Research Paper

Gender-Related Sexual Abuse Experiences Reported by Children Who Were Examined in an Emergency Department

Mona Hassan a,⁎, Cheryl Killion b, Linda Lewin c, Vicken Totten d, Faye Gary e

a College of Nursing, Texas Woman's University, Houston, TX b Francis Bolton School of Nursing, Case Western Reserve University, Cleveland, OH c College of Nursing, Wayne State University, Detroit, MI d Department of Emergency Medicine, Assistant Professor, Case University School of Medicine, Cleveland OH e The Medical Mutual of Ohio, Kent W. Clapp Chair and Professorship in Nursing, Francis Bolton School of Nursing, Case Western Reserve University, Cleveland, OH

a b s t r a c t

The purpose of this study was to examine the experiences of sexual abuse by 95 children of two gender groups to determine differences in their reported sexual exploits by perpetrators. Significant differences between female and male children were reported. Male child-victims experienced more anal penetration by penis (54.5%, 10.7% respectively) and finger (27.3%, 2.7% respectively), however; female child-victims experienced more mouth contact to their genitalia (22.7%, 10.0% respectively) and body kisses (47.9%, 9.1% respectively). A more gender-specific approach could help to facilitate prevention, and produce better outcomes.

© 2015 Elsevier Inc. All rights reserved.

Experiencing child sexual abuse at an early age can initiate lifelong problems. In this research, the focus was on child sexual abuse experiences as reported by two gender groups, male and female. Traumatic events could create a long period of psychological distress, which may negatively influence interpersonal relationships and coping skills of the children who have been sexually abused. The effects of this trauma can endure for years (Brodhagen & Wise, 2008; Krysinska, Lester, & Martin, 2009). The relation- ship between gender and outcome may depend on characteristics of the children and the consequences being measured. First, victims who were more closely related to the perpetrators and were abused for a longer duration suffered more severe physical and mental damage (Gilbert et al., 2009). However, findings concerning the relationships between gen- der of the victim and frequency of child sexual abuse have been mixed (Kouyoumdjian, Perry, & Hansen, 2009). Kinner (2007) argued that boys commonly are physically stronger and tend to protect themselves more than girls, whereas young female victims commonly are less able to physically resist sexual encounters than are male victims (Deering & Mellor, 2011). Male perpetrators are more able to use their physical strength to control and limit the child-victim's resistance to sexual encounters (Miner et al., 2010). On the other hand, Ranney et al. (2011) hypothesized that boys might be more reluctant to report sexual abuse. Boys may have fears related to their identities as males or worry about being labeled as homosexuals or sexual deviants. Therefore, male sexually abused child-victims may be less likely to disclose the abuse.

Due to increased public awareness, reporting and seeking medical care for child sexual abuse may be occurring with more frequency and promptness, which could bring attention to the magnitude of this prob- lem (Hilarski, Wodarski, & Feit, 2008). The signs and symptoms of child sexual abuse depend on several factors, such as the child's gender, age, developmental epochs, and whether the perpetrator used force during the sexual activity (Bode-Jänisch, Meyer, Schroeder, Günther, & Debertin, 2011; Kouyoumdjian et al., 2009). Aggravated physical and psychological symptoms may serve as warning signs for parents and health professionals for additional screenings and assessment; specifi- cally, behavioral problems and acting out should be considered as addi- tional warning signs (Fromuth & Holt, 2008; Kuehnle & Connell, 2009; Murphy, Potter, Stapleton, Wiesen-Martin, & Pierce-Weeks, 2010). Although child and youth sexual abuse have received broad attention, many studies reflect a fragmented approach that fails to show the inter- relationship between the different gender groups with regard to the in- tensity, frequency, and health outcomes of child sexual abuse (Balboni, 2011). Analyses of the emergency department reports of alleged child sexual abuse could help unravel the complexities of the phenomenon (Creswell & Zhang, 2009).

