Medical-forensic care of suspected child & adolescent victims of sexual abuse: What are we missing?
Updated: Apr 17, 2019
Child and adolescent victims of sexual violence often have significant immediate and long-term medical and mental health needs that impact their health and well-being across the lifespan (Department of Justice Office on Violence Against Women [DOJ OVAW], 2016; Ports, Ford, & Merrick, 2016). Those who fail to receive proper medical and mental healthcare after sexual victimization are also at an increased risk for sexual re-victimization (Crawford et al., 2017). The negative sequela can, however, be mitigated with proper, evidence-based intervention. Timely, high-quality care provided by pediatric healthcare professionals who specialize in the evaluation and treatment of child and adolescent victims of sexual abuse is essential to improving the health outcomes of these young patients (Horner, 2010; Porta, Johnson, & Finn, 2017). Unfortunately, many of them fail to receive the specialized medical care they so desperately need.
According to the national standards for the care of suspected child and adolescent victims of sexual abuse, only a suspicion should trigger referral to a medical provider with specialized training and experience in evaluating sexually abused pediatric patients (DOJ OVAW, 2016). Most suspected and alleged incidences of child and adolescent sexual abuse are reported first to the local authorities, not healthcare providers; therefore, too many fail to receive the specialized medical attention they need, particularly if the authorities do not feel it would add evidentiary value to their case, the suspected victim failed to disclose to confirm the suspicions, previous disclosures have been recanted, or if the suspected/alleged incident occurred more than a week prior. There are many reasons why children and adolescents are not referred by the authorities for specialized exams in accordance with the national standards, but the most common are related to a lack of quality education regarding the purpose of and need for the medical-forensic examination, misconceptions regarding the extent and invasiveness of the examination process, and personal biases and assumptions despite proper education (ie: resistance to change).
Multiple studies have demonstrated the high rate of non-disclosure in forensic interviews with suspected child and adolescent victims of sexual abuse, providing justification for specialized medical evaluation based on a mere suspicion (McElvaney, 2013). Why is this important to the health and well-being of these children and adolescents? A recent systematic review of the literature revealed that only 43% of the pre-pubertal children (those who had not yet reached puberty) who tested positive for and were diagnosed with gonorrhea (a bacterial, sexually transmitted infection) made a disclosure of sexual abuse during their forensic interview (McElvaney, 2013). More recently, out of 1,319 suspected pediatric sexual abuse victims tested for sexually transmitted infections (STI’s), 59% of those who were positive for an STI in their anus/rectum and 77% of those positive for an STI in their throat did not report that the alleged perpetrator’s genitals came into contact with those orifices (Kellogg, Melville, Lukefahr, Nienow, & Russell, 2017). Based on those findings, Kellogg and her colleagues (2017) concluded that reliance on patient disclosure, report of symptoms, or types of sexual contact (ie: oral, vaginal, anal) to determine the need for and locations of STI testing in pediatric patients would result in failure to properly identify, diagnose, and treat those infections (which are contagious and if left untreated, can lead to permanent sterility).
The American Academy of Pediatrics recommend ALL suspected child and adolescent victims of sexual abuse should be examined by a pediatrician or nurse practitioner with sub-specialty training in the care of sexually abused pediatric patients (Crawford et al., 2017). In a national sample of pediatricians, less than half of those surveyed felt competent to care for sexually abused children and adolescents, and more than 85% of them preferred all suspected cases be referred to a local expert in the community (Dubowitz, Feigelman, Lane, & Kim, 2009). More recently, in a national sample of Family Nurse Practitioners (FNP’s) who provide primary care to children, only 25.5% felt comfortable performing examinations on suspected child and adolescent victims of sexual abuse, and 77.3% preferred to refer all of them to an expert in pediatric sexual abuse for further evaluation (Ceccucci, 2018). Only 17.3% of those FNP’s felt they were clinically competent to render a definitive opinion on their findings after evaluating a suspected child or adolescent victim of sexual abuse, and only 12.7% of those felt competent providing court testimony based on that opinion (Ceccucci, 2018). Unfortunately, only 75% of those FNP’s surveyed could identify a local resource available to refer their suspected child and adolescent victims of sexual abuse to for further evaluation (Ceccucci, 2018). Even more astounding, less than 50% of those who were aware of a local resource actually referred their patients who are suspected victims of sexual abuse to that resource (Ceccucci, 2018).
Timely, high-quality, evidence-based, specialized, medical-forensic care is essential to the health and well-being of any suspected child or adolescent victim of sexual abuse. The Cottage offers this service to children and adolescents FREE of charge to their families. Each of our patients are provided specialized, trauma-informed, comprehensive care in a community-based setting that is calming, child-friendly, and non-judgmental. Our staff takes the time required to answer all questions, address any concerns, and provide the individualized care all our patients and their families need and deserve. There are no co-pays or deductibles to fulfill. Your visit, any potential laboratory studies, and most medications (if indicated) are provided at no charge to our patients or their insurance companies. No referral from the patient’s primary care manager or law enforcement are required. Simply contact The Cottage, directly, for an appointment. We are also available to answer any questions you may have about this process. At The Cottage, we firmly believe in the healing power of a community-based response to trauma and violence…
Ceccucci, J. (2018). Evaluating nurse practitioners perceived knowledge, competence, and comfort level in caring for the sexually abused child. Journal of Forensic Nursing, 14(1), 42-49. doi: 10.1097/JFN.0000000000000184
Crawford, J. E., Alderman, E. M., & Leventhal, J. M. (2017). Clinical report: Care of the adolescent after an acute sexual assault. American Academy of Pediatrics, Committee on Child Abuse and Neglect, Committee on Adolescence. Pediatrics, 139(3), e1-e11. Doi: 10.1542/peds.2016-4243
Dubowitz, H., Feigelman, S., Lane, W., & Kim, J. (2009). Pediatric primary care to help prevent child maltreatment: The Safe Environment for Every Kid (SEEK) model, 123(3), 858-864. doi: 10.1542/peds.2008-1376
Horner, G. (2010). Child sexual abuse: Consequences and implications. Journal of Pediatric Health Care, 24(6), 358-364.
Kellogg, N. D., Melville, J. D., Lukefahr, J. L., Nienow, S. M., & Russell, E. L. (2017). Genital and extragenital gonorrhea and chlamydia in children and adolescents evaluated for sexual abuse. Pediatric Emergency Care. doi: 10.1097/PEC.0000000000001014
Lane, W.G. & Dubowitz, H. (2009). Primary care pediatricians’ experience, comfort and competence in the evaluation and management of child maltreatment: Do we need child abuse experts? Child Abuse and Neglect, 33(2), 76-83. doi: 10.1016/j.chiabu.2008.09.003
McElvaney, R. (2013). Disclosure of child sexual abuse: Delays, non-disclosure, and partial disclosure. What the Research tells us and implications for practice. Child Abuse Review, 24, 159-169. doi: 10.1002/car.2280
Porta, C. M., Johnson, E., & Finn, C. (2017). Male help-seeking after sexual assault: A series of case studies informing sexual assault nurse examiner practice. Journal of Forensic Nursing, 14(2), 106-111. doi: 10.1097/JFN.0000000000000204
Ports, K.A., Ford, D.C., & Merrick, M.T. (2016). Adverse childhood experiences and sexual victimization in adulthood. Child Abuse & Neglect, 51, 313-322. doi: 10.1016/j.chiabu.2015.08.017
United States Department of Justice, Office on Violence Against Women. (2016). A national protocol for sexual abuse forensic examinations: Pediatric. Retrieved from: https://www.justice.gov/ovw/file/846856/download