Protecting Children From Sexual Abuse by Health Care Providers

Pediatricians and other health care providers are entrusted with the responsibility to improve the health and well-being of children. However, recent allegations of the sexual abuse of hundreds of children by a pediatrician in the United States have reminded us that some among the pediatric profession may use their position of authority and trust to take advantage of their patients.¹  The prohibition against sexual misuse of one's patients goes back in history to Hippocrates, who said: “I will come for the benefit of the sick, remaining free of all intentional injustice, of all mischief and in particular of sexual relations with both male and female persons….”²  This ban is echoed by statements of the American Medical Association, the Canadian Medical Society, and the British General Medical Council.^2,–,4  The American Academy of Pediatrics (AAP) strongly endorses this social and moral prohibition, because it constitutes common justice; it is particularly important for pediatric patients, who have greater developmental vulnerability than adults. This policy statement provides guidance for health care professionals and parents faced with concerns of possible sexual abuse or exploitation and other abuse of children by pediatricians, other physicians, other health care professionals, and related health care personnel.

Preventing child sexual abuse is the primary concern of this statement (Table 1). Child sexual abuse is usually perpetrated by people who do not meet the criteria for a specific psychiatric sexual disorder and is defined by the act itself, which is criminal. Pedophilia and hebephilia are less common psychiatric disorders of sexual attraction, on which a person may or may not act. The sexual abuse of children is, by no means, limited to adults with these psychiatric disorders. Sexual misconduct with patients is a subset of abuse of patients by health care providers and involves issues of inappropriate provider-patient boundaries and sexual behaviors.⁷  The AAP statement on professionalism also provides guidance on appropriate provider behavior.⁸  Child sexual contact can vary from a single, situational event to planned, compulsive, repetitive behavior. In the extreme, the provider's sexual orientation is to children and the provider repetitively acts on this drive, exhibiting and acting on the paraphilias, pedophilia, or hebephilia.

The medical literature on the frequency of sexual abuse of pediatric patients by providers is sparse^9,–,11  compared with what is known about abuse of adult patients. Likewise, there are few data on the incidence of pedophilia among pediatricians. What is known about sexual misconduct by physicians comes from surveys of physicians, surveys of adult patients, and studies of abusive physicians and of children reported for sexual abuse concerns. Data on sexual abuse of adult patients and the physicians who abuse them are reported to provide context to the epidemiology and offender behavior of patient sexual abuse.

Surveys of physicians and patients have revealed that sexual relations between physicians and adult patients are not rare and involve approximately 10% of all medical specialists who care for adults.¹²  Fifty-six percent of these physicians indicated that they had never received training in provider-patient sexual boundaries. Most of them believed that sexual contact with current patients is wrong, but only one-third of them opposed sexual contact with former patients.¹² 

Among the general literature about health or counseling care provider sexual misconduct with clients is a study of patients who sought psychiatric or counseling care secondary to previous provider sexual acts.¹³  Fifty-one percent of the offending providers were clergy, and 49% were health care professionals. Of the health care providers, 85% were from various counseling professions, 7.3% were physicians in medical specialties, and 3.7% were nurses. Likewise, in Ontario, Canada, in the 1980s, one-quarter of the health care providers who had been legally charged with patient sexual contact were psychiatrists. Surveys of psychiatrists revealed that 7% to 10% reported that they had had previous sexual contact with patients.¹⁴ 

Studies that examined reports of sexual misconduct by physicians have provided further epidemiologic data. A Canadian task force on sexual abuse of patients found that patients younger than 14 years accounted for 8.7% of these reports, whereas 80% of patients subjected to sexual contact were adult women.³  Male providers were responsible for 91% of the sexual contacts. Among 567 physicians disciplined by their state medical disciplinary boards between 1989 and 1996 for sexually related offenses involving patients, pediatricians accounted for 14 disciplinary events (2.9%), although they represented 7.8% of all physicians.¹⁵ 