CONCEPTUAL FRAMEWORK

The conceptual framework for this study was centered on Bronfenbrenner's ecological systems theory (1979), in which there are five levels of a system that interact to create an environment that im- pacts the lives of children, families, and communities: ontogenic (indi- vidual) development, microsystem (family, friends, school, church), mesosystem (combined effects of microsystem and exosystem), exosystem (community), and macrosystem (cultural) influences (see

Archives of Psychiatric Nursing 29 (2015) 148–154

⁎ Corresponding Author: Mona Hassan, RN, MSN, PhD in Nursing, 696 Pineloch Dr. #2311, Webster, TX 77598.

E-mail addresses: mah106@case.edu (M. Hassan), cmk61@case.edu (C. Killion), ew2538@wayne.edu (L. Lewin), Vicken.totten@case.edu (V. Totten), fxg21@case.edu (F. Gary).

http://dx.doi.org/10.1016/j.apnu.2015.01.006 0883-9417/© 2015 Elsevier Inc. All rights reserved.

Contents lists available at ScienceDirect

Archives of Psychiatric Nursing

journal homepage: www.elsevier.com/locate/apnu

Fig. 1). The ecological systems theory has been used by researchers to provide insight into the interplay of a child with family, community, and culture. Over time, it has enhanced understanding of the dynamics of child sexual abuse (Sinanan, 2011; Ulrich, 2008).

In this study, we examined gender-related sexual abuse experiences that occurred in the microsystem and mesosystems. Within the microsystem, the perpetrator is more likely to be a part of a child's world; according to Finkelhor, Hammer, & Sedlak (2009), perpetrators are often friends, neighbors, or family members who have access to chil- dren. Family dynamics plays a role in how individuals conceptualize physical and sexual abuse (Lutz-Zois, Phelp, & Reichle, 2011) because family support and cohesion may influence the child's ability to resist victimization and abuse (Miller-Perrin & Perrin, 2007). The mesosystem is evident through the interactions that occur between and among the child, the perpetrator(s), and parent(s)/caregiver(s) (Bronfenbrenner, 1979). Through the mesosystem, the perpetrator has opportunities to gain access to the male/female child (noted above, most of child- victims have been sexually abused by either a family member or a family acquaintance). Child-victims may have different experiences based on their gender. This fact might help to explain why some child-victims did not provide detailed information to the sexual assault nurse examiner (SANE; Brown & Campbell, 2010). Furthermore, an inti- mate relationship with the perpetrators might cause further disrup- tion in the family if additional “secrets” are disclosed (Floyed, Hirsh, Greenbaum, & Simon, 2011; Hwa et al., 2010; see Fig. 2).

Research Questions

After extensive review of the literature, we formulated the two ques- tions that are the foundation of this research:

Question 1. What were the demographic characteristics of the children, aged 6–14, who were treated for alleged sexual abuse in the emergency department of an urban Midwestern research and teaching hospital? Question 2. Was the child's gender associated with specific sexual abuse behaviors?

METHODS

Purpose

The purpose of this study was to examine the experiences of sexual abuse by children of two gender groups to determine differences in their reported sexual exploits by perpetrators. This descriptive, retrospec- tive study examined the recorded assault and abuse histories of a conve- nience sample of the hospital records of 95 children (6–14 years old) who were treated for alleged sexual abuse in the emergency department of an urban Midwestern research and teaching hospital. The inclusion criteria included data of children between 6 and 14 years of age whose clinical re- cords had comprehensive information about the medical evidence and other data collected during the interview in the emergency department. This age was chosen because it is the developmental epoch with the highest incidence of child sexual abuse (US Department of Health and Human Services, 2007). Children under age 6 were excluded because they are more likely to be pre-verbal or may not have had the language facility to express their reactions, and because the historical and clinical information that they could provide might have been limited (Hershkowitz, Lanes, & Lamb, 2007). Children over 14 years old were ex- cluded because they are more likely to be voluntarily sexually active with peers (Dixon-Mueller, 2008).

Sexual behaviors among middle-adolescents (10–14 years old) may occur as these children go through puberty (Miller-Perrin & Perrin, 2007). Menarche and spermarche are occurring ever-earlier, as early as at 9 years (Biro, Huang, Daniels, & Lucky, 2008; Semiz, Kurt, Kurt, Zencir, & Sevinç, 2008; Terry, Ferris, Tehranifar, Wei, & Flom, 2009). This research focused on two subgroups: boys (6–14 years old) and girls (6–14 years old). The groups were divided based on developmental milestones (signs) determined by gender.

