Childhood sexual abuse among university students in Tanzania

OBJECTIVES: There are no prevalence data for childhood sexual abuse among Tanzanian university students. This investigation addressed this paucity. The nature of sexual abuse was also investigated. METHOD: Participants (N=487) from a university in Tanzania completed a questionnaire which assessed abusive childhood sexual experiences, gathering information about age of victim, duration of abuse, perpetrators, amount of force or persuasion involved, and potential causes of child sexual abuse. A number of individuals were also interviewed about their experiences. RESULTS: The overall prevalence rate for child sexual abuse was 27.7%, with rates being higher for females than for males. The average age of the victim when abuse occurred was 13.8 years. Perpetrators were generally unidentified by respondents; nonetheless, a surprisingly high proportion of female perpetrators was noted. There was a considerable amount of force or persuasion involved in the abusive behavior: betrayal of trust, bribes and physical force were cited frequently. Poverty and superstition were the primary explanations given for child sexual abuse. CONCLUSION: The study provides evidence for the existence of child sexual abuse in Tanzania. Poverty feeds the "sugar daddy/mammy" phenomenon and combined with various forms of superstition is an important factor in child sexual abuse in Tanzania.     

Childhood disclosure of sexual abuse and mental health outcomes in adulthood: Assessing merits of early disclosure and discussion

BackgroundEmpirical research on the impact of early disclosure of child sexual abuse (CSA) on survivor health is limited and mixed. One recent study found that early disclosure may actually be detrimental for abuse cessation and adult symptomatology (Swingle et al., 2016). The current study re-examined the effects of early disclosure and related variables on long-term mental health for men with histories of CSA.ObjectiveThe primary aims of this study were to: a) investigate whether early disclosure and response to early disclosure were related to mental distress in adulthood, and b) examine whether having an in-depth discussion and timing of that discussion were related to mental distress in adulthood.Participants and settingData were collected from a large, non-clinical sample of male survivors (N = 487), ranging in age from 19 to 84 years, through an online, anonymous survey.MethodsHierarchical regression analyses were conducted by entering groups of variables in four steps: control variables, CSA severity, disclosure, and discussion.ResultsOverall, models explained between 24–28% of the variance in mental distress. None of the CSA severity variables reached significance. Both early disclosure (β = −0.126, p = 0.003) and response to first disclosure (β = −0.119, p = 0.006) were significant protective factors in Model 3. In the final model, having an in-depth discussion (β = −0.085, p = <0.036) and years until discussion (β = 0.102, p = 0.029) were also related to mental distress.ConclusionsResults support the merits of early disclosure and discussion on long-term mental health. Implications for future research and practice are presented.     

Caregiver perceptions about mental health services after child sexual abuse

The objective of this study was to describe caregiver perceptions about mental health services (MHS) after child sexual abuse (CSA) and to explore factors that affected whether their children linked to services. We conducted semi-structured, in-person interviews with 22 non-offending caregivers of suspected CSA victims < 13 years old seen at a child advocacy center in Philadelphia. Purposive sampling was used to recruit caregivers who had (n = 12) and had not (n = 10) linked their children to MHS. Guided by the Health Belief Model framework, interviews assessed perceptions about: CSA severity, the child's susceptibility for adverse outcomes, the benefits of MHS, and the facilitators and barriers to MHS. Interviews were audio-recorded, transcribed, coded, and analyzed using modified grounded theory. Recruitment ended when thematic saturation was reached. Caregivers expressed strong reactions to CSA and multiple concerns about adverse child outcomes. Most caregivers reported that MHS were generally necessary for children after CSA. Caregivers who had not linked to MHS, however, believed MHS were not necessary for their children, most commonly because they were not exhibiting behavioral symptoms. Caregivers described multiple access barriers to MHS, but caregivers who had not linked reported that they could have overcome these barriers if they believed MHS were necessary for their children. Caregivers who had not linked to services also expressed concerns about MHS being re-traumatizing and stigmatizing. Interventions to increase MHS linkage should focus on improving communication with caregivers about the specific benefits of MHS for their children and proactively addressing caregiver concerns about MHS.     