Recent national data suggest that approximately 8% of American children experience sexual victimization in a given year,¹⁶  although significant underreporting occurs. Official reports of sexual abuse provide some information on child sexual abuse by health care providers. In an Indiana study of children in out-of-home settings, including both general medical and psychiatric facilities, 1.56% of hospitalized children experienced any form of maltreatment.¹⁷  Approximately half of these hospitalized children's maltreatment was sexual abuse, which constituted 0.85% of all hospitalized children. Rates of abuse were similar in foster homes (overall abuse rate: 1.69%); 0.52% of the children in foster homes sustained sexual abuse. In comparison, rates of abuse were higher in residential homes, such as group homes, in which the overall abuse rate reached 12.0%, and 5.8% of the group-home children were sexually abused. One-third of the maltreatment in hospitals was at the hands of staff, compared with 25% in residential homes. In foster homes, caregivers were responsible for 78% of the maltreatment.

In a study of 38 complaints of pediatric patient abuse by hospital staff, 52.9% involved sexual issues.⁹  Males were accused in 87% of these sexual complaints. Physicians represented only 14.3% of the accused, and other providers—nurses (42.9%), therapists (21.4%), and volunteers (21.4%)—were accused more often. Overall, 24% of the abuse complaints were felt to be substantiated by internal review by the hospital's child abuse program, and 18% remained indeterminate. Child protective services staff and police substantiated fewer cases than did hospital staff.

Some literature further characterized the sexual relations between physicians and adult patients and the attributes of practitioners who engage in sexual acts with patients. In an anonymous physician survey by Gartrell et al,¹²  42% of the physicians who had engaged in patient sexual contact had admitted doing so with more than 1 patient; 11 victims was the upper range. Male-physician-with-female-patient events constituted 89% of the reports, female-physician-with-male-patient events constituted 6%, male-physician-with-male-patient events constituted 4%, and female-physician-with-female-patient events constituted 1%. Many physicians reported ongoing sexual relationships with their adult patients that involved multiple encounters. Kardener et al¹⁸  compared 59 physicians from adult specialties who acknowledged engaging in patient sexual contacts with 401 providers who denied such acts. Those who had engaged in sexual acts with patients were more likely to feel that provider-initiated, nonsexual affectionate physical contact with patients was appropriate. In addition, the physicians who admitted sexual contacts were more likely to perceive that such nonerotic physical contacts benefitted the patient and their relationship, contrary to the physicians who reported no sexual contact. It is unclear how these behaviors and attitudes with adult patients translate to pediatric patients, but rationalization and denial of effects on the patient seem to be a common thread.

Physicians who have sexual contact with patients come from all specialties of medicine. Most reported and recognized is inappropriate sexual contact between physicians and adult patients, which can vary from a single, opportunistic event to a pervasive, calculated pattern. When a single patient is involved, the physician may consider the events to represent consensual attraction while ignoring the inherent power differential in the relationship. Also ignored is the potential damage that may result. With multiple victims, the contacts are more likely predatory.

Child sexual offenders can have a “fixed” attraction to children or have a predominant sexual attraction to adults rather than to children but exhibit “regressed” sexual behavior by also sexually abusing children. Approximately half of the perpetrators of child sexual abuse have fixed (predominant) child attractions.¹⁹  Those with fixed child sexual attractions are more likely to abuse strangers or casual acquaintances rather than family members. Fixed offenders select male victims more often (42%) than do regressed offenders (16%). Both types of offenders predominately use threats or intimidation (49%) or seduction or enticement (30%) to engage their victims. Twenty percent of offenses are violent or brutal. Both types of offenders tend to be consistent in the age and gender of victims they prefer and the type of abuse they perpetrate (eg, fondling versus penetration). Abuse by fixed offenders seems more often to be planned and to involve more victims, whereas that of regressed offenders is often impulsive.

Males are most often involved in sexual contact with patients. However, homosexual adults are no more likely to sexually abuse children than are heterosexual adults.²⁰  Jenny et al²¹  also observed that among sexually abused children, the frequency of homosexual abusers was no different than their population prevalence.

