Keywords

child sexual abuse, domestic minor sex trafficking, sexual abuse, sexual assault, survivor issues

 

Authors

  1. Sabella, Donna PhD, MEd, MSN, CRNP, PMHNP-BC

Abstract

Child sexual abuse is a global issue that nurses must be aware of and knowledgeable about as they care for children in various care settings. This article focuses on the prevalence, potential risk factors, and possible signs and symptoms of child sexual abuse. It also provides information about what nurses can do should they suspect that a child has been or is being abused. Because consequences can be far reaching and exist for many years after the abuse, this article also addresses the possible long-term issues faced by survivors and provides resources that nurses can share with patients.

 

Article Content

In the time it takes to read this article, many children throughout the world will be raped, fondled, forced into prostitution, or sexually assaulted in numerous other ways. For some, these wounds will be carried into adulthood. Child sexual abuse can be difficult to talk about, and discussing it makes many people-including nurses-uncomfortable. Yet it's vitally important that nurses are aware of the prevalence, risk factors, and signs of sexual abuse, and familiar with the long-term consequences survivors face. In addition, nurses should know that although criteria and laws regarding sexual abuse may vary by location, there are commonly accepted descriptions of the different forms of sexual abuse. For more information, see What Is Child Sexual Abuse?1-11

  
Figure. Two drawings... - Click to enlarge in new window Two drawings by a seven-year-old girl suspected of being sexually abused by her father. In contrast to the drawing of her mother's house at left, the drawing of her father's house has what Scott Neubauer, education coordinator at the Child Abuse Education Foundation in Palmyra, Wisconsin, calls "multiple red flags": "storm clouds, excessive use of hearts," and running down the middle of the roof, what the girl identified as "a row of penises." Images courtesy of the Child Abuse Education Foundation.

Sexual abuse can occur at any age, but children are often the prime targets of such victimization. The sexual abuse of children is highly prevalent worldwide.2, 4 According to the World Health Organization, approximately 20% of women and 5% to 10% of men report having been sexually victimized as children; girls living in areas of conflict and refugee situations are particularly vulnerable to sexual assaults.12 According to UNICEF's fact sheet on child sexual abuse, sexual violence against children occurs in every country in the world and is a phenomenon that knows no social, economic, or age-related boundaries.11 Nor does it know relationship boundaries-abusers can be parents, stepparents, siblings, friends, caretakers, or strangers.13, 14 A National Institute of Justice study found that 74% of adolescents reporting sexual assault had been sexually abused by someone they knew.15

  
Box. What Is Child S... - Click to enlarge in new window What Is Child Sexual Abuse?

Some argue that sexual abuse is a problem of epidemic proportion in the United States.6 The government report Child Maltreatment 2012 estimates the overall prevalence of sexual abuse to be about 9.3%.16 Of the approximately 63,000 victims of sexual abuse reported in the United States in 2012, 2.6% were ages two and younger, 14% were three to five years old, and 17.2% were six to eight years old. Sexual abuse was most prevalent among older children and adolescents: 18.4% were nine to 11 years old, 26.3% were 12 to 14 years old, and 20.9% were 15 to 17 years old. It's generally believed that most child sexual abuse is unreported, so it's very likely that these statistics do not represent the actual number of children who have been victimized.

 

In addition, there is the phenomenon of domestic minor sex trafficking, also referred to as the commercial sexual exploitation of children, whereby children younger than age 18 are forced into prostitution. Owing to the nature of such crimes, exact figures are difficult to come by. According to the U.S. Department of Justice and the National Center for Missing and Exploited Children, it's estimated that 100,000 to 300,000 children are forced to provide sex to others each year in the United States.17 In addition, the FBI reports that the number of domestic minor sex trafficking cases in the United States has been on the rise in the last few years.18 The consensus is that child abuse, in all its forms, is a serious and universal public health issue that negatively affects not only those children being abused but also society, which shoulders the burden of the direct and indirect costs of the abuse.19-21

 

WHAT WE KNOW

We do not currently have-nor are we ever likely to have-exact figures regarding how many children are sexually abused in the United States and abroad. We do know, however, that this abuse occurs and that some children who have been sexually victimized are left with a number of physical and emotional short- and long-term consequences. In fact, evidence indicates that abused children tend to experience more physical and emotional problems than their peers who were not abused.4, 22

