Identification and Management of Sexual Abuse of a Child
Essentials
Primary care
Record the information leading to suspicion in detail, interviewing the child as little as possible. Listen calmly to the issues spontaneously brought up by the child or adolescent and record them verbatim.
Interview an adult bringing up such a suspicion separately, in the absence of the child.
Refer the child for physical examination in specialized care as follows:
as an emergency case in acute situations (incident within 3 days) or if the child has symptoms
within 24 hours in urgent cases (incident within 14 days)
by non-emergency referral if more than 14 days have elapsed since the assumed sexual abuse.
If sexual abuse of a child is suspected:
report the case to the police (legal obligations may vary from country to country);
make a child welfare notification to social services to safeguard and investigate the child's situation.
Find out about possible further local requirements and obligations.
Consult specialists and arrange multiprofessional involvement of other services and/or authorities (primary care, police, social services, specialized care, child and adolescent forensic psychiatry), as necessary.
Assess the need for psychosocial support and treatment as well as the urgency of the case, and refer the child to treatment. If a crime is suspected, the child should primarily be interviewed by the police before child psychiatric treatment. Nevertheless, it must be ensured that the child and the family are provided with the necessary support as well as health care and nursing even in an acute situation. Providing adequate support for the guardians is imporant for the child's well-being.
Specialized care
Report suspected sexual abuse of a child to the police, and make a child welfare notification to the social services. Legal obligations concerning such reporting may vary depending on the country.
Give professional assistance to the police investigating a suspected criminal offence involving a child.
A request for assistance may include a request for a forensic psychological interview, an assessment of interviewability or of the reliability of an already performed interview, somatic examination, harm evaluation and investigation of background data.
Find out about appropriate centres carrying out such investigations locally or regionally.
Somatic examinations when sexual abuse of a child is suspected
In acute cases, collect sexual assault samples; in prepubertal children within 3 days and in teenagers within 7 days.
Document all injuries as soon as possible within 2 weeks after the latest suspected incident. All observed fresh and healed injuries on the skin and in the genital region should be documented in detail.
Somatic sympoms and findings necessitate an assessment by a physician to detect a potential disease.
In non-urgent cases, examinations are mainly carried out on request for professional assistance by the police.
Experts should be consulted and multiprofessional assessment carried out and authorities or other services (primary care, police, social services, specialized care, third sector) involved.
Assess the need for psychosocial support and for child and adolescent psychiatric treatment as well as the urgency of the case, and refer the child to treatment. If a crime is suspected, the child should primarily be interviewed before child psychiatric treatment. Nevertheless, it must be ensured that the child is provided with the necessary psychosocial support as well as health care and nursing even in an acute situation. Providing adequate support for the child's guardians is important.
Note
Objectivity should be maintained in all investigations, and the legal protection of all those concerned should be taken into account.
Suspicion of child sexual abuse is often distressing also for professionals investigating the case. They should make sure to seek help and/or advice, as necessary.
Epidemiology
Based on studies carried out in various countries, the reported prevalence of childhood sexual abuse varies greatly depending on factors such as the age of the children or adolescents concerned and differences in the definition of abuse.
According to a Finnish school health survey, the prevalence of experiences of sexual abuse is 10-13% among 9th grade girls, and 3-4% among boys.
In 2018, 13% of the victims were boys in Finland.
It is very rare for biological parents to abuse their small children sexually.
Suspected sexual abuse of children is often recurrent.
Only a minority of these crimes are brought to the police's attention.
When to suspect sexual abuse
If the child reports sexual abuse.
If there is an eye witness or some other objective evidence for the deed, such as a photograph or a video.
If there is a physical symptom or finding that may also be due to a disease, an accident or other type of abuse.
If the child is found to be pregnant or to have a sexually transmitted disease.
If concern for the child arises in other preliminary investigations by the police.
Symptoms and findings
A sexually abused child may be completely asymptomatic both mentally and physically.
Symptoms and findings listed below also occur in other situations.
Possible physical findings
Pain, bleeding
Smarting on urination
Bruising, contusions, cuts
Leukorrhoea in a small girl
Sexually transmitted disease
Pregnancy
Sexually abused children may show emotional or behavioural changes or symptoms (such as depression, anxiety, fearfulness, self-destructive or aggressive behaviour, regressive or sexualised behaviour) or functional disorders (such as eating disorders, sleep disorders, enuresis, constipation, faecal soiling).