Religion in child sexual abuse forensic interviews

Religion is an under-studied factor affecting children’s sexual victimization and their willingness to discuss such experiences. In this qualitative study, 39 child forensic interviewers and child advocacy center (CAC) directors in the United States discussed religious influences on children’s sexual abuse experiences, their relationships to CACs, and their disclosures in the forensic setting. Participants reported both harmonious and dissonant interactions between religiously observant children and families on one hand and child advocacy centers on the other. Themes emerged related to abuse in religious contexts and religious justifications for abuse; clergy and religious supports for disclosures as well as suppression of disclosures; and the ways CACS accommodate religious diversity and forge collaborations with clergy. Participants discussed a wide range of religions. Recommendations for practice and research are included.     

Childhood sexual abuse by representatives of the Roman Catholic Church: A prevalence estimate among the Dutch population

Estimates of the extent of childhood sexual abuse (CSA) within in the Roman Catholic Church (RCC) in the general population are difficult to find. The independent Commission of Inquiry into sexual abuse of minors in the RCC in the Netherlands collected population-based data to estimate its prevalence. A large random online population sample was surveyed using a two-phase stratified sampling procedure. In Phase 1, 34,267 subjects aged 40 years and older were screened for childhood exposure to sexual abuse by non-family members, a history of institutionalization and a Roman Catholic upbringing. In Phase 2, a stratified subset of 2,462 subjects was assessed to obtain more detailed target information about sexual abuse reports within the RCC. We employed multiple imputation for the estimation of RCC CSA in the original Phase 1 sample. The prevalence of non-familial CSA in general (14.0%) was higher among women (17.2%) than among men (10.6%). The prevalence of CSA within the Dutch RCC (1.7%) was higher among men (2.7%) than among women (0.7%). As expected, older subjects reported more often CSA in the RCC than their younger counterparts. Respondents who stayed for some time in RCC run institutions for education or child protection had a higher risk to report sexual abuse. Although sexual abuse of minors by representatives of the RCC was a structural problem during a period that the Church was highly influential in the Netherlands, the estimated prevalence of the phenomenon is only a fraction of the prevalence rate of non-familial CSA.     

Childhood sexual abuse and abuse-specific attributions of blame over 6 years following discovery

OBJECTIVE: The purpose of this study was to examine patterns of change in attributions for childhood sexual abuse (CSA) over a 6-year period and whether such patterns were related to abuse severity, age, gender, and subsequent symptoms of depression and PTSD. METHODOLOGY: One-hundred and sixty children, 8-15 years old, were interviewed within 8 weeks of the time the CSA was reported to child protective services (i.e., the time of abuse discovery). Follow-up interviews were conducted 1-year later on 147, and 6 years later on 121 of the original participants. Abuse-specific attributions were obtained using two methods. Participants first responded to an open-ended interview question about why they believed the CSA had happened to them and then completed a rating scale about the extent to which possible attributions for the CSA applied to them (e.g., "Because I was not smart enough"). RESULTS: Over time, perpetrator-blame attributions were consistently more common than self-blame attributions for CSA (using both interview and rating measures). Youth were more likely to report self-blame attributions on the rating measure than the open-ended interview question. The interview method indicated that youth often felt confused about why the abuse happened up to a year following discovery but this response diminished by the third assessment. On average, ratings of perpetrator-blame attribution remained high over time (p<.05), whereas ratings of self-blame decreased (p<.01). Penetration was related to more self-blame (p<.05) and less perpetrator-blame (p<.05), and the use of force was related to more perpetrator-blame. The initial level of self-blame attribution ratings predicted subsequent symptoms of depression (p<.05) and intrusive experiences (p<.05) after controlling for age at abuse discovery, gender, and self-blame attributions for common events. Perpetrator-blame attributions were not related to symptoms. CONCLUSIONS: The findings of this study suggest that assessing responses to open-ended interview questions about the perceived reasons for the abuse and ratings of attributions are important for understanding how youth make sense of their abuse. Abuse-specific self-blame attributions at abuse discovery have a persistent effect on internalizing symptoms and should be assessed and the target of treatment as soon as possible after CSA has been reported to the authorities.     