 

Not all children will experience adverse sequelae, and those who do will do so to varying degrees,19, 23 depending on several factors, including their age at the time of the abuse, their relationship to the abuser, the duration of the abuse, the type of abuse, other forms of abuse they may have been subject to, and the child's level of resiliency.19 However, many children can and do suffer afterward, and for some the impact is long term, even into adulthood.12, 24-26 What's more, this impact can be felt by others, possibly adversely affecting families, communities, social and occupational outcomes, and a nation's social and economic development.12, 20, 27

 

RISK FACTORS, SIGNS, AND SYMPTOMS

Nurses interact with a variety of patient populations and regularly care for many people-any of whom could be a potential victim or survivor of child sexual abuse. Therefore, nurses need to be familiar with the risk factors and signs and symptoms associated with this type of abuse.

 

Several factors are believed to increase the risk that a child will be sexually abused. Among these is being young: one study found that the median age of the first incident of sexual abuse is 9.7 years.28 Other risk factors include being female2, 4, 9, 29-31; being placed in foster care29; being a runaway31; living in an area where there is civil unrest and war32; living in places where human trafficking, especially sex trafficking, occurs33; living in areas where arranged child marriages and female genital mutilation are allowed30; living in refugee camps32; living in areas of poverty and high unemployment4, 29, 30; having been previously victimized, either sexually or nonsexually30, 34; living in rural areas29; living with a parent who has a live-in partner29; and living in countries that have high rates of child sexual abuse.4, 9, 21, 29, 30, 34-37

 

The following are additional risk factors for child maltreatment, which includes child sexual abuse, as identified by the World Health Organization12:

 

* being younger than age four or an adolescent

 

* having special needs

 

* having parents or caregivers who have drug and alcohol problems

 

* having parents or caregivers who were themselves abused as children

 

* being raised in a home where there is violence between other family members

 

* living in a country or community with gender and social inequality

 

* living in a country or community where there are inadequate programs and policies to prevent child maltreatment, child pornography, child prostitution, and child labor

 

 

Inappropriate sexual knowledge, age-inappropriate sexual interest, and acting out sexually are often indications of a history of sexual abuse. For other possible emotional, psychosocial, or behavioral signs and symptoms of sexual abuse commonly observed in children, see Possible Indicators of Sexual Abuse.1, 8, 14, 37-43

  
Box. Possible Indica... - Click to enlarge in new window Possible Indicators of Sexual Abuse

Even in confirmed cases of child sexual abuse, many children show no obvious physical signs of the abuse.41 If a child does have physical indicators of sexual abuse, these may be evident in the vagina, anus, and mouth-such as evidence of semen, infections, and bruising and swelling-and should trigger a medical examination of the child by a qualified health care professional.5, 37, 41, 44 Other physical indicators include the following5, 37, 45:

 

* having a sexually transmitted disease

 

* having a urinary tract infection

 

* pain or difficulty urinating

 

* torn and bloody clothing

 

* trouble walking, sitting, or standing

 

* irritation in the genital area

 

* pregnancy

 

* bruises on the child's mouth, especially to the hard or soft palate

 

 

THE ROLE OF THE NURSE

Although some children will report having been sexually abused, not all will. Some children may never report abuse, whereas others may take years-even into adulthood-to disclose their victimization.1, 11, 23, 46 For this reason, it is important to screen for possible abuse by talking to both the child, if the nurse determines this is age appropriate, and the child's parent or guardian. The context and nature of the nurse's interaction with the child and parent will dictate which screening questions are appropriate.

 

Gail Hornor, a certified pediatric NP and recognized nursing expert on child sexual and physical abuse, has written about the types of screening questions she poses to children and their parents, and argues that routine screening for sexual abuse should be a standard of care for all health care professionals.6 In a developmentally appropriate format, Hornor does the following when interacting with a child6:

 

* has the child identify her or his body parts

 

* determines which words the child uses for body parts

 

* discusses with the child the concept of private parts and asks if anyone touches the child there

 

* if the child answers "yes" to the previous question, she investigates who touches the child and where and how

 

* with adolescents, she discusses both consensual and nonconsensual sexual activity and safe sexual practices

 

 