Abnormal behaviour or behavioural or emotional symptoms are not strongly suggestive of sexual abuse, and suspicion should not be based on such observations alone.
However, such symptoms in a child always require investigation.
Initially, explore the factors that prompted the suspicion of sexual abuse, notify the police according to the Child Welfare Act and submit a child welfare notification to social services, as necessary.
The child is usually interviewed either by the police or, to provide professional assistance for the police, by a child and adolescent forensic psychiatric or psychologic investigation unit.
Listen to any spontaneous report given by the child and record it verbatim.
If fewer than 3 days have elapsed from suspected sexual abuse of a child, make an emergency referral for physical examination at the paediatric/gynaecological outpatient clinic of a relevant specialized care hospital.
In acute examinations, if possible, the child should not wash him/herself or change clothes before the examination so that evidence is not lost.
If fewer than 14 days have elapsed from suspected sexual abuse of a child, make an urgent referral for physical examination at a relevant specialized care hospital within 24 hours.
If more than 14 days have elapsed from suspected sexual abuse of a child, make a non-emergency referral for physical examination.
Other authorities (paediatric forensic psychiatry or psychology unit, the police, social services) may be consulted, as necessary, even before taking any other measures.
Assess the family members' need for acute psychosocial support and crisis management and make referrals for appropriate crisis management facilities (child and family guidance clinics, child, adolescent or adult psychiatric outpatient departments, community mental health centres), as necessary.
Specialized care
Professional assistance for the police in investigations into child sexual abuse is centralised to university hospitals and central hospitals.
Interview of the child
If a crime is suspected, the child will be interviewed by the police or, on request for professional assistance by the police, by a psychologist or physician from a paediatric forensic psychiatric or psychologic investigation unit.
Paediatric forensic psychiatric or psychologic investigation units cooperate multiprofessionally with other authorities in planning and implementing investigations.
When sexual abuse of a child is suspected, the police will assess the need to apply for a child's advocate for the child due to the suspected crime.
Applying for a child's advocate is justified if the guardian cannot supervise the child's interests impartially.
Background data on the child's situation and on how the suspicion arose are collected from social services, health care and other sources, as necessary.
Based on the background data collected, the strength of suspicion and the possibility of interviewing the child are assessed and alternative hypotheses, such as the child being influenced in association with a custody dispute, suspicion arising from misunderstanding, or a misunderstanding of the events arising in interaction, are assessed.
Children below the age of 3-4 years can usually not be interviewed in association with suspected crime because their linguistic skills are not sufficiently well developed.
If children have been influenced (by leading interviews, for instance), it may no longer be possible to interview them reliably using a forensic psychological method.
Before interviewing the child, consultations may be held between the police, prosecutor and social services at the paediatric forensic psychiatric or psychologic investigation unit.
The parents and other near ones, as necessary, who know about the suspicion, should be heard usually by the police, depending on the situation, either before the child is interviewed or after it.
Before hearing a parent, the police will explain to them their position in the preliminary investigation.
In any acute situation, the child should be interviewed as soon as possible.
The child's interview is based on a framework developed for forensic psychological interviews, using mainly open questions and eliciting the child's own free recounting of the events.
The police is always present at an interview conducted at a paediatric forensic psychiatric or psychologic investigation unit.
For a successful interview, the situation must be calm and a good rapport created with the child.
The child should be explained the issues required by the Criminal Investigation Act, as appropriate for his or her age and level of development.
The interview must be videotaped and transcribed, i.e. written out verbatim.
The suspect will have the right to see the recording and submit to the police counterquestions to be presented to the child. Such counterquestions will be presented to the child by the police, psychologist or physician who originally interviewed the child. This interview must also be videotaped and transcribed.
Physical examination of the child in specialized care
The objectives of the physical examination of the child are to:
document physical injuries (bruises, ulcerations, scars, etc.) and treat them, as necessary
check the child's health and assess any alternative causes for the physical symptoms and findings
collect sexual assault samples (find out about locally available official sexual assault examination kits and instructions on their use)
prevent, verify and treat any sexually transmitted disease and take care of informing the person transmitting the disease
take care of postcoital contraception or confirming pregnancy and referring the child for treatment
assess the need for tetanus vaccination or booster
take care of arranging psychosocial support and crisis management for the child/adolescent and assess the need for child and adolescent psychiatric care
document the report in detail and any examination findings accurately by drawings and photographs. The examination visit should be videotaped, as far as possible.
