HJAR Nov/Dec 2024

HEALTHCARE JOURNAL OF ARKANSAS I  NOV / DEC 2024 9 Sexual abuse to children is difficult to talk about but critical to address. With 1 in 4 girls and 1 in 20 boys experiencing sexual abuse in childhood, it is a huge problem. 1 Unfortunately, many children do not dis- close their abuse until months or years after it occurs, contributing to missed opportuni- ties for prevention and treatment. There is a multitude of reasons that child sexual abuse frequently occurs in secrecy, but improv- ing knowledge and developing the skills to talk about this difficult subject are crucial first steps. As is the case with most things, child sex- ual abuse is nothing like how it is portrayed in television or movies. Child sexual abuse rarely leaves physical injuries and rarely leaves any physical evidence, making it par- ticularly difficult to recognize. Sexual abuse to children and adolescents is not often a “violent assault”but occurs with sexual con- tact that is unwanted, not understood, and harmful to children, yet unlikely to cause any lasting genital injuries. When present, genital and rectal penetrative injuries heal without scars, do not leave permanent dam- age, and an exam rarely proves contact. It is, in fact, “normal to be normal”from a physi- cal standpoint after sexual abuse occurs. 2,3 While it is helpful for children and teenag- ers affected by sexual abuse to know that their body remains healthy and unchanged, this is a barrier in recognition. It is easier for people to “believe what they see”; and when an offender might be a family mem- ber, a friend, a teacher, or a trusted individ- ual no one would ever suspect, the lack of physical evidence can be falsely perceived as evidence that nothing happened. The offender “profile” in sexual abuse to children and adolescents is another barrier to recognition that cannot be ignored. When a child is harmed, we often want to look for a monster, but offenders don’t always appear monstrous. Sexual abuse to children exists across all socioeconomic and cultural groups, and the vast majority of sexual abuse to children occurs by a family mem- ber or other trusted individual. 1 Offend- ers may even be regarded by the victim as someone they care for even after the abuse has occurred. The complicated relationships between an offender, family members, com- munity members, and the child inevitably contribute to seeds of doubt, and children are least likely to disclose when they think no one will believe them. However, given the lack of physical signs and symptoms, a child’s disclosure is the most common and most important way we identify child sex- ual abuse. It is exceptionally rare for children and adolescents to fabricate a story about sex- ual abuse, and it is surprisingly common for children to withhold a disclosure or even recant a true disclosure if they are not believed and supported. 4,5 To recognize and respond to the crisis of child sexual abuse, we must foster an environment and culture that encourages children to talk with trusted adults about confusing or unwanted expe- riences that are happening to them. Chil- dren should know how to talk about their own bodies, should know that adults do not make children keep secrets and that if an adult is making them uncomfortable, sad, or scared, they should always tell some- one. Children should also have multiple trusted adults they can talk to. While it is tempting to shelter children and restrict their access to others for their own pro- tection, isolation can foster secrecy. When it is impossible to recognize an abuser by their behavior and appearance, it is protec- tive for children to have an extended sup- port network with family members, teach- ers, healthcare providers, and other trusted adults who will believe them and help them when something bad is happening. When a child tells us that they are uncomfortable or scared, we should respond with belief and encouragement and avoid minimizing their reports. A child who isn’t supported when they disclose what we might consider a “minor” issue is less likely to disclose the bigger ones. For instance, if a child follows our advice and reports that they didn’t like it when their great-aunt gave them a hug, we must stop ourselves from dismissing their discomfort. When we meet their report with a “thank you for telling me that” instead of “just be polite” they may be more likely to keep talking to us about all of the things, big or small, that make them uncomfortable. While disclosures of sexual abuse are most commonly how sexual abuse is iden- tified, there are additional concerning signs and symptoms that healthcare providers should know. Children and adolescents who are being sexually abused may respond in a variety of ways; and although there is no singular behavior that is diagnostic of sex- ual abuse, if children are suddenly demon- strating any significant behavior changes from their norm, this is an opportunity to ask about what has changed. Additional spe- cific behaviors that should always warrant consideration of sexual abuse are abnor- mal or “problematic” sexual behaviors in children. There are many normal sexual behaviors in all ages, such as young children wanting to see people naked and touching their own bodies. However, behaviors that mimic sexual acts, sexual behaviors that cause injury, and those from which a child cannot be distracted and redirected warrant further investigation. 6 Additional signs of sexual abuse that may be recognized in the healthcare setting include unexplained genital or rectal injuries as well as sexually transmitted infections or pregnancy in the absence of consensual sexual activity. To accurately recognize and diagnose injuries and infections, providers must also be familiar with the variations of normal anogenital examinations. It is com- mon for providers to defer an anogenital exam because of patient discomfort, and it is an exam that should be approached with sensitivity. However, there is benefit in nor- malizing the anogenital exam as one that is not “traumatic” or “taboo” and is part of a child’s routine healthcare. Approaching the anogenital exam in this manner serves not only to provide experience and practice for providers to accurately differentiate normal and abnormal exams but also allows us to destigmatize conversations and questions about sexual development. With young children, it can be valuable for caregivers