Childhood abuse and community violence: Risk factors for youth violence

ObjectiveTo investigate the joint effect of child abuse and neglect (CAN) and community violence (CV) on adolescents with peers that commit youth violence (YV).MethodsThis is a school-based cross-sectional study of 699 students enrolled in four public and nine private schools in the municipality of Rio de Janeiro, Brazil. Participants were selected through a complex cluster sampling procedure. CAN was identified using the Childhood Trauma Questionnaire (CTQ). Exposure to CV was assessed by asking students if they have witnessed cases of lethal violence in the community. YV was measured indirectly through questions about having friends who have committed acts of crime. Multivariate logistic models were used to study the effects of emotional, physical, and sexual abuse and emotional and physical neglect in childhood on YV, controlled for confounders, according to different levels of CV.ResultsEmotional abuse OR = 3.32 (CI 95%: 1.79–6.17), sexual abuse OR = 2.33 (CI 95%: 1.20–4.54), and physical neglect OR = 1.81 (CI 95%: 1.02–3.20) increased the odds of YV in adolescents, whether cooccurring with CV or not. Physical abuse OR = 3.95 (CI 95%: 2.29 - 6.80) and emotional neglect OR = 2.93 (CI 95%: 1.83–4.72) are only risk factors for YV involvement when associated with CV.ConclusionsThese findings highlight the relevance of CAN and CV as risk factors for YV and the potential increase in adolescents’ vulnerability when exposed to both. Policies aiming at preventing and dealing with CAN are essential strategies to reduce YV, especially in areas with high levels of CV.     

Childhood sexual abuse: Long-term effects on psychological and sexual functioning in a nonclinical and nonstudent sample of adult women

The purpose of this study was to explore how the experience of childhood sexual abuse is related to long-term psychological and sexual functioning in a nonclinical and nonstudent community sample of women. Questionnaires were distributed to 1,500 nurses and returned anonymously. Fifty-four women who had been sexually abused as children (age 15 or younger) responded. These subjects were then matched with 54 nonabused control subjects. Although there was no difference on a measure of self-esteem, the abused group reported more symptoms of distress on the Global Severity Index and on seven out of nine subscales of the Derogatis Brief Symptom Inventory. They also reported more disturbance on a scale which examined psychological symptoms that have been commonly reported in the literature to be particularly associated with sexual abuse. These differences between the abused and nonabused groups were evident even after controlling for differences in subjects' perceptions of parental emotional support. Unlike the results for psychological adjustment, however, the abused subjects did not differ from the control subjects on self-reported levels of sexual satisfaction or sexual dysfunction.     

Childhood sexual abuse,risky sexual behaviors and adverse reproductive health outcomes among Chinese college students

BackgroundChildhood sexual abuse (CSA) is a serious public health problem worldwide.ObjectivesWe reported the prevalence of CSA and examined its association with risky sexual behaviors and adverse reproductive health outcomes among college students in China.Participants and settingParticipants were 17,966 college students from 130 colleges in Eastern, Central, and Western China, who completed the online questionnaire in January–August 2015.MethodsData were obtained from a cluster-random Internet-based survey. Multivariate logistic regression analyses were employed: risky sexual behaviors and adverse reproductive health outcomes were outcome variables, and various types of CSA were predictor variables, while adjusting for socio-demographic and lifestyle characteristics.ResultsThe overall prevalence of any type of CSA was 27.5%. Most perpetrators were friends/acquaintances (34.6%) or intimate partners (24.7%) of the victims. Respondents who reported penetrative CSA were strongly associated with regular unprotected sex (odds ratio (OR): 3.0, 95% confidence interval (CI): 2.2–4.0), early sexual debut (OR: 5.5, 95% CI: 3.3–9.1), having genital tract symptoms in the last 12 months (OR: 5.0, 95% CI: 4.1–6.0), unintended pregnancy (OR: 6.2, 95% CI: 4.2–9.0), and induced abortion (OR: 5.5, 95% CI: 3.7–8.2) (for boys, the survey asked about history of unintended pregnancy and induced abortion of their sexual partners). A dose-response relationship was found across non-contact, contact, and penetrative CSA.ConclusionsCSA experience may increase the likelihood of risky sexual behaviors and adverse reproductive health outcomes in victims’ early adulthood.     