The data were analyzed to explore the patterns of child sexual abuse among children who reported it at an urban Midwestern research and teaching hospital emergency department between 2006 and 2010. The alleged victims had been transported to the emergency department by parents or other family members. The child and parent(s)/ caregiver(s) were individually interviewed in a private and confidential place in the emergency department. The emergency department used a multidisciplinary model of care where sexual-abuse-related health

Fig. 1. Bronfenbrenner's ecological model used for study of child sexual abuse. Adapted from “The Ecology of Human Development: Experiments by Nature and Design,” by U. Bronfenbrenner, 1979. Copyright 1979 by the President and Fellows of Harvard College.

Fig. 2. Sub ecological model illustrating the focus of this study. Adopted from “The Ecology of Human Development: Experiments by Nature and Design,” by U. Bronfenbrenner, 1979. Copyright 1979 by the President and Fellows of Harvard College.

149M. Hassan et al. / Archives of Psychiatric Nursing 29 (2015) 148–154

assessments were conducted by nurses, physicians, and social workers who were expertly trained in evaluating children for suspected physical and sexual abuse. These assessments consisted of a private interview with the child, an interview with the caregiver, a complete medical history, and a physical exam. Furthermore, the assessment for sexually transmitted diseases and the appropriate collection of forensic evidence as indicated by clinical findings and histories were conducted.

During the child and parent(s)/caregiver(s) data collection activities, the first step was the interview/history-taking process, which was typically conducted by a SANE who had special training in interviewing children who come to the emergency department with complaints of having been sexually abused. The child and parent(s)/caregiver(s) may have been involved in several additional interviews depending on the child-victim's medical and psychological condition. All interviews were done during the initial encounter in the emergency depart- ment, which generally lasted from 30 to 60 minutes, followed by the physical assessment, which was completed by the SANE. Finally, the child-victim was interviewed and examined by the SANE. This process could last up to 3 hours. During this process, additional forensic data were collected for clinical and legal purposes. The child-victims had been seen only once when the interviews and physical examinations took place.

Maintaining patient privacy by keeping data safe and confidential demonstrates respect. All SANE records were separately maintained from other hospital records and were stored in a locked SANE office, in a separately locked file cabinet, whose key was kept only by the SANE. Data safety was maintained via a back-up database. The master link between coded data and identifiable data has been protected by a complex alpha-numeric password. Only the researcher has access to the data stored in the computer, as recommended by Burns and Grove (2010). At no time were the children's health records removed from the SANE office. During data collection, the researcher remained in the SANE office; variables were entered into a pre-designed data collection instrument developed by the researcher in the SANE office. The data collection form can be found in Appendix A.

The researcher collected data from the health records of the allegedly sexually abused children after acquiring approval from the Institutional Review Board (IRB) and with the approval of the Committee for the Protection of Human Subjects at Case Western Reserve University. The researcher asked for data on children who fulfilled the study criteria and analyzed their data using descriptive statistics to identify frequencies and chi-square tests for categorical data to examine the predictors of the perpetrator's sexual activities (Murphy et al., 2010).

Research Measure

A data collection form which is used all over the country for the as- sessment of child sexual abuse, the Sexual Assault History Form, was used in this study. It is the clinical data collection form that includes in- formation about the assault history as reported by the child-victim and/ or parent/caregiver. The data collection included a standard package of information that covers several domains about the child-victim and the perpetrator. The SANE, who is board certified, conducted all of the inter- views, and collected the clinical and forensic data for each of the child- victims. This hospital health record was used by all emergency depart- ment staff to record the historical and clinical events that were reported by the child or observed by the clinicians during the assessment of the child. It chronicled information about the perpetrator (e.g., age, gender, and relationship to the child), assault data (e.g., time of assault, time of examination at the emergency department, and documentation of child-victim resistance to the perpetrator (e.g. whether the child resisted and assailant's injury/bleeding). Additional data contained in the form were not analyzed in this study (see Appendix B). The re- searchers collected and coded all data in this study. This approach helped to ensure accuracy and consistency of data coding and entry.

