Developing guidelines for HIV antibody testing among victims of pediatric sexual abuse

The incidence of human immunodeficiency virus (HIV) infection acquired by children through sexual abuse is presently unknown. A telephone survey of 63 practitioners of pediatric sexual abuse (PSA) assessment in the five U.S. regions with highest prevalence of HIV infection was conducted to determine the present status of guidelines for HIV antibody testing of PSA victims. No formal protocol was used by any of those surveyed, and a literature review found no existing guidelines for HIV antibody testing of PSA victims. A standard set of clinical situations was presented to practitioners to assess whether a consensus exists of indications for HIV antibody testing of abused children. Seven clinical profiles with 12 criteria were presented including HIV antibody status, AIDS/ARC clinical profile, and behavioral profile of the assailant; clinical profile of the victim; pre-assault victim behavioral profile compatible with high risk of HIV infection (exclusively adolescents); parent/guardian anxiety/psychosocial profile; and profile of the assaultive act with respect to potential transmissibility of HIV. We found an 85% or greater consensus for 6 testing criteria, and based upon these propose an interim set of HIV antibody testing guidelines for PSA victims. There was no consensus about five testing criteria, but their frequent citation merits further consideration. Clinical application of interim guidelines and design of prospective studies to quantitatively evaluate them are reviewed.     

Medical evaluation referral patterns for sexual abuse victims.

It has been recommended that all children suspected of being sexually abused should have medical evaluations. To better understand practices and perceptions of child sexual abuse medical evaluations, a survey was conducted of 579 professionals attending educational programs on child sexual abuse; 85.8% (N = 497) responded. Half (50%) of the respondents reported no previous training in child sexual abuse. Of the 336 nonphysician professionals, 194 (57.7%) were in positions where they make referrals of the victims, and 69% of these did not refer all of the children they saw for medical evaluations. The first referral choice for medical evaluation was most often to the victim's primary physician (57%). For those professionals who did not refer all alleged victims for medical evaluation, neither the victims' age, gender, nor accessibility to care were generally considered relevant in determining the decision to refer. However, the type of abuse and presence of physical and psychological symptoms were considered relevant in making the decision. The majority indicated that the findings of the medical exam were very useful in substantiating or refuting the allegation of abuse. Further training for both medical and nonmedical professionals is needed to increase awareness of the need for and implications of the medical evaluation if children are to receive comprehensive assessments. Physicians may play an active role in this process through education of professionals and provision of care.     

Behavioral problems in alleged sexual abuse victims.

This study was conducted to compare the parental assessments of problem behaviors, using the Achenbach Child Behavior Checklist, among alleged sexual abuse victims (n = 81) and an age, race, and gender matched group of nonabused comparison subjects (n = 90). Alleged sexual abuse victims demonstrated significantly higher mean total behavior problem, internalizing and externalizing scores than the comparison sample. Subscale profiles were all in the direction consistent with withdrawal, impairment in social interaction, and sexual problems. Item comparison indicated that sexual abuse victims were more likely to be assessed as having some problem behaviors that have been reported as being indicative of sexual abuse. A significant difference was not obtained on several behaviors that have been previously reported as indicative of sexual abuse. These findings support concerns that sexual abuse victims do exhibit more problem behaviors, but caution must be exercised when interpreting individual behaviors because of their frequency in a nonabused sample.     

Neuroticism as a risk factor for child abuse in victims of childhood sexual abuse

Findings on the relationship of experienced sexual abuse and abuse behavior in adulthood are ambiguous. However, associations between experienced abuse and neuroticism as well as between neuroticism and active child abuse have been reported repeatedly. In our study, we compared pedosexual child abusers with consumers of internet child pornography and control subjects with adult-sexual preference with regard to traumatic childhood experience (Childhood Trauma Questionnaire, CTQ), personality traits (NEO – Personality Inventory – Revised, NEO-PI-R), and sexual abnormalities (Multiphasic Sex Inventory, MSI). In an initial analysis, sexual abuse experienced in childhood was not directly linked to sexual abuse behavior in adulthood. However, this relationship was mediated by neuroticism. In a second step, the CTQ scales were conflated and, using a structural equation model, direct links between the overall level of abuse experienced in childhood (generally high CTQ levels) and sexual abuse behavior in adulthood revealed again the mediation by neurotic personality. We conclude that the overall level of abuse experienced in childhood in general, and less sexual abuse experience in particular, modulates the tendency for child sexual abuse behavior in adulthood. Data suggest that, depending on the resilience of an individual, abuse experience during childhood increases the likelihood of developing neurotic personality traits in later life, which are in turn considered to increase the risk of child sexual abuse in child sex offenders.     