Child sexual abuse in Indonesia: A systematic review of literature,law and policy

BackgroundLike many middle-income countries, knowledge about child sexual abuse (CSA) is limited in Indonesia. The national government has stated a commitment to protect children from the worst forms of abuse, yet the sensitivity of CSA along with the complexity of culture and law, present substantial challenges.ObjectiveThis article reviews current knowledge about CSA in Indonesia, in the context of existing laws and policies that influence CSA prevention and intervention.MethodA systematic review of this research was conducted in the following manner: a review of scholarly literature and grey literature in English (19 papers) and in Bahasa Indonesian (11 papers), and a review of CSA-related Indonesian laws (4 documents) and policies (5 documents).ResultsThis review finds that knowledge about CSA in Indonesia is still limited. The taboos on discussing sexual matters were identified as factors that impede reporting of CSA. Poverty also leads to increasing children’s risk of sexual abuse. There was less attention to CSA occurring within family contexts and focus was more upon its occurrence outside of the family. The study identified that contradictory definitions of children within the law add to children’s vulnerability to CSA; this is especially the case for girls. Current child protection strategies in prevention and intervention lack specific focus on CSA.ConclusionFurther research is needed to enable the development of evidence-based approaches to better harmonize the development of law and policy with contemporary knowledge about CSA.     

Child sexual abuse in Japan: A systematic review and future directions

IntroductionEstimating the national prevalence of child sexual abuse (CSA) and its association with health and developmental outcomes is the first step in developing prevention strategies. While such data are available from many countries, less is known about the epidemiology of CSA in Japan.MethodsFor this systematic review, we searched English databases: Embase, Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily and Ovid MEDLINE(R), Ovid OLDMEDLINE(R), PsycINFO, and Japanese databases: Cinii, J-Stage, Children’s Rainbow Center Japan, Japan Child and Family Research Institute, Japanese Journal of Child Abuse and Neglect to identify articles published before July 2015 examining the lifetime prevalence of CSA in Japan using non-clinical samples. Data were extracted from published reports.ResultsWe initially identified 606 citations and after abstract review, retrieved 120 publications. Six studies that met the selection criteria and additional two relevant studies were reviewed. The range of contact CSA for females was 10.4%–60.7%, and the prevalence of this type of CSA for males was 4.1%. The range of penetrative CSA for females was 1.3%–8.3% and that for males was 0.5%–1.3%. A number of methodological issues were identified, including a lack of validated measures of CSA, and low response rates.ConclusionIn contrast to a lower prevalence of penetrative CSA, the prevalence of contact CSA among Japanese females may be comparable or higher in relation to international estimates. Future research on children's perceptions of and exposure to sexual abuse, crime and exploitation in Japan is discussed.     

Adult mental health outcomes of child sexual abuse survivors born at extremely low birth weight

The high prevalence of child sexual abuse (CSA) is concerning, particularly as survivors are at increased risk for multiple adverse outcomes, including poor mental health across the lifespan. Children born at an extremely low birth weight (ELBW; <1000 g) and who experience CSA may be a group that is especially vulnerable to psychopathology later in life. However, no research has considered the mental health risks associated with being born at ELBW and experiencing CSA. In this study, we investigated the mental health of 179 ELBW survivors and 145 matched normal birth weight (NBW; >2500 g) participants at ages 22–26 and 29–36. At age 22–26, CSA was associated with increased odds of clinically significant internalizing (OR = 7.32, 95% CI: 2.31–23.23) and externalizing (OR = 4.65, 95% CI: 1.11–19.51) problems among ELBW participants exposed to CSA compared to those who did not, though confidence intervals were wide. At age 29–36, CSA was linked to increased odds of any current (OR = 3.43, 95% CI: 1.08–10.87) and lifetime (OR = 7.09, 95% CI: 2.00–25.03) non-substance use psychiatric disorders, however, this did not hold after adjustment for covariates. Statistically significant differences in mental health outcomes were not observed in NBW participants exposed to CSA compared to NBW participants who were not exposed. Survivors of significant perinatal adversity who are also exposed to CSA may be at higher risk for psychopathology through the fourth decade of life.     

Child emotional aggression and abuse: definitions and prevalence

Objective

Research on and intervention for child emotional abuse and emotional aggression toward children have been severely hampered because there have been no agreed-upon, clinically usable definitions.

Methods

We have (a) proposed and field-tested a set of criteria to operationally define child emotional abuse for clinical settings and (b) used these criteria to design a parent-report measure of parental emotional aggression and child emotional abuse that could be used in research. In this paper, we review the development and field trials of these criteria for making substantiation decisions.

