Adolescent girls investigated for sexual abuse: history,physical findings and legal outcome

Objective: The aim of the study was to summarize the history of assault and record the results of medicolegal examination in adolescent girls under investigation for alleged sexual abuse, and to monitor the outcome of the legal process. The investigation period was 1990–94. Method: A consecutive series of 94 0-para girls, aged 9–22, median age 15.0 years, were examined in the head-to-toe manner including anogenital examination. Girls were referred from investigating police and social authorities. Only non-acute examinations were performed. Findings considered consistent with abusive vaginal penetration were hymenal distortion including deep clefts, hymenal and vestibular scarring, and introital diameter permitting vaginal inspection with a 17 mm speculum in the absence of consensual intercourse. Perianal scarring was recorded. STD sampling was made on indication. Findings were documented on body sketches. Medicolegal conclusions were grouped into three categories according to history and physical findings. Information on the outcome of legal procedures was collected from referring authorities. Results: For 82% (77/94) of the girls, referring agencies provided examining physicians with a detailed and consistent history of abuse, presented results comprise these 77 girls. Intrafamiliar abuse was alleged by 81% (62/77), onset prior to menarche by 53% (41/77), and repeated abuse by 74% (57/77) of the girls. Abusive genital penetration was reported by 77% (59/77) and anal penetration by 19% (14/77). Sequelae after admitted self-inflicted injury were found in 15% (12/77). Deep hymenal celfts and/or vestibular scars were found in 59% (35/59) of the girls reporting penetrative abuse, compared with 6% (1/16) when non-penetrative abuse was alleged, P<0.001. Girls with experience of voluntary intercourse could all be examined with a 25 mm speculum. Of the 17 girls without experience of consensual intercourse but alleging abusive penetration, 47% (17/36) could easily be examined with a 17 mm speculum, compared to none of 13 reporting non-penetrative abuse, P<0.001. Non-specific anal abnormalities occurred in 10 (13%) girls; more often when anal abuse was reported, P<0.001. No specific STDs were found. The medicolegal conclusion supported a history of abusive genital penetration in 41 (69%) cases; findings were non-specific in 11 cases and a normal anogenital status was found in 25 cases. The alleged abuse of 34 of the 77 (44%) girls was tried in court. One suspect was acquitted, 32 men were convicted of the abuse of 33 girls. Eleven perpetrators admitted abuse, and their histories were in concordance with the abuse alleged by the victims, as well as with the physical findings. Conclusion: A medicolegal diagnosis of alleged non-acute cases of sexual abuse relies on a detailed history. Adolescent girls alleging abuse may exhibit signs of admittedly self-inflicted extragenital injury. Our findings confirm that non-penetrative sexual acts leave no lasting genital signs, but that repeated abusive genital penetration significantly more often than non-penetrative abuse leaves deep posterior hymenal clefts and/or vestibular scarring, and a hymenal opening allowing examination with 17–25 mm specula also in girls without experience of voluntary intercourse. In cases with a confessing perpetrator, no discordance was found between the history of the victim, medicolegal conclusion and the history of the perpetrator.     

Medical/health histories and physical evaluation of physically and sexually abused child psychiatric patients: A controlled study

This study examines findings from a pediatric health history and child physical examination conducted for 105 outpatient and 105 inpatient children who were classified on the basis of their history of physical and sexual abuse. Based on multivariate and univariate analyses, physically abused children had more early developmental delays, neurologic soft signs, serious physical injuries, skin markings and scars, and stimulant drug use than their non-physically abused peers. Sexually abused children were reported to exhibit higher levels of sexual activity and stimulant drug use, and had more physical signs of genital manipulation than non-sexually abused children. These data highlight the need to further examine the impact of medical and developmental aberrations, the nature and origins of recurrent physical injuries in this population, and the extent of risk-taking in understanding the differences between physical and sexual child maltreatment.     

Medical examination of sexually abused children: medico-legal value

The Department of Forensic Medicine (forensic pathology and clinical forensic medicine), Aarhus, Jutland, Denmark, performs examinations of children suspected to have been sexually abused when reported to and requested by the police in Jutland, Denmark. Jutland covers an area of 210,000 km2 with about 300,000 inhabitants in Aarhus. A colposcope initially equipped with an Olympus camera, but now with a video camera attached has been used since 1994. Since 1994 the department has performed more than 100 examinations of children suspected of having been sexually abused. A preliminary study was taken to evaluate all cases from 1995 including the legal outcome. RESULTS: The material included 34 cases with three boys, mean age 11 years, and 31 girls, mean age 8 years, at the time of the examination. The sexual abuse events were fondling including penetration of the vagina, vaginal (14), anal (7), and oral (5) intercourse as well as cunnilingus and nontouching abuses. The medical examination was most often performed more than a week after the abuse. The examination revealed normal findings in 23 cases, nonspecific findings including erytherma in 13 cases, and in only one child was a traumatic lesion with rupture of the hymen seen. The perpetrators were above 25 years of ane and were family members or someone known to the child. Nine perpetrators were convicted at court, of whom three admitted having abused the child. CONCLUSION: A medical examination in cases of sexual child abuse seldom provides a legal proof of sexual abuse. The most important is the story told by the child. Therefore, the examination is a supplement which may support or remain neutral to the story told by the child.     