Suicide attempts in sexual abuse victims and their mothers

Suicide attempts occurred in 11 of 201 (5.4%) families in which sexual abuse was substantiated during a 2$\text{1}\text{2}$-year study period. Thirteen attempts occurred in the eleven families—five in mothers and eight in daughter-victims. No perpetrators in this social agency sample attempted suicide. Three mothers made attempts within the 1st week after the sexual abuse report; these three had borderline personalities, prior suicide attempts, personal histories of incest, and, surprisingly, all returned rapidly to adequate maternal functioning. The two mothers who made attempts later had primary depressions with underlying dependent personalities and never returned to successful mothering of their victimized daughters, both of whom themselves attempted suicide later in the family's treatment course. All eight daughters who attempted suicide were 14 to 16 years old and had been involved in incest with father figures. None of their families remained intact after the disclosure of incest, and their mothers actively blamed and disbelieved these victims. Seven of the eight had behavior problems which may have masked depression.     

Characteristics of victims and perpetrators of intrafamilial sexual abuse

BackgroundIntrafamilial sexual abuse (SA) is one of the most traumatic experiences a person can experience and comes with lifelong effects. Considering the increase in the number of children in orphanages due to intrafamilial SA in Turkey, addressing this problem in more detail is crucial. For this reason, this study aims to determine the characteristics of intrafamilial SA cases.MethodIn this study, the characteristics of 216 intrafamilial SA cases who were referred to the Ankara Child Advocacy Center between 2010 and 2015 were analyzed retrospectively. The ages of the victims varied between 3 and 17.ResultsThe most common identity of the perpetrator was the biological father (50%), biological sibling (14.4%), stepfather (13.9%), and parent’s boyfriend (12%). Of the perpetrators, 6.5% were female and 93.5% were male. Of the victims, 3.3% had a history of pregnancy. In addition, one out of four victims (27.3%) had experienced physical violence from their parents, the socioeconomic level of the majority of the families (90.2%) was low, the education levels of their parents were low (high-school-level education and below), and one of two families (52.6%) experienced domestic violence. Furthermore, the perpetrators in the biological intrafamilial SA group exhibited similar behavior with the sociolegal group in terms of penetration, and the age distribution of the victims was similar.ConclusionsConsequently, this study has revealed a lot of new information about intrafamilial SA cases. These findings will hopefully be useful in identifying and preventing victims at risk for intrafamilial SA.     

Educational program on evaluation of alleged sexual abuse victims

Increased awareness of the problem of child sexual abuse has resulted in increasing numbers of children presenting to professionals for the evaluation of possible sexual victimization. A multidisciplinary project to develop professionals' knowledge and skills in the identification and evaluation of possible victims is described. The program focused on the child as a victim and emphasized developmental perspectives with regard to identification, interviewing children, the medical examination, and children in the legal system. Fifty-one medical and social work professionals from ten Indiana counties attended the program and responded to questionnaires about their experience and knowledge. Of 40 (78%) respondents, 63% had had no previous training in the medical evaluation for child sexual abuse. Child protective workers referred alleged victims primarily to the child's regular physician (37%) or emergency room (31%) for medical examination. Knowledge about child sexual abuse improved significantly at two weeks postsymposium (p = .001) and remained improved at six months postsymposium (p less than .02). These original participants have subsequently organized similar multidisciplinary programs in their local communities for medical, social, law enforcement, and legal professionals; thus, they have been "seeds" for further educational and cooperative efforts throughout the state.     

