Child Sexual Abuse

Kalpana Pandit B.Sc. Nursing 3rd Year

What is Abuse?
Abuse is mental, emotional, physical or sexual

injury to a child or failure to prevent such injury to a child.

Four Types of Child Abuse

physical abuse
sexual abuse emotional

abuse neglect

CHILD SEXUAL ABUSE Definition

Child sexual abuse is the exploitation of a child or

adolescent for the sexual

gratification of another person.

CHILD SEXUAL ABUSE Definition

Under the definition of sexual abuse there are two

categories: non-contact and contact.

Definition of Sexual Abuse: Non-Contact

forced to watch sexual acts

forced to listen to sexual talk, including

comments, tapes, and obscene phone calls sexually explicit material such as videos, DVDs, magazines, photographs, etc.; can be in-person, on the computer via e-mails, and otherwise through the Internet forced to look at sexual parts of the body includes buttocks, anus, genital area (vulva, vagina, penis, scrotum), breasts, and mouth sexually intrusive questions or comments; can be verbal, on the computer, or in notes
http://bodyprinciple.wordpress.com/2011/04/02/april-is-child-abuse-awareness-month/

Definition of Sexual Abuse: Contact

being touched and fondled in sexual areas,

including kissing forcing a child or youth to touch another persons sexual areas forced oral sexoral sex is when the mouth comes in contact with the penis, the vagina or the anus; many children believe that oral sex is talking dirty forced intercoursecan be vaginally, anally or orally; penetration must occur; penetration can be with body parts and/or objects (the most common body parts used are the fingers, tongue and http://bodyprinciple.wordpress.com/2011/04/02/april-is-child-abuse-awareness-month/ penis)

SEXUAL ABUSE: Includes the following types of sexual maltreatment:

Sexual abuse Incest: any physical sexual activity

between family members; blood relationships is not required (abusers can include stepparents, unrelated siblings, grandparents, uncles and aunts) Molestation: a vague term that includes indecent liberties, such as touching, fondling, kissing, single or mutual masturbation or oral-genital contact.
Exhibitionism/Exposing

children to adult sexuality Performing sexual acts in front of a child, exposing genitals, telling "dirty" stories, showing pornography to a child.

SEXUAL ABUSE: Includes the following types of sexual maltreatment:

Child pornography:

arranging and photographing, in any media, sexual acts involving children, alone or with adults or animals, regardless of consent by the childs legal guardian; also may denote distribution of such material in any form, with or without profit.
Child prostitution: involving children in sex

acts for profit and usually with changing partners. Pedophilia : literally means love of child and does not denote a type of sexual activity but

RISK FACTOR FOR CHILD SEXUAL ABUSE:

Parental unavailability.

Lack of emotional closeness and

flexibility. Social isolation. Emotional deprivation. Communication difficulties.

Clinical Manifestation of Child Sexual Abuse

Physical findings: Bruises, bleeding, laceration, or irritation of external genitalia , anus, mouth ,or throat. Turn , stained, or bloddy under clothing. Pain on urination or pain, swelling, and itching of genital area. Penile discharge. Sexual transmitted disease, non specific vaginitis. Difficulty in walking or sitting. Unusual odor in the genital area. Recurrent UTI. Presence of sperm.

Suggestive behaviours:

Sudden emergence of sexually related problems,

including excessive or public masturbation, age inappropriate sexual play, promiscuity, or overtly seductive behaviour. Withdrawn behavior, excessive day dreaming. Poor relationship with peers. Sudden changes such as anxiety, loss or gain of wt. excessive anger at mother for not protecting daughter.

Suggestive behaviours:
Regressive behaviour, such as bed wetting or

thumb sucking. Sudden onset of phobias or fears, particularly fears of the dark, men ,strangers. Running away from home. Substance abuse, particularly of alcohol or mood alleviating drugs. Profound and rapid personality changes, especially extreme depression, hostility and aggression. Rapidly declining school performance. Suicidal attempts or ideation.

Methods used to pressure children into sexual activity

Children is offered gift or

privileges The adult misrepresents moral standards by telling the children that it is okay to do Isolated & emotionally and socially impoverished children are enticed by adult who meet their needs for warmth and human contact

Methods used to pressure children into sexual activity

The successful sex offender

pressures the victim into secrecy regarding the activity by describing it as a secret between us that other people may take away if they find out
The offender play on the childs

fears, including fear of punishment by the offender, fear of repercussion if the child tells, and offer of abandonment or rejection by the family.

Physical Examinations
Evaluations for the

Diagnosis & Treatment of Child Sexual Abuse

Physical Exam
Findings diagnostic of trauma and/or sexual

contact
Examples: Lacerations or bruising Hymenal transection (area of hymen torn through

or nearly through the base) Infection such as chlamydia > 3years old Pregnancy Sperm on sample taken from childs body

Examination Techniques

Physical Findings
5-10% of children have physical findings

Genital (female)
Bruising Transections Absent hymenal tissue Abrasions Sexually Transmitted Diseases

Physical Findings
Genital (Male)
Penile Abrasions Bites, Bruises Urethral/Anal Discharge Sexually Transmitted

Infections Scars

Its normal to be normal.

Joyce Adams, MD

Physical Exam

A normal exam does not

exclude the possibility of sexual abuse or prior penetration

The genital examination of the abused child rarely differs from that of the nonabused child. Thus legal experts should focus on the childs history as the primary evidence of abuse. Berenson, A. Am J. OB/Gyn 2000

Children Referred for Possible Sexual Abuse: Medical Findings in 2384 Children
Referrals based on disclosure, behavior changes,

medical findings Overall 96% had normal exams 5.5% abnormal when disclosed

penetration 1.7% abnormal without history penetration 8% exams abnormal when had medical findings STIs, acute genital trauma, healed Heger et al Child Abuse & Neglect 2000 hymenal trauma, transections

Why are exams normal?

Nature of assault may not be damaging

Perception of penetration
Disclosures often delayed Complete healing can occur The hymen changes with puberty

Stay Moral, Go Oral

Adolescents do not consider oral sex to be sexual activity. Need to ask if anything has been in the mouth!

PREVENTION
School-based child education programs

successful
teaching children Child Sexual Abuse concepts and

self-protection
Negative:
increased anxiety, feeling less in control for younger

children, and feeling more discomfort with normal touch in older children
Putnam. J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 42:3, MARCH

2003

PREVENTION
Parental Education

Truth versus myths When to start- 10 yo is too late! How often Mental Health Care for parents prior abuse

Communication
Young children are concrete thinkers

Judgment
Caregivers

Nursing Management
Protect child from further abuse.

Provide safe environment.

Provide adequate support and referral. Allows child to express feeling about return home

or going to foster care. Evaluate care giver. Provide education to parents of child physical and developmental needs. Beware of time for continued abuse or neglect.

Nursing Management
Provide counseling and education about

appropriate parenting skills. Provide trust environment in family. Given child time to adjust. Prepare time to deal with threats and possible physical force. Teach children how to say no, ask for help and control who touches them and how.

Nursing Management
Self protective and limit setting behavior for

children. Listen carefully to understand the child. Know local resources and chose help carefully. Provide opportunity to talk about the assault. Provide opportunity for the entire family to go through a recovery process.

Summary
Child Sexual Abuse is prevalent

Diagnosis of CSA not usually by

physical exam findings or behavior alone Many sexual behaviors are normal Disclosures -- most important and need to be obtained appropriately Think about any other possible evidence!

Thank You