Regardless of the child's age, physical examinations should be performed urgently if fewer than 14 days have elapsed from the suspected event. Fresh or healing findings can then still be observed.
Examination procedure
Start the examination by collecting sexual assault samples and documenting any skin injuries.
Sexual assault samples are taken
If fewer than 3 days have elapsed from the assumed deed, in small children collect samples that would normally be taken from the genital area from the navel, inguinal fold, external genitals and anal cleft.
If 7 days or fewer have elapsed from the assumed deed and the patient is an adolescent, collect samples as extensively as possible according to the instructions given in the sexual assault kit.
Collect samples also from all other areas where stains are found or traces suspected to occur based on the history. The type of suspected stain/secretion is recorded according to the sexual assault kit instructions.
Carry out a normal paediatric examination.
In addition, examine the mouth and the skin carefully and document all findings with photographs.
Inspect the genitalia and the anal area.
Examination requires special expertise.
A reliable examination requires that the child is examined using various examination techniques utilizing different examination positions.
A very small child is examined, as applicable, on the lap of an adult that assists the examination.
In girls, examine the external genitals and hymen in supine position with legs either in frog-leg position or spread open at the side of the examination table, using the labial separation technique (spread the labia to the sides) and traction technique (carefully pull the labia majora outwards). Best view of the hymen is often obtained in prone knee-chest position by lifting the buttocks. In adolescents, the hymen is examined with the help of a cotton swab and the balloon of a urinary catheter (Foley catheter technique).
In boys, examine the penis and testicles.
In both sexes, examine the perineum in supine position.
Examine the anus in supine, left lateral and prone knee-chest positions.
A girl is also investigated in prone knee-chest position on the examination table, where the hymen structures are examined by lifting the buttocks and the anus is examined by spreading the buttocks.
All findings observed on the skin should be photographed or videoed. Findings in the genital region are always documented irrespective of what is found or not found.
A colposcope should preferably be used.
In acute, urgent and unclear cases, make an appointment with a specialist for follow-up examination within 2 weeks.
It is important to create a good rapport with the child before physical examination. The physical examination gives a good opportunity to support the integration and strengthening of the child's perception of his/her own body and health, by commenting that he/she is healthy.
Further measures
Those concerned about the investigation are informed by the police on any medical examinations conducted at the request of the police.
The paediatric forensic psychiatric or psychologic unit can give an expert statement for preliminary investigation. A separate physician's statement regarding the somatic examination is usually requested.
The police may request a physician's statement on an assessment of the harm caused by the crime.
Social services will assess the family's need for support and services and the need for child welfare activities.
The various authorities cooperate closely and multiprofessionally in giving recommendations for treatment and defining the need for services.
Feedback consultations will be arranged for the family and the adolescent at the child and adolescent forensic psychiatric or psychologic investigation unit, and in that connection an agreement on further treatment will be made and information given on the performed examination process. A representative of social services may participate in the consultations, as necessary.
The child and adolescent forensic psychiatric or psychologic investigation unit has the right to give the party arranging further treatment the necessary information.
There are evidence-based treatment methods for children subject to sexual abuse. The child may have a need for child or adolescent psychiatric treatment even if the suspicion of sexual abuse would not be supported by the findings of examinations. The assessment of the need for psychosocial support and treatment, as well as referral to care are carried out individually.
Diagnostic child or adolescent psychiatric assessment and treatment are provided in child or adolescent psychiatric care or at a family guidance clinic or in another suitable unit.
References
Joki-Erkkilä M, Niemi J, Ellonen N. Child sexual abuse--Medical statement conclusions in criminal legal process. Forensic Sci Int 2014;239():31-6. [PubMed]
Laitinen R, Metsäpelto L, Honkanen V, Koivuranta-Vaara P, Mäki T, Reen T, Sajantila A, Sulkava R, Virtanen A, Kauppila R. Oikeuslääketieteellinen näytteenotto Suomessa [Collection of forensic medical evidence in Finland]. National Institute for Health and Welfare (THL). Report 32/2014,137 pages. Helsinki, Finland 2014. http://urn.fi/URN:ISBN:978-952-302-400-7