Pedophilic molesters often choose vocations or activities that provide them access to children.²²  They carefully select victims, who are often vulnerable, and groom them for prolonged periods while assessing their response to gradually more intrusive sexual activities and their ability to remain silent. They also groom the child's parents and the community to trust them, or even depend on them, for isolated child supervision.

Childhood adversities, in particular, child sexual abuse, childhood family dysfunction, and childhood emotional abuse, likely play a significant role in the development of adult pedophilia.²³  However, most child sexual abuse victims do not become sex offenders. In a study of 224 sexually abused boys, 12% later committed sexual offenses.²⁴  Associated child neglect, lack of supervision, abuse by females, and intrafamilial violence were risk factors for their becoming offenders. Sexual abusers, in general, begin early in their lives. Forty percent of all sexual assaults against prepubertal children are perpetrated by older juveniles.²⁵  Some of these events provide the precedents for the development of adult pedophilia, which usually follows juvenile sexual offenses against younger children.

Several aspects of pediatric practice represent unique vulnerabilities for pediatric patients, including frequent, potentially private, contact with children. Pediatricians have a special responsibility to address these vulnerabilities and provide well-considered and well-implemented protections for the children in their care. However, any other field that provides frequent, potentially private, contact with children also has the same potential to attract adults with a sexual orientation to children.²⁵  The prevalence of pedophilia in the general population and among pediatricians is unknown.^25,26 

In summary, the available literature suggests that a minority of physicians, including pediatricians in particular, engage in sexual relationships with patients. Most of these encounters are heterosexual and occur between adult providers and their adult patients. However, some children are victimized by health care providers including pediatricians. There are no circumstances in which any sexual relationship between a physician and pediatric patient is appropriate. Concern about the sexual abuse of children by a physician requires careful investigation. The following guidance is offered to parents and pediatricians who have concerns of sexual abuse by a pediatric health care provider.

Physicians are responsible for assessing the physical health and development of children, including genital health and pubertal development. Many diseases involve anogenital structures, and genital diseases and anomalies can have important consequences for children. During the course of pediatric physical examinations, it is often appropriate and necessary to examine a child's anogenital region. Other body regions also are sexually sensitive, such as the female chest; the perception of what is a sensitive area will vary among individual children. In addition to the physical examination, the provider's history-taking and verbal interaction can involve sensitive topics.²⁷ 

Bright Futures, which describes preventive care that is to be covered under the Affordable Care Act of 2010 (HR 2590 §2713), is a common source for guidance on age-appropriate examinations during well-child care.²⁸  It provides recommendations for genital examinations from the newborn to preadolescent to adolescent periods. The newborn examination should assess for anogenital anomalies and testicular descent. The first year of life is an important time to observe for diaper-area skin problems, dislocated hips, femoral pulses, hernias, and normal testicular descent. It is also appropriate to ensure normal male and female anatomy during infant examinations. Subsequently, it is reasonable to assess for genital normalcy, including lack of inflammation, rash, or premature maturation, during each annual examination. Beginning at approximately the 7- to 8-year visits, Bright Futures recommends evaluation for signs of normal maturation and development to assist in health surveillance and anticipatory guidance. From then, into adolescence, the male examination will involve inspection for hernias, hydroceles, varicoceles, and inflammatory conditions. The female examination will include inspection for maturation, hymenal normalcy and patency, hernias, and dermatologic and inflammatory conditions. Routine intravaginal examinations and Papanicolaou tests are currently not recommended until the age of 21 years.²⁹ 

In addition to regular well-child examinations, anogenital examinations are appropriate in relation to specific illness complaints. The rule in deciding whether to perform an anogenital examination during acute care should be the pertinence of the examination to the specific complaint. For example, a health care provider would be remiss not to perform a rectal examination in a child with encopresis, but such a procedure would be inappropriate for a simple sore-throat complaint. It is important for pediatricians to not avoid sensitive but indicated examinations for fear of abuse accusations. Certain conditions, such as vaginal and anal anomalies, may require repeated examinations, treatment, or dilations. Whether to wear gloves for genital examinations is dictated by local standards of care. Examinations of infants often will not involve the use of gloves, whereas gloving should become routine by the time the child is a preschooler. Gloving will also be determined by the specific complaint.

