News media reports of sex abuse are on the rise. As the public’s interest in the subject peaks, health care professionals should be aware of their legal obligation to investigate and report suspected child sex abuse to law enforcement authorities. This office recently settled a case for a girl who was injured by sexual abuse, prompting us to address this disturbing topic here.
The child sex abuse offenses in Oregon and California include subjecting a child to any sexual contact, including any intentional touching of intimate parts of a child, or of the perpetrator by the child, for purposes of sexual arousal or gratification. Offenses also include any participation in the production, possession, paying for or sale of visual recordings of sexually explicit conduct involving a child, or paying to observe such conduct, for the purposes of sexual arousal or gratification. In California, masturbation in the presence of a child is also an offense.
Reporting Child Abuse Physicians and other health care professionals in Oregon and in California are required by state law to report suspected abuse of children.
In Oregon, physicians are among the “public or private officials” required to report if they reasonably believe that any child they have come in contact with has suffered abuse or that any person they have been in contact with has abused a child. Physicians must immediately report (or cause a report to be made) by telephone or otherwise to the local office of the Department of Human Services, the designee of the Department, or to a law enforcement agency in the county where the physician was at the time of the contact. (ORS 419B.010, 410B.015)
The definition of “public or private official” also includes interns or residents, dentists, licensed practical or registered nurses, psychologists, optometrists, chiropractors and naturopathic physicians, as well as numerous non-medical occupations.
In California, “mandated reporters” include medical providers (the list is the same as those listed above under Oregon law), plus psychological assistants, licensed business professionals and other non-medical service providers and government employees.
In California, mandated reporters who, within their professional capacity or scope of employment, observe or have knowledge of a child and reasonably suspect that the child has been the victim of abuse or neglect must report to any police or sheriff’s department (not including school district police or security), county probation department designated to receive reports, or the county welfare department. (Pregnancy of a minor does not, in and of itself, constitute a basis for a reasonable suspicion of sexual abuse.) (California Penal Code [CPC] §§11166. (a) and 11165.9)
In both states, failure to report is a criminal offense.
Recognizing Child Sexual Abuse
What signs may give you “reasonable cause” to believe or reasonable suspicion that a child you are treating (or you know of or have observed) has suffered sexual abuse?
Physical findings which are strong indicators sexual activity has occurred include: 1) hymenal disruption (scars, tears or abrasions); 2) injuries of the posterior forchette in girls; 3) significant anal relaxation or presence of large anal scars; 4) presence of STD’s and such things as genital warts; and 5) chronic genital irritation; and also, to a lesser degree, painful urination and encopresis.
More subtle are emotional and psychological symptoms exhibited by children victimized by abuse. While all such symptoms may not occur in every case and their presence or absence should not be considered proof sexual abuse has or has not occurred, the following dynamics are often seen in a child who has been abused:
- Poor peer relationships, inability to make friends, sudden changes of relationships with friends at school.
- Lack of trust, particularly of significant others.
- Nonparticipation in school events (especially gym classes or activities which may require the child to undress in front of others).
- Inability to concentrate at school.
- Sudden drop in school performance.
- Extraordinary fears.
- Overly seductive behavior to other children and adults.
- Self-destructive behavior.
- Sleep disturbances.
- Regressive behavior.
- Social or emotional withdrawal.
- Clinical depression.
- Suicidal feelings.
- Loss of appetite.
- Sudden change in moods (commonly, irritability or short temper in a child not that way normally).
- Taking excessive baths; also, repeatedly washing or rubbing the spot where they have been touched or where they feel uncomfortable.
- Somatic complaints (pains in areas touched by offender).
- Gender role/sexual identity problems (especially in boys abused by men).
- Self-image, -esteem, -respect, -confidence problems.
- Becoming manipulators.
Where abuse is inflicted by one of the parents or illicit sexual activity is encouraged or participated in by a family member, the following family dynamics may be present:
- Extreme overprotectiveness of the child.
- Extreme paternal dominance.