Results

Agreement between master reviewers and field decisions was extremely high in a 5-site development trial (96% agreement, κ = .89) and a 41-site dissemination trial (90% agreement, κ = .73). We compare these criteria to other research criteria in the literature. We then present data collected using a self-report measure designed to parallel these criteria from an anonymous online survey of US Air Force personnel and their spouses. The final sample (N = 52,780) was weighted to be representative of the United States civilian population. The prevalence of parents’ emotionally aggressive acts was much higher than the prevalence of emotional abuse (acts plus impact), but rates of parents’ acts of emotional aggression were lower than those typically reported in the literature. Additional analyses tested for differential effects due to gender of perpetrator (i.e., mothers or fathers), age of victim, and clustering within families. These factors did not drive rates of aggression or abuse.

Conclusions

In sum, the criteria developed and proposed appear to support reliable clinical decision making regarding child emotional abuse and can be translated to research survey tools that better capture the continuum of parents’ emotional aggression and child emotional abuse than the measures that are currently available, advancing the state of the science with respect to child emotional abuse.     

Epidemiologic variations in childhood sexual abuse

We retrospectively reviewed records of 566 children ranging from 6 months to 16 years of age who presented to a sexual assault crisis center. They represented 33.2% of all alleged sexual assault victims seen over a 36 month period. There were 103 males (18.2%) and 463 females (81.8%). Significant differences in presentation were demonstrated with respect to the victim's age, sex, and race, but the major factor influencing the variation is the victim/assailant relationship. Younger children were more likely than older children to present with histories of multiple assaults (p less than .0005), by known assailants (p less than .0005), occurring in the child's or assailant's home (p less than .001) and to report less violence (p less than .05). More risk of violence (p less than .0005) or evidence of trauma (p less than .0005) and less reporting of home assaults (p less than .0005) or multiple assault episodes (p less than .0005) were found in assaults by strangers when compared with non-stranger assaults. A lower frequency of reporting was found in females between 7 and 11 years of age. The dynamics of childhood sexual abuse are discussed in relationship to these findings. A number of victim and assailant related factors determine reporting patterns of childhood sexual abuse.     

Pathways from childhood abuse to prospective revictimization: Depression,sex to reduce negative affect,and forecasted sexual behavior

Research suggests that adverse events in childhood, such as childhood physical, sexual, and emotional abuse, confer risk for later sexual assault. Psychological distress, coping strategies, and sexual behavior may help explain the path from childhood abuse to revictimization. The present study explored how the use of sex to regulate negative affect (SRNA) operates independently, and in combination with other psychosocial factors to increase college women's (N = 541) risk of experiencing prospective adult sexual assault (ASA). Sequential multiple mediator models in Mplus were used to assess the effect of three different forms of childhood abuse on prospective ASA, both independently and while controlling for other forms of childhood abuse. The indirect effect of adolescent sexual assault (AdolSA), depressive symptoms, SRNA, and participants’ response to a sex-related vignette was tested using bias-corrected bootstrapping. In the full path model, childhood emotional abuse and AdolSA predicted ASA, while childhood physical and sexual abuse were directly associated with AdolSA, but not ASA. Additionally, depressive symptoms and participants’ estimate of their likely behavior in a sex-related vignette directly predicted prospective ASA. Results using bootstrapping revealed that a history of childhood abuse predicted prospective ASA via diverse direct and indirect paths, as well as through a similar multiple mediator path. Overall, findings suggest that a combination of affective, coping, and sexual expectancy factors contribute to risk for revictimization in adult survivors of childhood abuse. Future research directions and targets for risk-reduction programming are discussed.     

A longitudinal perspective on boys as victims of childhood sexual abuse in South Africa: Consequences for adult mental health

Childhood sexual abuse of boys was examined in a longitudinal cohort in South Africa, with data on abuse collected at six age points between 11 and 18 years. Potential personal and social vulnerability of male sexual abuse victims was explored and mental health outcomes of sexually abused boys were examined at age 22–23 years. Reports of all sexual activity – touching, oral and penetrative sex – increased with age and sexual coercion decreased with age. Almost all sexual activity at 11 years of age was coerced, with the highest rates of coercion occurring between 13 and14 years of age; 45% of reports of coerced touching were reported at age 14, 41 percent of coerced oral sex at age 13, and 31% of coerced penetrative sex at age 14. Sexual coercion was perpetrated most frequently by similar aged peers, and although gender of the assailant was less often reported, it can be presumed that perpetration is by males. Boys who experienced childhood sexual abuse tended to be smaller (shorter) and from poorer families. No relationships to measured childhood intelligence, pubertal stage, marital status of mother or presence of the father were found. There was no significant association between reports of childhood sexual abuse and mental health in adulthood and when personal and social vulnerabilities were taken into account.     

