Indicators Of Child Sexual Abuse : Medical Indicators

by Child Welfare Information Gateway

Sexual abuse may result in physical or behavioral manifestations. It is important that professionals and the public know what these are because they signal possible sexual abuse. However, very few manifestations (e.g., gonorrhea of the throat in a young child) are conclusive of sexual abuse. Most manifestations require careful investigation or assessment.

Unfortunately, early efforts at cataloging indicators of sexual abuse were problematic. They included extremely rare findings, such as blood in a child's underpants and signs that could be indicative of many problems or no problem at all, such as "comes early to school and leaves late." Recent efforts to designate signs of sexual abuse are more helpful.

They differentiate between physical indicators and psychosocial indicators. Although physical indicators may be noted by many people, a definitive determination is generally made by a medical professional. Similarly, anyone may observe psychosocial indicators; however, often but not always, a mental health professional is responsible for forming an opinion that the symptoms are indicative of sexual abuse.

A differentiation is made between higher and lower probability indicators. That is, some indicators are diagnostic of sexual abuse, whereas others may be consistent with or suggestive of sexual abuse but could indicate other circumstances or conditions as well.

In this chapter, higher probability findings and lower probability physical indicators are discussed first. A comparable discussion of psychosocial indicators will follow. It should not be surprising that the indicators specified in this chapter are similar to the effects described in the previous chapter since indicators are to a large extent the effects of sexual abuse before disclosure. Therefore, these indicators should become a focus of treatment and not simply used to support or rule out an allegation of sexual abuse.

Medical Indicators of Child Sexual Abuse

Significant progress has been made in the medical field in the determination of sexual abuse. Medical professionals are no longer limited to the presence or absence of a hymen as the indicator of possible sexual abuse. A variety of types of genital findings have been documented. In addition, notable progress has been made in identifying anal findings. Moreover, physicians are able to describe the effects of different kinds of sexual activity, and subtle findings can be documented using magnification (a colposcope or otoscope).

However, this progress is not without its controversies. Knowledgeable and conscientious physicians may differ regarding conclusions about certain physical findings. This difference of opinion is primarily due to the fact that data collection regarding the physical signs of sexual abuse has preceded careful documentation of characteristics of genitalia and anal anatomy of children who have not been sexually abused and of variations among normal children. These legitimate differences of opinion have been augmented by challenges to the medical documentation from defense attorneys, their expert witnesses, and alleged offenders.

It is also important to appreciate that for the majority of sexually abused children there are no physical findings. These findings, particularly vaginal ones, are most useful with prepubertal victims. As children become older, the possibility of consensual sexual activity needs to be considered. Further, changes that occur with puberty render insignificant some symptoms that have great significance in young children.

Two High-Probability Physical Indicators

Despite the progress noted above, the highest probability indicators are ones identified over 10 years ago. They are:

• pregnancy in a child and
• venereal disease in a child.

The reason these findings are high probability is because there is little dispute over the fact that they require sexual activity.

Some professionals assume that pregnancy in a child less than age 12 signals abuse although others designate the age of 13 or 14. Of course, not all situations in which children of these ages become pregnant are abusive, and pregnancy in older adolescents can be a consequence of sexual abuse.

Venereal disease may be located in the mucosa of the vagina, penis, anus, or mouth. The upper age limits for venereal disease raising concern about sexual abuse are similar to those for pregnancy. In addition, there is a lower age limit, usually of 1 or 2 months, because infants may be born with venereal disease acquired congenitally if the mother has the disease.

Interestingly, variations are found within the medical community regarding the certainty that sexual activity causes particular venereal diseases in children. Specifically, there is consensus that syphilis and gonorrhea cannot be contracted from toilet seats or bed sheets, but some differences of opinion exist about other venereal diseases (genital herpes, condyloma acuminata or venereal warts, trichomonas vaginalitis, and urogenital chlamydia), despite the conclusion that such infections are caused by sexual contact in adults. In a recent review of the research, Smith, Benton, Moore, and Runyan conclude that there is "strong evidence" that all of these venereal diseases are sexually transmitted, except for herpes, for which there is "probable evidence." They also review the evidence on human immunodeficiency virus (HIV) and conclude that there is strong evidence it is sexually transmitted as well, unless contracted pre- or perinatally.

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