at all crime scenes. The officer in charge of security for the crime scene can also be in charge of the sign-in sheet. It includes the name, agency, and telephone number of all individuals who enter and depart from the scene. The security officer ensures that only authorized individuals enter through one designated entrance to the scene. Cross-contamination occurs when individuals are allowed to use more than one entrance into the building. In addition, it is extremely difficult to account for everyone who enters and departs from the scene when more than one entrance is used.
11. Isolate and separate witnesses or suspect(s). Do not permit any conversation among them. Hold witnesses and suspects for investigators.
12. Do not allow anyone to smoke in the crime scene area. People, including officers, are often nervous or excited at the scene and need to smoke a cigarette or chew gum, unaware that the cigarette butt or gum they throw down or put in an ashtray will contaminate the scene. An officer’s cigarette butt will be tested for saliva, secretor status, and DNA, adding “evidence” to the scene that is not involved with the crime. A secretor secretes his or her blood type in body fluids such as saliva, semen, vaginal fluids, and sweat. For example, should a suspect smoke a cigarette at the crime scene, this would be collected as evidence. The forensic analyst analyzes the cigarette for saliva and determines the blood type of the person who smoked the cigarette. The same analysis can be performed with

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