When interacting with parents, Hornor suggests asking whether they suspect or have concerns that their child has been sexually abused; whether they were sexually abused as children and, if so, if the child has contact with the abuser; and whether their child associates with anyone who has abused or has been accused of abusing a child.6

 

Despite these suggestions, there is no standard list of questions nurses can draw upon when screening for child sexual abuse, as the types of questions will depend on the child's age and cognitive and maturity level. For general screening questions that can be asked if sexual abuse is suspected, see Sample Screening Questions.47 However, it is important to remember that while the nurse may be well intentioned, she or he may find that asking some of these questions can lead to adverse consequences, including in a court of law, where the questioner can be accused of asking leading questions. Detailed and lengthy questioning is best left to those with the training and credentials to do so.48-50

  
Box. Sample Screenin... - Click to enlarge in new window Sample Screening Questions.

Nurses can play an important role in referring children who have been abused to health care professionals who specialize in providing the care these children need. Many agencies and organizations have sexual assault nurse examiners on staff to help with care and evidence collection, as needed, for victims of sexual assault, as well as a list of and information about local resources nurses can share with patients or their families. Included in that information should be the names and addresses of local professionals trained and experienced in working with people who've been sexually abused. For more information on national resources for child sexual abuse, see Resources.

 

As mandated reporters of suspected child abuse-of any type, not just sexual abuse-nurses should have received information about the process of reporting any suspicions or direct knowledge of abuse to the proper authorities. School nurses, for instance, are excellent resources, because they see many children daily and are thus in a position to immediately report suspected abuse of any child who attends school.

 

THE CONSEQUENCES OF SEXUAL ABUSE

Each person reacts differently to being sexually violated. This reaction is owing to a number of factors, such as age, type and duration of abuse, age at which the abuse started, and the person's relationship to the abuser. For this reason, being sexually abused or assaulted can result in various adverse consequences.

 

In a meta-analytic review of studies that examined the connection between child sexual abuse and health, Irish and colleagues reported that people who were sexually abused as children had more physical health problems and symptoms-including general health complaints and cardiopulmonary, gastrointestinal, gynecologic, and pain symptoms-than people who didn't have a history of child sexual abuse.22 Likewise, a review by Collin-Vezina and colleagues found that children who had been sexually abused experienced more symptoms of mental health and behavioral conditions than those who hadn't been abused or had experienced other types of trauma.4

 

The repercussions of sexual abuse are typically described in terms of short- and long-term consequences, but the reality is that short-term effects can continue well beyond the immediate aftermath of the abuse. A person sexually abused as a child, for instance, can experience symptoms long after the initial abuse-into adolescence and even adulthood. These symptoms can affect one's physical, cognitive, emotional, and interpersonal functioning for years to come.5, 42

 

Short-term consequences. Potential adverse psychological effects and behaviors include depression, alcohol and drug abuse, high-risk sexual behavior, suicide and suicidal ideation, anxiety, guilt, anger, posttraumatic stress disorder, sexual dysfunction, eating disorders, and dissociative disorders.6, 28, 30, 51, 52 There are also several short-term physical effects and indicators, such as bruises and bleeding in the genital and anal areas, difficulty walking or sitting, and infections, such as urinary tract infections and vulvovaginitis.53

 

Long-term consequences. In addition to the above-mentioned short-term problems, which may eventually be considered long-term consequences, various sources note the following long-term or persistent untoward sequelae of sexual abuse6, 9, 14, 23, 40, 52, 54-57:

 

* unhealthy coping mechanisms

 

* poor interpersonal relationships

 

* sexual problems and problems with intimacy

 

* promiscuity

 

* posttraumatic stress disorder

 

* depression

 

* mood and anxiety disorders

 

* overall poor health and a variety of medical disorders

 

* guilt and shame

 

* increased suicide attempts

 

* self-destructive behaviors

 

* psychosomatic pains

 

* substance abuse

 

* borderline personality disorder

 

 

WHAT NURSES CAN DO

The earlier the abuse is recognized and the person receives treatment, the better.12 In the United States, nurses and other professionals are mandated reporters, and any suspicion of child sexual abuse must be reported to the proper authorities. Because procedures and statutes vary from state to state, each nurse should be familiar with local reporting steps. Information can be obtained from a state's board of nursing, and state guidelines are available through the Web site of the Rape, Abuse and Incest National Network (https://rainn.org/statelaws).