Paternal support for child sexual abuse victims: A qualitative study

BackgroundThe current state of knowledge regarding the role of non-offending fathers in supporting their sexually abused children is very scarce.ObjectiveThe objective of this study is to further our understanding of fathers’ roles following disclosure of their children’s sexual abuse (SA) by evaluating fathers’ perceptions of the impact of disclosure on their involvement and support of their children.Participants and methodThis qualitative study relies on individual semi-structured interviews conducted with 17 fathers of allegedly abused children.ResultsInductive thematic analysis first highlighted that some reported a period of disengagement from the child during which they put into question their role and attitudes, followed by a period of re-involvement. This period of difficulties experienced by some fathers in regard to their involvement towards their children was due to either their own important psychological distress, their ambivalence towards their child or even because of feelings of uneasiness experienced during physical contact with them. Despite this, findings indicate the presence of thoughts and attitudes that suggest children are a source of concern for fathers. The four forms of abuse-specific support previously observed among mothers (believing the child, seeking out professional services, protecting him/her from the offender, supporting him/her emotionally) were also observed among fathers. In accordance with the activation theory, a form of support specific to fathers, namely, encouraging the child to open up to and explore the world outside the family, thereby, fostering the child’s self-esteem development, was observed and constitutes a relevant finding.ConclusionClinical and empirical implications are discussed.     

Interviewing young sexual abuse victims with anatomically correct dolls

Two groups of children were interviewed with a structured format to elicit their responses to sexually anatomically correct dolls. Significant differences were found between the responses of children who had not been referred for suspected sexual abuse and those who had. Nonreferred children (n = 25) revealed very few behaviors indicative of abuse whereas referred children (n = 25) demonstrated significantly more sexually related behaviors when presented with the dolls. Of the age groups studied (2-6 years), 3 year olds were the most responsive to the dolls, while older children tended either to reveal their experiences or to become very nonresponsive. The authors argue for the use of structured interview techniques with use of the anatomical dolls and the collection of normative comparison data relative to the evaluation of suspected sexual abuse.     

Resilience factors in the victims of sexual abuse: state of affairs

OBJECTIVE: The aim of this literature review is to examine factors leading to the recovery of child sexual abuse survivors. METHOD: This paper provides a definition of resilience and presents the individual and environmental protective factors. A methodological examination of the studies is carried through. RESULTS: Researchers have documented that 20% to 44% of adult who were sexually abused during their childhood show no apparent signs of negative outcome. However, very few studies as been interested in resilient women and their protective mechanisms. Recent research on protective factors reveal that searching for support, disclosing the abuse and giving a meaning to the abuse are all adaptative cognitive strategies. Furthermore, the perception of benefits and having an external attributional style are both related to less psychological distress. Social support, in general and after the revelation, also appears as a determinant of resilience. However, avoidance, even if victims find it very useful, proves to be a non-adaptative strategy, which may lead to be a catalyst to victims' symptomatology. Definitional problems and the lack of longitudinal studies limit the conclusions that can be drawn. CONCLUSION: The rare studies involving resilient victims show that social support as well as certain cognitive coping strategies may lead to recovery. However the extent of their contribution remains unknown.     

Identifying teenage sexual abuse victims by questions on their daily lives

Child sexual abuse (CSA) is an international public health problem. While general practitioners are perhaps ideally positioned to detect CSA, a lack of simple tools and their discomfort in bringing up such a sensitive subject reduce the likelihood of its being brought up and flagged in primary care. However, it may be possible to identify victims of CSA by observing its consequences on student well-being, overall well-being and risk behavior. This study investigate the predictive value of daily life events possibly associated with CSA: relationship difficulties with peers and teachers, autolytic attempts, self-mutilation, low self-esteem, addiction, poor body image, physical and psychological violence, low quality of sleep. We carried out a crosssectional survey involving a representative sample of 1719 15 year-old adolescents enrolled in 192 randomly drawn schools from two French regions. In their classrooms, they filled out a version of the Health Behavior in School-Aged Children international (HBSC) self-questionnaire. Compared to their coevals, these youth were more likely to regularly consume cannabis, OR 4.40 [1.85; 10.48] and to express fear of violence, OR 2.05 [1.28; 3,28]. They were less likely to feel satisfied about their weight, OR 2.24 [1.13; 4.40] and more likely to feel unaccepted by others, OR 1.65 [1.03; 2.65]. The C-index (concordance statistic) taking into account gender, regular cannabis consumption, fear of violence, not having the right weight and not being accepted by others, was 0.79. The C-index also including self mutilation and autolytic attempts was 0.83. Indirect thematic could likewise facilitate detection and identification of CSA.     