Participants

A convenience sample of 95 hospital health records of sexually abused children was used for this study. The mean age of the sample was 11.4 (SD = 2.8) with a range of 6 to 14 years. Of these 95 chil- dren, most were female (86.3%, n = 82) and African American (87.4%, n = 83) (see Table 1).

Data Analyses

Descriptive statistics concerning children's and perpetrators' demo- graphics and characteristics of the assault, including frequency, were assessed for the full sample (n = 95). All questions were answered by this population during the assessment procedure. A chi-square test was utilized to test the homogeneity of the nominal variables between the two gender groups of children. The t-test was also used to compare continuous data. The sample was divided into younger male/female children 6–9 years of age (n = 27, 28.4%, respectively) and older male/female children 10–14 years of age (n = 68, 71.8%, respectively) to analyze the genital injuries for both genders. Guided by the codebook, data coding included three parts: (a) the child's general demographic data, (b) the perpetrator's demographic data, and (c) information on the child's sexual assault history (see Appendix A). The researcher used the Statistical Package for the Social Sciences (SPSS version 18) to compute all data analyses. Statistical analyses began with preparatory activities such as treatment of missing data, identification of outliers, and cleaning tasks (Field, 2009).

RESULTS

Perpetrator's Characteristics

The majority of the perpetrators were male (96.8%). Of the fifty- three of the records that reported the age of the perpetrators, the mean age was 23.8 years (SD = 8.46) and the actual age ranged from 16 to 47 years. Chi-square analyses indicated no significant correlation between the age groups of the children and the perpetrators.

Relationship to Perpetrator

The relationship of the child-victim and the perpetrator(s) was found to be statistically significant; only 20% of the perpetrators were strangers or unknown to the children. The children had been abused at a higher rate by a relative (mother's boyfriend, mother's ex- boyfriend, biological father, stepfather, uncle, brother, stepbrother, cousin, mother's cousin's son) or an acquaintance (grandmother's boy- friend, friend, sister's ex-boyfriend, roommate, classmate, brother's friend, boyfriend, ex-boyfriend, cousin's boyfriend) than were abused by a perpetrator who was a stranger.

Type of Sexual Abuse

Using chi-square analyses, the results indicated that the two gender groups were different with respect to sexual abuse activities. All of the “no,” “unknown,” and “not applicable” responses were combined for

Table 1 Gender and Race/Ethnicity of Child Sexual Abuse Victims Reporting to Emergency Department.

Variable n %

Gender (n = 95) Male 13 13.7 Female 82 86.3

Race/ethnicity (n = 95) Caucasian 12 12.6 African-American 83 87.4

150 M. Hassan et al. / Archives of Psychiatric Nursing 29 (2015) 148–154

the sexual abuse activities questions, and Fisher's exact test was used to analyze the differences between the gender groups. To address question 2, whether the child's gender was associated with specific sexual abuse behaviors, chi-square and Fisher's exact tests were used to analyze data homogeneity of the nominal variables between the genders based on their demographic characteristics and the location on the body of the sexual contact to determine the relationships. As indicated in Table 3, except for oral sex (oral contact by the child-victim's mouth to the perpetrator's genitalia and oral contact of the perpetrator's mouth to the child-victim's genitalia) and lubrication, the relationships between gender and sexual abuse activities were statistically significant at the level of .05 and less (p b .05). In other words, the male and female chil- dren were not homogenous with respect to sexual abuse activities. Male child-victims suffered more anal penetration than females by either the perpetrator's penis (54.5 and 10.7%, respectively; χ2 = 13.55) and/or the perpetrator's finger (27.3 and 2.7%, respectively; χ2 = 10.28). Fe- male child-victims experienced more body kisses, licking, or bites (47.9 and 9.1%, respectively; χ2 = 5.89), more perpetrator ejaculation (25.7 and 0.0%, respectively; χ2 = 3.64) than males, and more perpetra- tor condom usage than males (19.5 and 0.0%, respectively; χ2 = 8.91; see Table 2).