Patients should be provided privacy during disrobing and appropriate draping during examinations. Again, the age of the patient and the individual child's and family's temperament will dictate the level of draping and gowning required. The child's comfort should be paramount.

The AAP recently revised its policy on the use of chaperones for pediatric examinations.³⁰  In general, examinations of younger children should be chaperoned by the child's parent or caregiver. As children become older, their caregivers and the children themselves should participate in the decision of whether to use a chaperone. A full explanation of the examination and the reason(s) for it is always warranted. Likewise, offers of chaperones are recommended, but the decision of whether to use one should be a joint decision of the patient, family, and provider. In general, it is wise for male providers to have a chaperone during female genital examinations. However, even same-gender examinations can be misunderstood and can benefit from chaperoning. The patient's wishes and comfort should determine the gender of the chaperone. Providers should check to determine whether their state or hospital has specific chaperoning mandates and, if so, should abide by them. Providers also should be alert to riskier situations for which they should direct the decision toward chaperone use.²⁷  Examples include the intoxicated adolescent, the child with developmental or behavioral difficulties, or the child who has been a sexual abuse victim. In these cases, normal examination practices may be misinterpreted as assaultive. False allegations of provider sexual abuse of patients do occur.³¹  Being attuned to patient and parent cues and appropriately using nonfamily chaperones are the provider's best protections. Documenting the offer and use of chaperones in the medical record is good practice and provides additional practitioner protection.

As in other situations of child sexual abuse, grooming behavior by a physician may occur to gain a child's confidence and acquiescence to subsequent abuse.^22,32  Grooming behavior includes perpetrator actions that increase the child's trust and dependence on the perpetrator while gradually obtaining the child's accommodation to sexual contacts. The intrusiveness of sexual activities may escalate slowly. Grooming may include the use of unusually “child-friendly” settings and unusual social contact beyond or outside the normal clinical interaction. Favors or gifts beyond minimal value may be given to the child. Pedophiles, similar to other sex abusers, may select emotionally vulnerable and needy victims.^22,32 

Practitioners who sexually abuse patients may have unique indications or frequencies for genital examinations. The examination techniques themselves may be idiosyncratic, such as involving inappropriately prolonged or intimate contact, contact intended to sexually stimulate the patient, examinations that lack normal gowning and draping for modesty, unnecessarily invasive examinations, or inappropriately ungloved contact. The examination or clinical interaction may be accompanied by inappropriate sexually suggestive, or sexually complimentary, comments. Parents or chaperones may be excluded from situations in which they would normally be present. For example, caregivers of preadolescent children may be excluded from examinations by the provider. The provider may tell the child not to tell the parents or caregivers about the encounter. Photographs of the child may be taken beyond those normally required for clinical documentation. Providers may share inappropriate details about their own personal, social, or sexual background. During the visit, offers of extracurricular contact and activities may be tendered. Unsolicited phone, e-mail, or text contacts, unrelated to clinical care needs, may be among the initial attempts to establish extracurricular interactions.

All medical and health care staff involved in the care of children should be screened for past allegations of abusive behavior with children during the recruitment-and-hiring process, which should include careful checking of past employment situations and criminal and child abuse registry background checks. However, such procedures cannot be relied on to provide protection. Staley et al³³  reported that less than 1% of people who molest children have a criminal record.

