Recognizing Sexual Abuse

Dr. Greene's Answer

Some of the most poignant episodes of my pediatric training were long visits with children victimized by sexual abuse. I vividly remember sitting with tears streaming down my face after hearing how children had been scarred by those they trusted.

How sad that we need to be discussing this subject for a three-and-a-half-year-old! Unfortunately, there is no age at which a child is exempt from sexual abuse. About one-third of cases occur in kids younger than six years of age, about one third in children ages six to twelve, and one third in children ages twelve to eighteen. The Fourth National Incidence Study on Sexual Abuse estimated that 1.8 in 1000 children were victims of sexual abuse.  Unfortunately, many of these children do not disclose this abuse until they are adults.

Sexual abuse includes any activity with a child for the sexual gratification of an adult or significantly older child (more than about 4 years older). Children’s intense need for affection and nurturance from older figures makes them vulnerable. Adults and older children hold a position of tremendous power in their lives. It is the abuse of this power, and the abuse of children’s trust, that is so damaging.

Three Categories of Sexual Abuse

1. Molestation, which is defined as the touching or fondling of the genitals of a child, or asking a child to touch or fondle an adult’s genitals, or using a child to enhance pleasure from sexual acts or pornography
2. Sexual intercourse, which includes vaginal, oral, or rectal penetration
3. Rape, unlawful sexual activity carried out with force against a person’s will or carried out with someone under a certain age or someone who is not able to consent fully.

Most abuse begins with innocent physical contact. A needy adult then makes this a routine. Once a routine is developed, it is not uncommon to progress to intercourse.

The most common perpetrator of sexual abuse is either a family member or a close friend of the family. Sexual abuse by a stranger is quite uncommon.

Sexual abuse commonly comes to light through the child’s disclosing the incident of sexual contact to a trusted adult. Historically, a child’s word was not taken seriously. Over the last twenty years, the pendulum swung to the opposite extreme; if a child described sexual contact, it was considered a fact, and the volunteering of such information was considered very strong legal evidence. Recently, the pendulum has returned to a more balanced position: take it very seriously whenever a child mentions sexual contact, but understand that not everything said necessarily mirrors physical reality. It is important to listen to your child and bring up any and all concerns to your pediatrician who can then take appropriate next steps. 

Determining a Child is a Victim of Sexual Abuse

The best way to clarify a situation, such as you have described, is to have your child examined by a sexual abuse specialist. Most children’s hospitals have a sexual abuse team or will be able to refer you to a specialist in your area. (The two hospitals that offer this service in your area are Santa Clara Valley Medical Center in San Jose and the Keller Center at San Mateo Medical Center). Your pediatrician can also help you navigate where best to take your child for an evaluation. 

A sexual abuse examination is comprised of two basic elements. First, and perhaps most important, your daughter would be interviewed by an expert who very gently elicits information from her about what might have happened. Efforts are made to minimize the number of times a child has to tell the story and the number of people visibly present during the interview. The interviewer will let your child set the pace and may use pictures or dolls to draw her out, without suggesting to her what might have occurred. 

This is generally followed by a physical examination of the external genitals, checking for any sign of trauma (such as bleeding, tears, or inflammation), laxity, or discharge. Sometimes this will be done with magnification, using an instrument called a colposcope. This will be done with a chaperone and often a parent in the room in order to ensure comfort for the child.  A parent or a loving caregiver by the child’s head can give them support and reassurance throughout the exam. 

Note that a physical examination cannot in and of itself confirm or rule out sexual abuse. In at least half of the cases of child abuse that are confessed by the abuser, there are no findings on physical exam.

Clues to Help Recognize Sexual Abuse

Children who have actually been abused will often recant their initial statement because they are afraid of their abuser or because their abuser convinces them that this is “their little secret.” And children who have never been sexually abused will, based on normal child development, go through phases of curiosity and misunderstandings about their genitals and about sexual activity.

Several clues are associated with sexual abuse (but often the only clues are a child’s verbal statement and their physical exam is normal):

• Genital infections, redness, or discharge
• Burning with urination
• Urinary tract infection
• The new onset of either bed-wetting or stool problems
• Sudden increased sexuality with peers, animals, or objects
• Seductive behavior
• Age-inappropriate sexual knowledge
• Regression
• Other dramatic behavior changes

Hopefully, nothing significant happened to your little girl, but if my daughter came to me with the same story, I would not let the situation go uninvestigated. The scenario you have described is the most frequent way actual sexual abuse is detected.

Whatever turns out to be true, it’s important to prepare our children to protect themselves against sexual abuse. Begin by teaching them the proper names and significance of their private parts as soon as they are able to understand (about age 3). This will help to teach them that although these parts of their body are private, it is ok to talk about them and ask questions. Then they will be ready to understand and communicate what has happened to them.

Three Key Messages Children Should Understand

• Say no if somebody tries to touch your nipples, rectum, or genitals.
• Tell a trusted adult if someone tries to touch you.
• Don’t keep secrets — if somebody tells you to keep a secret, let your parents know right away.

Parents need to be careful about who spends time alone with their children – where and when.  Parents should also be ready to listen and take it seriously when their child has a question or concern.  Open lines of communication are incredibly important for children in order for them to feel comfortable talking about confusing or scary experiences.  

For a parent or caregiver, recognizing sexual abuse is just the beginning of the healing process — but it’s a very important first step.   Studies have shown that the long term outcomes of children who have been abused are much better if they are believed and taken seriously at the time of disclosure. Abuse should be treated by a supportive team of experts.

You have the power to make a big difference. 

References and Resources

Jenny C, et al. The evaluation of children in the primary care setting when sexual abuse is suspected. Pediatrics. 2013; 132(2):e558-e567.  

Finkel  MA, et al. Medical Evaluation of Child Sexual Abuse: A Practical Guide. Elk Grove Village, IL: American Academy of Pediatrics; 2009.

Laskey A, et al.  COUNCIL ON CHILD ABUSE AND NEGLECT. Protecting Children From Sexual Abuse by Health Care Professionals and in the Health Care Setting. Pediatrics. 2022 Sep 1;150(3).