Activities Since the Time of Sexual Abuse

Using chi-square and Fisher's exact tests, the results indicated that activities the child performed after the occurrence of sexual abuse did not vary significantly by gender. Although more males than females brushed teeth or used mouthwash (45.5 and 32.4%, respectively; χ2 = 0.72) and more females than males had “consenting” sexual inter- course within 72 hours of sexual abuse with someone other than the of- fender (15.1 and 0.0%, respectively; χ2 = 1.91), these differences were not significant (see Table 3).

Body Tears

Using chi-square analyses, the results indicated that the two genders were not different when comparing mucosal tears related to the sexual abuse (p N .05). Female child-victims had more injuries in some of the body parts such as facial injuries (6.4%, 0% respectively; χ2 = 0.88), anal injuries (2.5%, 0% respectively; χ2 = 0.33), and injuries to the posterior body (e.g., back of the shoulders, back of the thighs, and back of the legs) (12.8, 7.7% respectively; χ2 = 0.28). Male child- victims had more injuries on their anal area (e.g., chest, abdomen, and anterior parts of the thighs) than females (15.4 and 15.1%, respectively; χ2 = 0.06) (see Table 4).

DISCUSSION

In this study, the majority of the reported cases were African American child-victims. There is some evidence that African American female children are more vulnerable to sexual abuse than are their Cau- casian counterparts (Mersky, Berger, Reynolds, & Gromoske, 2009). Based on US Census Bureau statistics for 2005–2009 (2011), the number of African American children between 5 and 14 years in the Midwestern city where the data were collected, was more than double the number of Caucasian children of the same age (United States Census Bureau, 2011); as a result, the sample is skewed the general population in this study toward African American child victims. Most of the children re- ported child sexual abuse to the hospital where data collected were fe- male populations. Most of child-victims had no physical evidence of sexual abuse. The majority were sexually abused by a family acquain- tance or a family member. Extra-familial is distinguished from intra- familial sexual abuse insofar as it is more often a single episode that oc- curs outside the home environment. Intra-familial abuse is more likely to occur more than once and within the confines of the home. It was hy- pothesized that limited clinical and familial history were disclosed

Table 2 Type of Abuse by Gender of Child Sexual Abuse Victims Reporting to Emergency Department.

Sexual abuse behavior Gender No/unknown (%) Yes (%) χ2 p

Anal penetration by penis Male 45.5 (n = 5)

54.5 (n = 6)

13.55 .002⁎

Female 89.3 (n = 67)

10.7 (n = 8)

Anal penetration by finger Male 72.7 (n = 8)

27.3 (n = 3)

10.28 .015⁎⁎

Female 97.3 (n = 71)

2.7 (n = 2)

Child's mouth contacted perpetrator's genitalia Male 90.0 (n = 9)

10.0 (n = 1)

0.79 .340

Female 77.9 (n = 60)

22.1 (n = 17)

Perpetrator's mouth contacted child's genitalia Male 90.0 (n = 9)

10.0 (n = 1)

0.85 .325

Female 77.3 (n = 58)

22.7 (n = 17)

Condom used Male 100 (n = 12)

0.0 (n = 0)

8.91 .012⁎

Female 80.5 (n = 62)

19.5 (n = 15)

Body areas kissed, licked, bitten Male 90.9 (n = 10)

9.1 (n = 1)

5.89 .014⁎⁎

Female 52.1 (n = 38)

47.9 (n = 35)

Ejaculation Male 100 (n = 11)

0.0 (n = 0)

3.64 .050

Female 74.3 (n = 55)

25.7 (n = 19)

Lubrication Male 90.9 (n = 10)

9.1 (n = 1)

1.42 .217

Female 74.6 (n = 53)

25.4 (n = 18)

⁎ p b .05. ⁎⁎ p b .01.

151M. Hassan et al. / Archives of Psychiatric Nursing 29 (2015) 148–154

because of repeated sexual exploits by family and/or family friends (Brown & Campbell, 2010).

