Clinical and Health Affairs
Talking to Sexually Abused Children: Tips for Physicians
By Kathleen McDowell, M.A.
■ A child who has been sexually abused typically is not going to be forthcoming about the abuse. Therefore, it can be difficult and time-consuming for a physician who suspects sexual abuse to get the child to disclose what is happening. This article reviews strategies that can help physicians establish a trusting relationship with a child that may enable them to speak openly about what is going on in their lives.
Jolynn just turned 7 years old. Her mother has brought her to the doctor today because she has been complaining of stomach aches. Jolynn is sitting on the exam table when Dr. Johnson enters. She notices that the girl is sullen and is looking at the floor. Her mother notes that Jolynn does not sleep well and wakes up looking tired.
Scott is 12 years old. His school principal caught him smoking pot. Upset, his father brought Scott to his pediatrician to talk about the issue and the fact that he also has gotten into altercations with other children. As Dr. Smith enters the exam room, he notices that Scott looks very anxious.
Both doctors examine the children, asking first about physical concerns. Then Dr. Johnson asks Jolynn how long she has experienced stomach pain, and Dr. Smith asks Scott when he first smoked marijuana. Both doctors ask the children if anything is going on at home that they should know about. Each child looks at their parent, then at the doctor, and says nothing.
Each physician proceeds with the appropriate examination. Seeing no physical issues to address, each physician asks the parent if they know what is going on. Is their child under any stress? Is their child being bullied? Is there any abuse happening? Is someone touching them sexually? The parents say that nothing is going on. But is that the full story?
Most of the time that will be the full story. Jolynn may have exaggerated about her stomach aches in order to miss school. Scott may simply have succumbed to peer pressure and tried pot. However, there are enough exceptions that physicians need to consider the possibility that both children have been sexually abused. An estimated one in four girls and one in six boys will have experienced an episode of sexual abuse before they turn 18.1 Of those who have reported abuse, 34% are under 12 years of age, and one in seven is younger than 6.2 In addition, 96% of reported female rape victims under the age of 12 know their attackers. Twenty percent are fathers, 16% are other relatives, and 50% are acquaintances or friends.3
A child who has been sexually abused typically is not going to be forthcoming about the abuse. She may feel she is in a no-win situation. Does she tell her secret in order to get the acts to stop and risk betraying the family? This is often the case if the assailant has threatened to harm her, her family members, or her pets if she tells. Because it can be difficult and time-consuming to get children to disclose abuse, physicians will likely have to exercise both suspicion and sensitivity if they are to tease out the source of the child’s troubles.
The Psychological and Physical Effects of Abuse
There are a number of reasons for physicians to put forth the effort. For one, they and other health care providers are mandatory reporters of sexual abuse. In Minnesota, the law requires those who work in health care, social services, child care, mental health, education, law enforcement, and corrections, and the clergy, to report suspected child abuse and maltreatment. According to Minnesota Statute 646.556, when sexual abuse of a child is suspected, the responsibility of reporting falls to the person who suspects it. Physicians and others have 24 hours to make a verbal report and up to 72 hours to file a written report with either the county’s child protection unit or law enforcement.
In addition, sexual abuse takes a toll on physical and mental health. Some of the long-term mental health effects of childhood sexual abuse include post-traumatic stress disorder (PTSD), depression, anxiety, and low self-esteem.4 These feelings and disorders can manifest in self-destructive behaviors. Children who have been abused may exhibit sexual promiscuity or turn to alcohol or other drugs to manage or decrease a flood of negative emotions or to boost positive feelings.5 They also may experience difficulty learning, exhibit eating disorders, and have suicidal thoughts.6
Childhood sexual abuse has an effect on physical health as well. Research has shown that there are connections between childhood sexual abuse and gastrointestinal, reproductive, and pain-related issues; heart and liver diseases; and diminished immune system capacity.4,7 The gastrointestinal problems patients may experience as either a child or adult include irritable bowel syndrome, nonulcer dyspepsia (indigestion), and chronic abdominal pain.8 Girls and women who have suffered sexual abuse also are at greater risk for sexually transmitted diseases, pelvic inflammatory disease, multiple yeast infections, premenstrual syndrome, early hysterectomy, excessive menstrual bleeding, genital burning, painful intercourse, dysmenorrhea, and menstrual irregularity than those who have not.9 People who have experienced child sexual abuse are also at greater risk for weight gain and obesity. For example, women who had reported sexual or physical abuse as children were twice as likely as those who had not to experience obesity and depression in middle age, engage in binge eating, and report dissatisfaction with their body.10
Childhood sexual abuse also has an impact on brain development. Magnetic resonance imaging has shown the potential for structural abnormalities in the brains of children who have been abused. For example, children subjected to trauma were found to have reduced gray matter volume in areas related to visual memory.11 Children who have been neglected and abused have a smaller corpus callosum with poor integration of the cerebral hemispheres compared with those who have not been abused.12 And chronic or overwhelming stress has been shown to lead to decreased grey matter volume in the hippocampus.13
Detecting Abuse
A child who is not disclosing sexual abuse may show a number of signs and symptoms that should raise a physician’s level of suspicion. Among the physical signs of sexual abuse are injuries and bruising in the genital area; pain, discoloration, bleeding or discharge from the genitals, anus, or mouth; and persistent or recurrent pain during urination or bowel movements.14 But often, the signs of sexual abuse are not visible, and a physician can only probe based on a hunch or the behavior described by a parent or guardian or exhibited in the exam room (Table). (Note that it may be a warning sign when the parent continues to answer for a child who is capable of responding for themselves.)