Pediatric training programs should include education on appropriate professional boundaries, professional interactions during sexually sensitive or explicit discussions or examinations, and when and how to use examination chaperones. As part of the trainee's expected skills acquisition in the categories of “intrapersonal skills and communication” and “professionalism,” programs should assess the success of this training. Assessment for inappropriate behavior will be most successful if it includes a review, which queries peers, parents, and nursing staff as well as physician mentors. Concerns about sexual misconduct or contact between a trainee and a patient should be reported to the appropriate state investigative and licensing authorities and may warrant discharge from the training program.

Institutions should have policies and training in place to educate staff about appropriate provider-patient boundaries⁷  (Appendix A). Staff should be explicitly informed that sexual contact with patients and their caregivers is strictly forbidden. Policies about chaperoning of sensitive examinations should be implemented. Such examinations should only be conducted in formal examination or clinical settings.²⁷  Staff should be trained, particularly in settings in which child behavioral issues are likely, to recognize and defuse eroticized and/or disruptive child behavior. Policies and procedures should be in place for staff to report concerns of sexual impropriety (Appendix B). Staff should be educated about these policies and procedures and their responsibility to report concerns expeditiously. However, DesRoches et al³⁴  recently reported that physicians who are aware of impaired or incompetent colleagues only report two-thirds of these cases to the appropriate authorities. Staff should be taught that such underreporting will not be condoned. Institutions should have policies and procedures for investigating, managing, and reporting these complaints.³⁵ 

Solo practitioners may present greater potential for both real and false accusations of sexual abuse. Their office staff may be less able to provide chaperoning. Likewise, the power imbalance between the provider and his or her staff is more focused, staff exposure to different practice styles is more limited, and staff may be dissuaded from or lack an avenue for reporting concerns. As such, extra efforts to include safeguards are appropriate. Included might be patient handouts that describe examination policies about genital examinations and rigorous chaperone usage.

Examples of hospital policies on staff-patient boundaries (Appendix A); chaperones for outpatient care (Appendix C); and reporting, evaluation, and management procedures for staff allegations (Appendix B) are available at the end of this statement. These appendixes represent the policies developed by Seattle Children's; they are used by permission of Seattle Children's. They do not represent AAP policy. Although they are specific to a single large pediatric-only hospital, the intention is to provide guidance to others for policy development. The Centers for Disease Control and Prevention also provides advice about screening and monitoring staff, safe environments, and complaint evaluation and management for programs that involve youth.³⁵ 

Parents and medical staff should bring any suspicions of inappropriate sexual contacts or troubling events to the attention of the office manager or pediatric practice's medical director in cases that arise in pediatric offices. With institutional or hospital cases, concerns should be brought to the attention of the managing nurses and physicians of the involved service, the hospital's child protection program, the hospital administration, or the hospital's patient or parent advocate. Provisions for confidential reporting should be available. Because concerns may arise from misinterpreted but medically appropriate actions, it is preferable that designated hospital evaluators conduct an initial evaluation before reporting to mandated state investigative agencies. However, when there are conflicts of interest between the accused and the manager, lack of an appropriate manager, or fear of retribution, it may be necessary to report directly to mandated state investigative agencies.

When managers receive reports of possible abuse, the concerns need to be evaluated expeditiously, and appropriate steps should be taken to protect other patients from abuse during the investigation (see Appendix A for sample procedures). Likewise, steps should be taken to maintain the confidentiality and reputation of accused practitioners during the time at which complaints are investigated. Institutions should offer accused providers confidential, outside supportive services. The risk of provider psychological morbidity and self-harm can be significant.