- Marked role reversal between mother and daughter (i.e. the child takes on the nurturing and care-taking role when the mother is physically or psychologically absent).
- Severe overreaction to the child’s receiving sex education.
- Social isolation of the family from the rest of the community and attempts to isolate the children.
- Child exposed to several men in relationships with the mother; little or no family supervision, controls or limits for the child; unstable family unit.
Unfortunately, too often abuse is not detected or reported until long after the abuse has occurred, giving time for the body to repair any physical injury which may have resulted from the abuse. Or the act of abuse may not cause injury and not leave any physical mark. In the last two decades, an area of medical specialty has developed spawning numerous articles and texts detailing potential medical evidence. Much of this literature has been summarized for non-medical professionals in Evidence in Child Abuse and Neglect Cases by John E. B. Myers, (3rd Edition, Wiley, New York, 1997).
Investigation of Child Sexual Abuse
As a health care provider, you may feel unqualified or ill-equipped to analyze the situation. You need do no more than report your suspicion or reasonable belief. Upon receiving your report, state and local law enforcement agencies have people who can investigate. Psychologists, doctors and social workers are available who are specially trained to conduct interviews and elicit information in a way that reduces the child’s fear of disclosure and minimizes further trauma to the child.
Understandably, given the emotional trauma and volatility of being victimized by abuse, obtaining from the abused child information of sufficient detail and credibility to be useful in legal proceedings requires the utmost sensitivity and skill on the part of the interviewer.
Interviewers need specialized training in the developmental stages of children, proper questioning techniques, the legal issues involved and the needs and expectations of an investigation. First and foremost, the interviewer must establish rapport with and gain the trust of the child. With a trained interview specialist, it is possible to limit the number of interviews and the number of people actually conducting them, which enhances the effectiveness of the child victim interviews.
Investigations often proceed on two tracks and involve a multi-disciplinary team. One track is the criminal investigation of the suspected abuser by a law enforcement agency. The other is by a “child protection agency,” to which the abuse may have been reported. In cases of intra-family abuse, such investigation is usually essential to assure safe custody of the child victim. Cross reporting and coordination between the agencies is necessary. The goal of coordinated investigation and ongoing reevaluation of the information gathered is to assure proper prosecution of the abuser and any needed protection of the victim.
Forensic Medical Exams
In terms of the timeliness of the disclosure of information raising suspicion of abuse, it is important to recognize delay is common. One may expect several months delay due to shame and fear of reprisal. Reports of sexual exploitation which seem old or stale should not, then, be viewed askance. In such cases, forensic medical exams to look for the physical findings listed above may be appropriate, depending on the nature of the abuse reported.
On the other hand, every case involving a child who has been assaulted or abused within 72 hours of the disclosure should involve a forensic medical examination with an emphasis on gathering biological evidence, to avoid the irretrievable loss of any such evidence. A colposcopic examination should be performed on any child claiming to have been molested.
To the extent the capability of collection and analysis is available, the child should be examined for samples of loose hairs, fibers, debris, lubricants, finger nail scrapings and residue of bodily fluids.
Such examinations commonly reveal greater abuse than the child initially reports. For example, in one case semen was found in the child’s mouth, between the teeth, as late as seven days after the event. The child had said nothing about oral sex.*
The unfortunate reality in our society of these most tragic and damaging forms of child abuse has made necessary the reporting requirements. The situation calls for informed and careful coordination between the medical and legal communities.
This article was prepared by Thomas Petersen and Peter E. Yeager
* Information on the recognition and investigation of child sexual abuse was drawn from S. L. Goldstein, The Sexual Exploitation of Children: A Practical Guide to Assessment, Investigation and Intervention; CRC Press, LLC; Boca Raton, FL (2d Ed. 1999), pp. 81-90, 368-70, 375-77 & 382, and is used with the permission of the author.
If you suspect sexual abuse of a child, or if a child is in need of counseling, please contact a local children’s advocacy center, us or local law enforcement authorities for further information.