 

As always, the immediate concern should be to ensure that the child or adolescent is safe and that any urgent or life-threatening medical conditions are addressed. The nurse can then begin to address the child's behavioral or emotional needs, often in association with the family. Although nurses typically do not provide long-term mental health intervention or treatment unless they are functioning in an advanced practice role, they are often the first line of defense for anyone who has been sexually abused, and they can play a vital and key role in directing this person to the right support and treatment resources.

 

If a minor discloses abuse, it is important for the nurse to listen to what the child is saying, be supportive and nonjudgmental, remain calm and not overreact, and assure the child that she or he was right in telling the nurse about the abuse. It is also very important to let the child know that she or he is not to blame for what happened. If appropriate, the nurse can share with the child information about the next steps, which can help to empower the victim. It is also good practice to separate the child from any adult accompanying her or him, so that the nurse can interview the child alone. It can be very scary for a child to be asked to name an abuser who may be standing nearby.

 

The type, level, and duration of behavioral treatment for sexual abuse depends on numerous factors, including the person's current age; the age at which the abuse began; the type of abuse; the level of victimization; and the child's developmental stage, cognitive abilities, and reaction to the abuse. Although no one treatment is specifically recommended, working to empower children who've been sexually abused can be beneficial.14 Several therapies can be used to treat both children and adults who were victims of child sexual abuse. These include individual and group therapy, family therapy, dialectical behavior therapy, cognitive-behavioral approaches, and trauma-informed therapeutic approaches.24, 46, 58

 

In addition to encountering younger children and adolescents who were sexually abused and in need of treatment while still minors, nurses may also come in contact with adult survivors of child sexual abuse. Although the two groups have somewhat similar needs in regard to treatment and support, therapeutic approaches and expected outcomes differ between these two populations owing to differences in age, cognitive abilities, and developmental levels.

 

REMAINING AWARE AND INFORMED

It is easy to feel discouraged and helpless knowing that child sexual abuse occurs throughout the world every day. Yet, as nurses, we have a unique opportunity to help these children. When we encounter someone who has been sexually abused, whether in our professional or personal lives, we can be present and available, offering guidance and the appropriate resources. By making sure we are aware of this phenomenon, informed about risk factors and possible signs and symptoms, and knowledgeable in how to respond when caring for a person who has been sexually abused, we can, hopefully, be a part of the person's journey toward healing.

 

Resources

Several national and global organizations offer information and support to children, their families, adults who were abused as children, and nurses.

 

Adults Surviving Child Abuse (ASCA)

 

This Australian site offers information for adults who have survived all forms of child abuse.

 

http://www.asca.org.au

 

Child Welfare Information Gateway

 

Provides a list of agencies offering support and information regarding child abuse.

 

http://www.childwelfare.gov/organizations

 

Covenant House

 

An organization that works with homeless and trafficked children in the United States, Canada, and Central America; these children have often been sexually abused.

 

http://www.covenanthouse.org

 

National Child Traumatic Stress Network

 

Provides information in English and Spanish to parents whose children have been sexually abused.

 

http://www.nctsn.org/trauma-types/sexual-abuse

 

National Children's Alliance

 

Provides information on how communities can take a stand against child abuse.

 

http://www.nationalchildrensalliance.org

 

National Sexual Violence Resource Center

 

Provides numerous resources for caretakers and organizations working to combat child sexual abuse.

 

http://www.nsvrc.org/projects/child-sexual-assault-prevention/preventing-child-sexual-abuse-resources

 

Polaris Project

 

A national resource for those who have been trafficked or forced into prostitution and need help getting out; also a resource for those wanting information about human trafficking, including sex trafficking.

 

http://www.polarisproject.org

 

Stop It Now!

 

A resource for adult survivors of child sexual abuse.

 

http://www.stopitnow.org/help-guidance/online-help-center/adult-survivor

 

Washington Coalition of Sexual Assault Programs

 

Provides an overview of the effects of child sexual abuse and assault.

 

http://www.wcsap.org/effects-sexual-assault

 

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For 13 additional continuing nursing education activities on sexual assault topics, go to http://www.nursingcenter.com/ce.