Not all of the child-victims exhibited physical evidences of sexual abuse. Child-victims' physical trauma may be hard-to-find (Modelli, Galvão, & Pratesi, 2012). In some instances, young child-victims may have erased physical evidence through self-cleaning activities, eating, drinking, or engaging in sex-related behaviors after an assault and before the physical assessment at the emergency department (Gavril, Kellogg, & Nair, 2012).

It is important to note that the findings of this study suggested that not all child-victims reported penetrative sexual activities; therefore, not all child-victims had physical genital contact. Also, most of the per- petrators were family members or known to the child-victims; this sug- gested that the perpetrators might have been less aggressive, and the assault could have resulted in limited evidence of trauma (Murphy et al., 2010). In addition, it could be hypothesized that delays in reporting the abuse allowed for healing to begun to occur. Limited reported genital injuries of both male and female child-victims were substantiated by previous reports in the scientific literature (Alexander, 2011; Berkowitz, 2011). Superficial genital injuries tend to heal very fast, and leave limited residual physical evidence (Pillai, 2008). In their research study, Modelli et al. (2012) could find physical evidence in only 10% of the suspected sexually abused children less than 12 years old (n = 1762). Children might have been fondled or their genitals might have been touched by the perpetrator. Whereas

these activities may not produce physical evidence, they do result in psychological and emotional trauma which is more difficult to assess (Carlstedt et al., 2009).

Assault-related sexual penetrative activities were found less fre- quently in both male and female child-victims, a finding that is consis- tent with other research (Al-Mahroos & Al-Amer, 2011; Cromer & Goldsmith, 2010). In this study, female child-victims reported more physical trauma than did males. Even though the number of children who reported anal penetration was small (n = 19), this study demon- strated that more male child-victims experienced anal penetration than did female child-victims. This finding is supported by Bahali, Akçan, Tahiroglu, & Avci (2010), Campbell, Patterson, Dworkin, & Diegel, (2010), and Hwa et al. (2010). The findings related to violence against females could be explained in several ways. First, the sample comprised primarily female child-victims. Female child-victims ex- perienced more genital touching, and aggressive sexual behaviors, and more bleeding from the genital area. On the other hand, male child-victims experienced more oral and anal sex, and anal tears (Al-Mahroos & Al-Amer, 2011). In their study, Rhodes et al. (2011) reported that males younger than 16 years experienced sexual acts that were more aggressive in nature than did their female counterparts. By contrast, in their 36-month survey of 3338 adolescents (14–18 years old) at an emergency department, Ranney et al. (2011) reported that the severity of the physical injuries from child sexual abuse is the same in both genders.

Table 3 Activities Following Abuse by Gender of Child Sexual Abuse Victims in Emergency Department.

Activity Gender No/do not know (%) Yes (%) χ2 p

Brushed teeth or used mouthwash Male 54.5% (n = 6)

45.5% (n = 5)

0.72 .299

Female 67.6% (n = 50)

32.4% (n = 24)

Engaged in voluntary sexual activity Male 100.0% (n = 11)

0.0% (n = 0)

1.91 .192

Female 84.9% (n = 62)

15.1% (n = 11)

Masturbated Male 100.0% (n = 12)

0.0% (n = 0)

.64 .558

Female 94.9% (n = 74)

5.1% (n = 4)

Had food Male 16.7% (n = 2)

83.3% (n = 10)

1.91 .192

Female 21.3% (n = 16)

78.7% (n = 59)

Bathed Male 75.0% (n = 9)

25.0% (n = 3)

.24 .453

Female 68.0% (n = 51)

32.0% (n = 24)

Table 4 Gender Differences in Injuries From Sexual Abuse.