Investigative interviews of alleged sexual abuse victims with and without anatomical dolls

Verbal and nonverbal responses by alleged victims of child sexual abuse were coded for length, amount of information, and the manner in which they were elicited by the interviewer. In 16 of the interviews, anatomical dolls were employed for the purposes of demonstration, whereas they were not used in another eight cases matched with respect to other characteristics of the children and the alleged events. Children interviewed with dolls provided an equivalent number of details and spoke as many words in the substantive portion of the interview as did children interviewed without dolls, and interviewers in the two groups used similar probes to elicit information. However, the average responses by the children were significantly longer and more detailed when dolls were not used. Children gave longer and more detailed responses to open-ended invitations when dolls were not used. Caution is necessary when interpreting these findings.     

Methodological considerations in research on the prevalence of child sexual abuse

Recent studies with nonclinical populations have yielded widely varying estimates of the prevalence of child sexual abuse. This paper focuses on four representative studies, describing how differences in methodology and sample characteristics may contribute to the variation in prevalence rates. Two aspects of data collection appear to be the most significant factors accounting for discrepant findings. First, the use of face-to-face interviews is associated with much higher prevalence rates than the use of self-administered questionnaires. Second, higher prevalence rates are reported in studies that use multiple questions to ask about specific types of abusive sexual behavior. Variation in the age range of subjects is an additional factor that may also have an effect on prevalence rates. The evidence reviewed points to several aspects of methodology and sample characteristics that do not seem to influence prevalence findings. These are the use of random sampling techniques, the area of the country in which the study is conducted, the educational level of subjects, and the ethnic composition of the sample.     

Recorded offending among child sexual abuse victims: A 30-year follow-up

In this paper we employed a prospective design to examine the effect of child sexual abuse (CSA) on life-course offending by comparing victims to both their siblings and random controls in the Netherlands. Information on victimization was gathered from court files and on offending from official criminal records. We found that victims of CSA were more at risk of offending than random controls, but so were their siblings. Only female victims were more likely to offend than their own siblings. The increased risk for offending was not specifically found for sexual offenses, instead it was found for various types of offenses. The found difference between female victims and siblings held true for abuse perpetrated by someone outside the family. We therefore conclude that family and environmental factors are the most important to explain offending among male CSA victims, while these factors alone are not enough to explain the effect of CSA on offending for females.     

Exploring the disclosure of child sexual abuse with alleged victims and their parents

OBJECTIVE: The goal of the present study was to examine how children disclosed sexual abuse by alleged perpetrators who were not family members. METHODOLOGY: Thirty alleged victims of sexual abuse and their parents were interviewed. The children were interviewed using the NICHD Investigative Interview Protocol by six experienced youth investigators. The same principles were followed when the parents were asked to describe in detail what had happened since the abusive incidents. The statements made by the children and parents were then content analyzed. Major characteristics of the children's and parents' reported behaviors were identified by two independent raters. FINDINGS: More than half (53%) of the children delayed disclosure for between 1 week and 2 years, fewer than half first disclosed to their parents, and over 40% did not disclose spontaneously but did so only after they were prompted; 50% of the children reported feeling afraid or ashamed of their parents' responses, and their parents indeed tended to blame the children or act angrily. The disclosure process varied depending on the children's ages, the severity and frequency of abuse, the parents' expected reactions, the suspects' identities, and the strategies they had used to foster secrecy. CONCLUSIONS: The children's willingness to disclose abuse to their parents promptly and spontaneously decreased when they expected negative reactions, especially when the abuse was more serious. A strong correlation between predicted and actual parental reactions suggested that the children anticipated their parents' likely reactions very well.     

Differences between accounts provided by witnesses and alleged victims of child sexual abuse

OBJECTIVES: To determine whether child witnesses of sexual abuse were more or less informative about the alleged incidents than alleged victims when interviewed similarly. METHOD: Twenty-six alleged victims of child sexual abuse (aged 5 to 14 years; M=9.8 years) and 26 children who had witnessed but not experienced similar events were interviewed by experienced youth investigators about the alleged abuse. Children in the two groups were matched with respect to their age, relationships with the alleged perpetrator, and seriousness of the alleged offenses. All children were interviewed using the NICHD investigative interview protocol. RESULTS: Witnesses and victims provided similar amounts of information about the incidents of abuse. Interviewers used more open-ended invitations and elicited more information using open-ended prompts from witnesses than from victims, whereas they used more risky (including suggestive) prompts when interviewing victims. DISCUSSION: These results confirm that young children can be informative witnesses about events that they have either experienced or witnessed.