Changes in the prevalence of child sexual abuse, its risk factors, and their associations as a function of age cohort in a Finnish population sample

Objective

We examined (1) the prevalence of childhood sexual abuse (CSA) experiences as a function of cohort and gender, (2) the prevalence of factors associated with CSA as a function of cohort and whether the association of these factors with CSA remained the same irrespective of cohort, and (3) whether any cohort differences could be explainable by cohort differences in reporting bias.

Method

We used the responses of 4,561 men (M = 29, SD = 7 years) and 8,361 female (M = 29, SD = 7 years) Finnish participants who responded to the Childhood Trauma Questionnaire-Short Form as well as questions regarding family structure.

Results

The prevalence of CSA experiences varied between 0.7-4.6% for men and 1.8-7.5% for women depending on the item. Younger cohorts reported less CSA as well as less of the risk factors (physical neglect and abuse, emotional neglect and abuse, parental substances abuse, not growing up with both biological parents) that were positively associated with the likelihood of CSA. The effects of these risk factors did not vary as a function of the cohort. Also, the declining trend was not explainable by social desirability being higher in the younger cohorts.

Conclusions

The results suggest that there is a real decline in the prevalence of CSA and it is associated with a simultaneous decline in factors associated with CSA.     

Childhood maltreatment experiences and problematic sexual outcomes in adult males who have sexually offended: Further evidence of the potency of male caregiver psychological abuse

BackgroundAlthough research on the developmental antecedents of sexual offending has tended to focus on sexual abuse, recent research in juveniles and adults who have sexually offended suggests that psychological abuse perpetrated by a male caregiver may be a particularly important factor in the development of problematic sexual interests and behaviors.ObjectiveThis study aimed to extend previous findings by investigating the association between psychological abuse by a male caregiver and problematic sexual outcomes in a sample of adult males who had sexually offended.ParticipantsParticipants were 529 adult males incarcerated for sexual offenses, 21% of whom were civilly committed.MethodsChildhood maltreatment and problematic sexual outcomes were assessed using the Multidimensional Assessment of Sex and Aggression, a contingency-based inventory that assesses domains related to sexual aggression. Hierarchical regressions were calculated examining the association between childhood abuse types and sexual outcomes.ResultsChildhood sexual abuse was associated with child sexual (β = .247, p < .001) and other paraphilic interests (β = .189, p < .001). Male caregiver psychological abuse also emerged as marginally associated with child sexual interest (β = .100, p = .059), even after controlling for other abuse types.ConclusionsThese results partially replicate recent findings in a juvenile sample and challenge conventional developmental theories of sexual offending, by suggesting that male caregiver psychological abuse may play a role in the etiology of child sexual interest among males who have sexually offended. This study also suggests a possible gender symmetry effect moderating the developmental consequences of abuse.     

The use of telemedicine in child sexual abuse evaluations

OBJECTIVE: To describe the advantages, disadvantages and current status of child abuse consultations conducted through telemedicine networks. METHOD: The results of a telephone survey of seven statewide telemedicine networks are reported and discussed with respect to goals, funding, technical support and expertise, infrastructure, and extent of use. Quality assurance and liability issues concerning telemedicine child abuse consultations are also reviewed. RESULTS: The goals of telemedicine networks in child abuse are to provide (1) expertise to less experienced clinicians primarily in rural areas; (2) a method for peer review and quality assurance to build consensus of opinions particularly in sexual abuse cases; and (3) support for professionals involved in an emotionally burdensome area of pediatrics. Problems encountered by existing networks include: (1) funding for equipment and reimbursement for consultation; (2) consistent technical support: (3) clinician lack of technical expertise, knowledge, or motivation; and (4) lack of network infrastructure. Legal considerations include licensure exemptions for consulting across state lines, potential for malpractice, patient confidentiality and security of images forwarded over modem lines, and liability of the equipment, consulting site, and the consultant in criminal proceedings. CONCLUSIONS: Telemedicine consultations offer a unique opportunity to raise the standard of care in child abuse evaluations, but success depends on clinician motivation, appropriate infrastructure, and ongoing funding and technical support.