In cases with more definite concerns for abuse that rise to the equivalent of a “reasonable cause to believe” that abuse has occurred, institutional staff are legally required to report, and parents can report to their state's protective services and/or the police. A contact listing for state agencies designated to receive and investigate reports of suspected child abuse and neglect is available from the US Department of Health and Human Services Child Welfare Information Gateway (www.childwelfare.gov/pubs/reslist/rl_dsp.cfm?rs_id=5&rate_chno=11–11172). For more information about the status of current individual state laws and related resources, contact the AAP Division of State Government Affairs (800-433-9016, ext 7799, or [email protected]). Once it is determined that abuse concerns rise to this level, it is possible that concerns will become public and end the accused staff member's confidentiality. More substantive complaints also warrant reporting to the appropriate state professional licensing board. When within-hospital complaints are considered substantiated, they constitute a hospital “critical incident,” which generally requires reporting to the state's hospital licensing commission and conducting a critical incident review directed at how policies and procedures could be improved to prevent such incidents. It is the responsibility of institutions to warn the public of such provider behavior through these formal channels, not simply to pass the provider and issue on to some other setting. Likewise, if concerns have become public but have been evaluated and found baseless, institutions, with the consent of the accused, should make public the exonerating findings.

The physical and psychological health consequences sustained by children and adults who have been victims of sexual abuse are significant, and children victimized by physicians will require assessment, followed by medical care and counseling, as indicated. Although not all children exposed to sexual abuse go on to experience sequelae, there is increased risk of a broad range of problems including emotional, behavioral, cognitive, social, and general health impairments. Included are both internalizing and externalizing psychiatric disorders.³⁶  Past sexual abuse is associated with a greater frequency of depression, anxiety, substance abuse, conduct/antisocial personality disorder, and suicidal ideation and attempts.³⁷  Other childhood associations have included poor self-esteem; posttraumatic stress disorder (PTSD); regressive, withdrawn, or neurotic behaviors; sexually inappropriate behaviors; eating disorders; delinquency; and general behavioral disorders.^38,39  Similar psychological problems remain more common in adults who were victims of childhood sexual abuse.^39,40  In a meta-analysis, childhood sexual abuse was correlated with adult anxiety disorders, depression, eating disorders, PTSD, sleep disorders, and suicide attempts.⁴¹  Past victims of sexual abuse are at increased risk of further sexual victimization in childhood and adult life.⁴²  The absolute risk for victims of preadolescent sexual assault for some of these consequences of abuse include a 23% risk of PTSD and a 25% to 33% risk of subsequent major depression in young adulthood.³⁶  Physical and sexual abuse victims experience a doubling of their suicide risk.⁴²  A New Zealand study attributed 13% of the country's adult mental health burden to sexual abuse.³⁷  Specific data about the psychiatric morbidity of child sexual abuse in the medical setting are lacking. However, because such sequelae of sexual abuse generally are more common when the sexual abuse has been more frequent and more physically intrusive, is accompanied by other forms of abuse, or occurs in the setting of other family dysfunction,^36,39  isolated assaults by medical providers might result in less future morbidity. Adults who have been exposed to childhood abuse or have witnessed intimate partner violence use more health and mental health services and have poorer health status, more depression, and more interpersonal violence victimization than controls.⁴³  Although child abuse victimization is associated with the development of criminality and violent criminality, sexual abuse alone or associated with other forms of abuse is not associated with increased violent criminality.⁴⁴ 

The effects of medical provider sexual contacts or abuse have been most studied in the context of adult psychiatric patients. Patients abused by male providers tend to have increased distrust of and anger directed toward men and to therapists in general and an increase in the number and severity of their mental health and psychosomatic symptoms.⁴⁵  In a study of adults who were seeking clinical mental health care after provider sexual contact, posttraumatic stress disorder, major depression, suicidality, misuse of prescription drugs and alcohol, disturbed interpersonal relationships, and employment disruption were all reported.¹³  Eighteen percent of these patients were revictimized in subsequent counseling interactions.

Despite these reports of responses to sexual abuse in general and adult responses to sexual abuse by medical and counseling providers, there is no literature on the specific reactions of pediatric patients to medical provider sexual abuse.

Institutions should anticipate that sexual abuse victims and their parents will require assessment and likely will need follow-up counseling. They should assist in referring and financially supporting such efforts.