Location of injury Gender No/do not know/not applicable Yes χ2 p

Face Male 100% (n = 13)

0% (n = 0)

.88 .454

Female 93.6% (n = 73)

6.4% (n = 5)

Anus Male 100% (n = 13)

0.0% (n = 0)

.33 .739

Female 97.5% (n = 78)

2.5% (n = 2)

Anterior view of the body Male 84.6% (n = 11)

15.4% (n = 2)

.06 .739

Female 84.9% (n = 1)

15.1% (n = 1)

Posterior view of the body Male 92.3% (n = 12)

7.7% (n = 1)

.28 .510

Female 87.2% (n = 68)

12.8% (n = 10)

152 M. Hassan et al. / Archives of Psychiatric Nursing 29 (2015) 148–154

Body kisses, ejaculations, and condom use were significantly different between male and female child-victims. For females, protection against sexually transmitted diseases and prevention of conception may be some of the reasons why male perpetrators used condoms when having sex with them (Speizer, Goodwin, Whittle, Clyde, & Rogers, 2008). Some male perpetrators who are physically and psychologically attracted to children have greater needs to satisfy their sexual urges by having sexual encounters with younger female children, who are considered more sexually attractive than older females; these perpetrators are usually classified as pedophiles (McGee, O'Higgins, Garavan, & Conroy, 2011). Perpetrators may kiss the child-victim to initiate the sexual arousal (Gannon & O'Connor, 2011). Approaching the victim by showing special interest in him/her, using language and other seductive behaviors to prepare the young child for the unfamiliar experience are all common practices among pedophiles. Touching and kissing are thought to decrease fear and the perception of physical harm among the child- victims (Tuch, 2008).

A normal physical examination and the absence of physical evidence do not rule out sexual abuse (Fortin & Jenny, 2012), nor is physical evidence crucial as proof of sexual assault (Girardet et al., 2011; Kotik, Zaitsev, Shperber, & Hiss, 2011). In fact, the child's disclosure is consid- ered one of the most critical elements for the documentation of child sexual abuse. The child-victims' perceptions of the sexual abuse activi- ties are influenced by their cognitive abilities and limited experiences, and may not be supported by the physical evidence. Therefore, putting together all available pieces of data helps the health care professional to understand the child-victim's experience of the child sexual abuse, which may not be provable in any other way (Finkel, 2011).

LIMITATIONS

Significant associations were drawn from this study of child sexual abuse, however, not all clinical records contained all variables, and missing data decreased the power of statistical testing. Chart retrospec- tive review hindered further collection of missing data. The number of reported penetrative sexual activities and the corresponding physical evidence were limited for both gender groups. This could be remedied by research studies with larger sample sizes and greater age ranges. Furthermore, studies that use sampling techniques, such as simple random selection, would help to make these studies more robust (Nada & Suliman el, 2010).

RECOMMENDATIONS

Given the immediate cost of child sexual abuse, including physical and psychological trauma, the findings from this study indicate the need for the intensification of efforts that address the prevention, early detection, and prompt intervention for these children. For both gender groups, the long-term effects of child sexual abuse are numerous; just a few of these consequences are depression, anxiety, somatic con- cerns, sexual health disorders, and feelings of shame and guilt. Since males may have experienced anal penetration, health care providers should be particularly sensitive to the possibility of physical injuries that could occur in the anal areas. On the other hand, girls are more likely to have physical injuries and may have anterior bodily or vaginal injuries. Family members and health care providers should be attuned to the methods by which young children might express their distress, such as crying, clinging, anxiety, and fears that are associated with touch and closeness. Sexually abused children might develop eating problems, have nightmares, or withdraw from interpersonal interactions with family members and friends. For both gender groups, increased efforts should be made to provide safe places for them to live, play, and learn. These spaces ought to be physically attractive and provide physical and psychological security for all children and youth (Fortin & Jenny, 2012; Hart, Lee, & Wernham, 2011; Troiano, 2011).

Our study suggested that perpetrators frequently are known to their victims and have unsupervised access to them. It is essential that family, friends, and health care providers be more diligent about keeping chil- dren safe and out of harm's way. Involving the general public through increased awareness about child sexual abuse could help to decrease the incidence of this devastating experience. Finally, the researchers recommend that further studies be done to determine the emotional, psychological, and physical impact that child sexual abuse has on children over a longer period of time, and the specific therapeutic approaches that could provide the best treatment outcomes (Hart & Glaser, 2011; Hart et al., 2011).

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