In these cases, the physician’s challenge is to get the child to open up. This may be difficult, as the child may view the physician as yet another adult they need to fear or cannot trust. There are, however, a number of ways health care providers can put a child at ease and earn their trust:
- Create a safe environment. Make sure the environment is private, quiet, and familiar to the child. Let the child know that you are concerned and that you will do all that you can to keep them safe.
- Pay attention to what is and is not being said. How does the child respond when you are doing an examination? Does he flinch? Does he cower? How does he or she look at the parent? Is there a sense that the child feels safe and comfortable with the parent? If you suspect sexual abuse may be occurring and that the parent may somehow be involved or that the child may be uncomfortable discussing it with the parent present, ask to have a conversation with the child without the parent in the room. If you do interview a child privately, be sure to have another professional in the room.
- Be mindful of your tone and facial expression. Is your tone inviting, safe-sounding, slow-paced, gentle? Or is it clipped, as though you are rushing to get to the next patient? Also, remember to use kind eyes.
- Ask simple questions about physical signs such as, “That looks painful. Do you want to tell me how you got it?” or “Do you want to talk about that bruise you have?” Don’t ask leading questions such as “Did you get that bruise when someone hit you?” Also, avoid “why” questions, which can add to the child’s confusion and will not offer helpful information.
- Consider the child’s age. For young children, use simple terms and phrase your questions accordingly. For teens, consider asking the parent to leave the room and then use age-appropriate terms and ask about age-appropriate issues. Are they smoking, using drugs or alcohol? Are they being bullied or experiencing violence? Is someone touching them in ways that make them uncomfortable?
- Refrain from correcting the child. If you do not understand a term a child uses to describe a body part, ask the child to explain further or point to the body part. Let them use their own words. And let the child know when you understand them.
- Let the child know that it is O.K. to feel hurt, angry, confused, or scared.
- If the child indicates that he or she has experienced sexual abuse, let him know that you believe him, as it is quite rare for a child to lie about such abuse. Then tell the child you will be contacting the people who will be able to help. Protecting the child is your primary responsibility. You can discuss your concerns and your duty to report child abuse with the parent or guardian after interviewing the child. In addition, you might provide a referral for the child to a specialist or counselor.
- Remember to respect the child’s privacy. Refrain from asking too many details, as they will need to share their story later on.
- Keep your emotions in check so that you don’t inadvertently convey disapproval of the child, the parents, or the situation. Do not express judgment or blame the child or the parents.
- Let the child know they did the right thing by letting you know about the abuse. And let them know they are not to blame. They may feel guilt or fear punishment for disclosing this information.
The most important aspect of communicating with children about something as deeply personal and painful as sexual abuse is to really listen to what the child is saying. Then, make every effort to help the child feel safe. If a child reports sexual abuse that is unsubstantiated or not supported through assessment, consider making a referral to a mental health or sexual abuse professional. Remind the child that you are their advocate, that your door is always open and that you are willing to be there as a confidant and a resource, no matter what.
Conclusion
After examining and talking to Jolynn, Dr. Jones suspected she was being sexually molested by a family member, and he reported her case to child protection services. Scott finally told Dr. Smith that he was being abused by a neighbor; Dr. Smith contacted the authorities.
Of course, not every child exhibiting behaviors and symptoms similar to these two children is being sexually abused. However, when there is a change in a child’s behavior or when physical symptoms can’t be explained or resolved with conventional treatment, it may be that something is going on with them either at home or at school. For that reason, it is important for physicians to take the time to ask appropriate questions in a nonthreatening way and consider making referrals to mental health and other services to address further concerns.
A child may hope that a physician can figure out their problem without their having to explain what is happening and betray a family member or divulge a secret that the perpetrator told them to keep. If a child is not forthcoming, it may be that he or she is doing what is needed to avoid further abuse. For that reason, health care providers need to view children who are behaving oddly or badly with compassion and speak in ways that will help them reveal what is troubling them. MM
Kathleen McDowell is a family sexual violence consultant in Minneapolis whose area of focus is the long-term health issues associated with child sexual assault.
References
1. Centers for Disease Control and Prevention. Adverse Childhood Experiences Study: Data and Statistics. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Available at: http://www.cdc.gov/nccdphp/ace/prevalence.htm Accessed November 16, 2011.
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3. Bureau of Justice, US Department of Justice. “Half of Women Raped during 1992 Were Younger than 18 Years Old.” Press release, June 22, 1994.
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