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Child Sexual Abuse: Talking Points in the Office :

March 22, 2017

Pediatricians are experts at prevention dialogue in practice settings: from fevers, car seats and safety gates, to locking up medications, toxins and guns — and everything in between — keeping kids safe and promoting healthy development is core to our commitment to families.

Pediatricians are experts at prevention dialogue in practice settings: from fevers, car seats and safety gates, to locking up medications, toxins and guns — and everything in between — keeping kids safe and promoting healthy development is core to our commitment to families. Surveys have shown, however, that dialogues about preventing child sexual abuse often are a challenge, with the most common barriers to providing guidance being lack of time, training and uncertainty about how to approach the topic.

When do we start talking about this issue and do it confidently and with the same level of comfort as when we discuss any other milestone or illness?

My Colorado colleagues Drs. Chiesa and Goldson, a child abuse pediatrician and a neurodevelopmental pediatrician, have chosen to emphasize both the medical and developmental aspects of this topic in their succinct and up-to-date review “Child Sexual Abuse,” in March Pediatrics in Review. And their review is timely as we approach the month of April, which since 1983 has been designated as National Child Abuse Prevention Month.  Child sexual abuse is indeed one of the most emotionally challenging forms of child maltreatment — and potentially time-consuming office visits — encountered by pediatric clinicians. 

I offer a few comments about some of the review’s key points on awareness, prevention, and victim outcome, with the hope this prompts some thoughts and starts a conversation within your practice, with your patients, and in your communities.

Sexualized imagery bombards us and runs the gamut from provocative commercial ads, to healthy and less-than-healthy depictions of sex on television and in movies, to the exploitive, graphic nature of pornography. At the 2016 AAP National Conference and Exhibition (NCE), we had a dynamic plenary talk on this very topic — Media’s Impact on Youth Sexuality, by Gail Dines, PhD.

Controlling access or limiting exposure to this imagery may seem like a losing battle for parents. How many times have we heard the history in the emergency department, child advocacy center, or clinic: “Teenager here for evaluation of possible sexual assault,” and the unfortunate story starts with “meeting someone online”?  The victimization of adolescents and young adults is now not infrequently connected to the use and abuse of social media in all forms: the internet, social connection websites, image sharing apps, and innumerable microblogging, social networking and geosocial networking applications.  Guidelines for clinicians and parents on understanding social media and its impact on children are only part of the solution.  Community-based dialogue amongst parents, clinicians, local child abuse pediatrician, and victim advocates is a creative suggestion.

How do you discuss social media safety with your patients?  Have you ever gathered in community setting – maybe a school, church, day care, or child advocacy center – and talked about preventing sexual abuse or adolescent assault?

As the PIR review points out, professionals can support parents by emphasizing goals for healthy child sexual development, including privacy, open communication, empathy, and accountability.

During toilet training, embedding the concepts of hygiene with privacy, modesty, personal space and safety is the best opportunity.  

I often tell pediatric trainees to “script this” in some succinct comfortable way: “Next visit we are going to start talking about toilet training. This a time to teach about keeping clean and safe from harm. Have you thought about how to have that conversation with your child?”  

What may be overlooked is the chance to ask that parent if abuse or assault is a part of their past: “This can be a hard topic sometimes if a parent experienced molestation. Because I am here for your child and you, know that we can talk about that anytime.”  

How do you approach this practice-based guidance on personal space, privacy?  

Embedded in the event of sexual abuse or assault– in addition to the violation of societal norms, the erosion of trust in others meant to be trusted, and exploitation of power dynamic in a relationship – is the inherent fear that the victim outcome is always bleak. This, of course, is not true but it remains a concern nonetheless for the parent or patient who presents for care.  

When sexual abuse has been identified as part of a patient history, we can absolutely promote resiliency and ongoing physical, behavioral, emotional and sexual health.  As a reminder, this is an adverse childhood experience that, like interpersonal violence, may go unreported.  It is not screened for or even discussed often enough during routine health care as children grow older.  Detail a bit more beyond the diagnosis on the EHR problem list, for example: when was event(s), who was the offender(s), any early or later trauma symptoms, important contacts in any current case, and name of therapist.

Understanding the event from the patient and parent’s perspective is important, and will take time beyond any medical care or referral to counseling if needed.  Consider who is also potentially helping your patient. Ask for permission to speak with a therapist engaged with the child or teen; make a note about the investigating agency contact or victim advocate, and ask for updates on the case; schedule time to speak with an involved school counselor or teacher.

Finally, this may be an occurrence in childhood or adolescence that may be understood and integrated as a life experience, and within a sustained, supportive environment, the outcome may be securely healthy.  As adolescents make choices about sexual activity and access related health needs, addressing an adverse experience in the past may seem inappropriate. Their developmental trajectory of identity and independence still needs guidance as these life choices can trigger memory of past events, and supportive office-based dialogue about sexual health can be helpful as patients navigate this time.

In your screening for Adverse Childhood Experiences (ACEs) in your practice, how often is sexual abuse or assault reported?  What is your experience in helping adolescents with this past trauma history?

Besides the review by Drs. Chiesa and Goldson, I hope readers of PIR find this blog and subsequent comments to be helpful, practical resources.  The American Academy of Pediatrics Clinical Report “The Evaluation of Children in the Primary Care Setting When Sexual Abuse Is Suspected,” from the AAP Committee on Child Abuse and Neglect, is an excellent resource, along with the additional resources below.


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