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Child Sexual Abuse: Are Health Care Providers Looking the Other Way?
Abstract and Introduction
This article provides an abbreviated literature review on the role of health care providers in recognizing and reporting child sexual abuse (CSA). Barriers to reporting CSA, data on health care providers' reporting habits, and screening criteria for CSA are also included. Recommendations to enhance recognition of CSA and increase reporting of suspected cases are presented.
Child sexual abuse (CSA) is defined as any sexual activity with a child when consent is not or cannot be given; it includes sexual penetration, sexual touching, exposure, and voyeurism (Berliner, 2000; Finkelhor, 1979). Child sexual abuse is a crime and all states have laws related to CSA that specify the age at which an individual can consent to sexual contact, usually between 14 and 18 years (Myers, 1998). In addition, every state mandates that professionals, including physicians and nurses, report suspected child abuse to child protection agencies. The mandate does not require the ability to prove the suspicion, only that reporting must occur any time there is suspicion of CSA. However, multiple studies have demonstrated that professionals do not always report suspected child abuse (Delaronde, King, Bendel, & Reece, 2000; Horner & McCleery, 2000; Ladson, Johnson & Doty, 1987; Lentsch & Johnson, 2000).
Barriers to reporting CSA include inadequate knowledge and training related to CSA, lack of confidence in the evidence collected, fear of harming the child and/or family, lack of confidence in the ability of the social service agency to deal with the investigation, concerns about interacting with the legal system, loyalty to the family, and the belief that an accusation might lead to undesirable consequences (Delaronde et al., 1999; Leder, Emans, Hafler & Rappaport, 1999; Vulliamy & Sullivan, 2000; Willis & Horner, 1987). In addition, Willis and Horner (1987) in their survey of 101 Family Medicine physician faculty and residents found that many physicians did not believe CSA actually occurred at the rates indicated by the literature.
In 2002, 56% of reports of alleged child abuse and neglect were made by professionals. The remaining 44% were made by parents, relatives, friends, alleged victims, alleged perpetrators, and anonymous callers. The largest percentage (16.1%) of professional reports were made by educational personnel, followed by legal and law enforcement personnel (15.7%), and social services personnel (12.6%). Medical personnel reports accounted for only 7.8% of professional reports (United States Department of Health and Human Services [US DHHS], 2004).
Physicians, nurses, and other health care professionals have an important role to play in identifying and treating CSA (American Academy of Pediatrics [AAP], 1999). They can afford the child a safe and private environment in which to disclose and they have the skills to assess, document, and treat or refer for treatment of CSA (Diaz & Manigat, 1999). Clearly, health care providers must expand their role in identifying and reporting CSA. The American Academy of Pediatrics (1999) and the American Professional Society on Abuse of Children (1998) both recommend that providers observe for signs and symptoms of child sexual abuse during routine encounters. They agree screening for abuse (physical or sexual) should be incorporated in every well-child visit.