It is the responsibility of pediatricians to protect and foster the health of their patients. As such, sexual encounters with patients are destructive and are strictly forbidden. Pediatricians have a responsibility to recognize and report sexually inappropriate acts by their colleagues and other medical staff. When they have “reasonable cause to suspect or believe” (individual states' reporting thresholds vary; providers should check their specific state's law) that abuse has occurred, they are legally required to report to appropriately mandated governmental investigative agencies and licensing boards. The sexual abuse of a child by a pediatrician is a devastating violation of ethical and legal behavior that can severely impair the child's future physical and mental health. When children are abused by those who are entrusted with their medical care, the profession has the responsibility to take the necessary actions to protect future patients from harm by those providers. These actions include helping families affected by abuse by ensuring proper emotional support. Pediatricians should also work with government agencies and licensing bodies to ensure that in the future children are protected from pediatricians and other health care providers who sexually abuse patients.

To protect and foster the health and to earn and maintain the trust of their patients:

1. It is the responsibility of pediatricians to protect and foster the health of their patients. As such, sexual encounters with patients are destructive and are strictly forbidden.

2. Pediatricians and health care providers should know that most sexual offenses of children occur at the hands of adults who have a primary sexual orientation to other adults. However, adults who have a primary sexual attraction to children constitute more risk for planned and multiple-victim child offenses. Sexual offenses are perpetrated by both heterosexual and homosexual offenders. Any sexual abuse of children by medical providers is a profound betrayal of their responsibility for patient well-being, trust, and medical ethics.

3. Medical trainees should be educated about appropriate provider-patient boundaries and appropriate use of chaperones for examinations.

4. Employees of medical facilities for children should be screened for previous abuse of a child by them both through formal state registries and through contact with previous employers.

5. Pediatricians should be educated about the indications and techniques of the genital examination, should perform routine genital examinations during annual checkups, and should know the indications for performing genital examinations to evaluate other specific medical concerns.

6. Pediatricians must explain to parents and verbal children why they are performing each element of the examination and respect their need for modesty by providing appropriate draping and allowing privacy while changing. They should offer chaperones and provide them whenever requested or required as part of standard practice and local regulations or when the provider feels that a chaperone is needed.

7. Employees of medical facilities for children should be trained about staff-patient boundaries, chaperone use, and their responsibility to immediately report concerns of patient abuse by other staff members. Institutions should have policies and procedures in place to conduct these trainings.

8. Parents should be informed that they have a right to request chaperoned examinations. They should be aware that if they have concerns about sexually inappropriate examinations or provider actions, they should report to the clinic's or medical facility's administration. If their concerns are sufficient, they themselves have a right to report to their state's protective service for investigation.

9. All health care providers and health care institutions are legally mandated reporters for suspicions of child abuse. If health care providers or institutions have reasonable cause to suspect that another health care provider has sexually abused a child, they are legally mandated to report to protective services and/or the police.

   • Institutions should have policies and procedures in place to receive and evaluate concerns for patient abuse.

   • Accused employees should have complaints about them managed confidentially, sensitively, and expeditiously. They should be provided with independent, confidential support and counseling services during the investigation.

   • Individuals and institutions are responsible for following legal guidelines about reporting concerns for child abuse to the appropriate institutional, local, and state authorities.

   • Individuals and institutions should cooperate with appropriate protective, legal, and licensing agencies in their investigation of concerns for sexual abuse by medical providers.

   • Institutions remain responsible for the future protection of patients from abuse. They should not pass problem providers along without appropriate notifications.

10. Institutions should assist victims of sexual abuse by staff to receive appropriate assessment and consideration of the need for counseling.

Cindy W. Christian, MD

Kenneth W. Feldman, MD

Cindy W. Christian, MD, Chairperson

James E. Crawford-Jakubiak, MD

Emalee G. Flaherty, MD

Rich Kaplan, MD

James L. Lukefahr, MD

Robert D. Sege, MD, PhD

Kenneth W. Feldman, MD

Harriet MacMillan, MD

American Academy of Child and Adolescent Psychiatry

Janet Saul, PhD

Centers for Disease Control and Prevention

Tammy Piazza Hurley