What to ask when sexual abuse is suspected - BMJ

1 Arch Dis Child: first published as on 1 November 1987. Downloaded from on December 25, 2022 by guest. Protected by Archives of Disease in Childhood, 1987, 62, 1188-1195. What to ask when sexual abuse is suspected J M LEVENTHAL,* A BENTOVIM,t A ELTON,t M TRANTER,t AND L READt *Department of Pediatrics and the Child Study Center, Yale University School of Medicine, New Haven, Connecticut, United States of America, and tDepartment of Psychological Medicine, Hospital for Sick Children, Great Ormond Street, London Over the past few years there has been a consider- that the parents might be offended and angry?

2 If able increase in the recognition and reporting of the direct questions are asked and the child denies that sexual abuse of children. 1 2 Although the child often anything has happened, has the diagnosis of sexual reveals the abuse to an adult such as a parent or abuse been excluded? How much questioning is teacher, physicians who provide medical care to necessary before being reasonably certain that children (including paediatricians and general prac- nothing has happened (given that it may be imposs- titioners) are often the first professionals to suspect ible to exclude completely such a diagnosis)9.

3 That abuse has occurred. Much has been written There are at least three different circumstances about the possible presentations of sexually abused when there is no direct allegation but when the children from vaginal discharge to symptoms less doctor may consider the diagnosis of sexual abuse obviously related to sexual abuse such as abdominal and have to ask questions of the parent and child. pain, encopresis, or running away from 4 These are: There are an increasing number of reports of the (i) when a child has a complaint that might be variety of physical findingsS8 and on the appropri- directly related to the possibility of sexual abuse , copyright.

4 Ate laboratory 9 10 Despite this in- such as a girl with a vaginal discharge;. crease in attention to the problem, however, little (ii) when a child has a complaint that is not has been written about how the physician should directly related to the possibility of sexual abuse , raise the possible diagnosis of sexual abuse with such as abdominal pain or encopresis;. either the parent or child. (iii) when a child has no complaint but an incidental finding, such as an enlarged hymenal Raising the possibility of sexual abuse ring, makes the doctor suspicious.

5 In a doctor's surgery concern about sexual abuse can A COMPLAINT RELATED TO THE POSSIBILITY OF sexual . be raised in two different ways. Firstly, the parent abuse . (usually the mother) or occasionally an older child The first is perhaps the easiest occasion on which to or adolescent raises the issue with the doctor. The raise the question of sexual abuse . Direct questions parent is seeking help to discover what has happened may be part of the history taking before examining and to protect the child. For example, a mother may the child: 'Do you have any idea how your daughter mention that she is worried about sexual abuse got this vaginal discharge?

6 ' 'Could anyone have because last week her 7 year old daughter said that touched her in the vaginal area where she is having her uncle 'had been rude with her.' The mother does this problem?' When a preadolescent child is being not think that her daughter is making this up, but examined with the mother in the room, it might be cannot be sure. By raising the issue she is giving appropriate to ask the mother's permission to talk to implicit permission for the doctor to talk to the child the child: 'I'd like to ask your daughter some about the event and carry out an appropriate questions about the same topic, as well.

7 ' During the medical examination. examination of the child's vulva, the doctor might By contrast, the issue can be raised if the doctor, ask, 'What do you call this part of your body? What during the evaluation of the child, becomes comes from there?' If the child has difficulty suspicious about the possibility of sexual abuse . In answering, the mother may be asked what the family such circumstances he will be faced with several calls that part of the body. The doctor may then ask questions. Could the child have been sexually about touching: 'Has anyone touched you there?

8 ' If abused, or could there be some other explanation the child denies that anyone has touched her, the for his findings? What is the best way to raise the doctor may ask about who helps her in the bath: issue with the parent(s) and child, keeping in mind 'Who washes you there? Do you wash yourself there 1188. Arch Dis Child: first published as on 1 November 1987. Downloaded from on December 25, 2022 by guest. Protected by What to ask when sexual abuse is suspected 1189. now or does someone help you?' 'Does anyone ever abused. If, however, either the responses or the put ointments or medications there?

9 ' 'Does anyone medical examination raise concern, then arrange- else ever touch you there?' Watching the way that ments should be made for a case conference to be the mother or child responds may be as helpful as convened and for the child to be interviewed more the actual responses to the questions. For example, extensively by a clinician with special expertise in the doctor may be less concerned about the possibil- the diagnosis and treatment of sexual abuse . If the ity of sexual abuse if the child seems relaxed for the parent asks why you are concerned about sexual setting and answers questions appropriately (this abuse , it is easy to explain that because of all the may include embarrassment or amusement, or both, recent publicity about the problem, it is medically at the questions about names of parts of the body or indicated to ask such questions.)

10 Amazement at questions about who touches her private parts). In contrast, more worrying kinds of A COMPLAINT NOT DIRECTLY RELATED TO THE. responses might include obvious changes in mood POSSIBILITY OF sexual abuse . after specific questions (such as looking sad, fright- Under these circumstances the doctor may be asked ened, or 'frozen'); more difficulties than expected to evaluate a child with a psychosomatic complaint for age in answering certain questions; or a string of such as abdominal pain, anorexia, or a psychiatric 'No' responses that seem to shut out the interviewer symptom such as attempted suicide.