Medical Findings and Legal Outcomes in Sexually Abused Children*

Abstract: A previous study published in 2000 on a small group of children concluded that the medical examination in cases of sexual child abuse seldom provided legal proof of sexual abuse [J Forensic Sci 45(2000):115–7]. The present consecutive study included children referred to the police for a forensic medical examination. A colposcope was used to evaluate the anogenital findings which were classified as normal, nonspecific, and abnormal. Four hundred and eighty‐two children were included. Abnormal anogenital findings were found in 38% of the girls and 20% of the boys, but there was no relation between abnormal anogenital findings and the two legal outcomes: “appearing in court” and “being convicted.” However, the age of the child turned out to be a more important factor in relation to legal outcome than the physical findings. The results of this study suggest that the child’s statement and not the physical findings were important for legal outcome.     

Clinical forensic examination findings and legal outcome in cases of suspected sexual child abuse

The clinical forensic examinations conducted at the Institute of Legal Medicine of the Hanover Medical School between 1999 and 2008 in cases of suspected sexual abuse of children were evaluated retrospectively and analysed with regard to their legal outcome. In total, the study included 223 children (172 girls, 51 boys) with a median age of 8.6 years. In 34 children (15.2%), forensically relevant diagnostic findings due to anogenital injury and/or detection of semen were recorded. Perpetrators were convicted more often when they were not a member of the victim's family. In cases with victims aged seven years or older, conviction was more common. The study shows that medical findings can best be preserved by an immediate clinical forensic examination. Suspected sexual child abuse can often not be proved by medical examination results, but in some cases diagnostic findings are not mandatory for conviction.     

An exploration of childhood victimization and family-of-origin characteristics of sexual offenders against children

A comparison of the childhood victimization experiences and family-of-origin characteristics of 33 sexual offenders against children, 66 violent offenders, and 25 nonviolent offenders participating in assessment or treatment at a forensic division of a Canadian psychiatric hospital was undertaken using a semistructured interview designed specifically for this study. Overall, 31.5% of the sample reported contact sexual abuse (i.e., oral, vaginal, or anal) by age 14. Sexual offenders against children reported significantly more sexual abuse than both violent and nonviolent offenders and were more likely to have been sexually propositioned and exposed to. Sexual offenders against children were also more likely to report physical discipline as the primary type of discipline in the home. Analyses of the variables concerning characteristics of parents, siblings, and significant others also indicated significant differences between groups. Implications of these findings on the intergenerational hypothesis are discussed as well as their relevance for treatment.     

Clinical forensic examination findings and legal outcome in cases of suspected physical child abuse

Clinical forensic examinations performed at the Institute of Legal Medicine of the Hanover Medical School between 1999 and 2008 in cases of suspected physical abuse of children were analyzed retrospectively with special emphasis on the legal consequences. Altogether, 192 children (85 girls, 107 boys) with a median age of 4.4 years were examined. In 47 cases (24.5 %), the clinical forensic examination findings were interpreted as accidental injuries, birth traumas or unspecific findings. 29 victims (20.0 %) had suffered a shaken baby syndrome. Only part of the presented cases ended with conviction, which was more likely if the victims were aged between 7 and 11 years. Prison terms of 2 years and more were imposed only if the child suffered potentially or acute life-threatening injuries or if additional anogenital lesions were diagnosed indicating sexual child abuse.     

Distinct age-related differences among victims in cases of suspected child abuse

Evidence describing age-related differences among children with suspected physical and sexual child abuse is lacking. We describe findings in severe cases of suspected abuse. Cases with 756 children <15 years old were included during 2001–2013 at the Department of Forensic Medicine, Aarhus University, using forensic evaluation documents, medical records, and court proceedings. Eight percent of children <4 years old died from child abuse, 36% through violence resulting in death, and 64% by manslaughter, whereas 1% > 4 years old died, solely by manslaughter. External injuries were mainly located to head and torso in children <4 years old, changing to the upper and lower extremities in older children. Child sexual abuse was suspected in 52% of cases with living children <4 years old, 83% of children 4–7 years of age, 88% of children 8–11 years of age, and 93% of children >12 years old. Anogenital findings were mainly caused by other medical conditions in children <4 years old, hymenal clefts in the superior half of the hymenal rim were almost exclusively found in children between 8 and 11 years of age, whereas both superficial and complete hymenal clefts in the inferior half of the hymenal rim were found in children >12 years old. The present study describes age-related differences in victims of suspected child abuse. Fatal versus nonfatal child physical abuse and the significance of hymenal findings in child sexual abuse could be studied further.     

The aftermath of child sexual abuse of African American and white American women: The victim's experience

Several aspects of the victim's personal experience in the aftermath of child sexual abuse are described. Subject recruitment involved a multi-stage stratified probability sample of 126 African American and 122 White women, ages 18 to 36 years in Los Angeles County, matched on education, marital status, and the presence of children. Few ethnic differences were related to the initial response and short-term effects of the victim's experiences. Lasting effects of sexual abuse included sexual problems for women of both ethnic groups, but avoidance of men resembling the perpetrator was identified among African American women. Ethnicity may be a contributing factor to other adjustment related problems that African American women encounter in addition to their child sexual victimization. The implications of these findings and issues in the assessment of the aftermath are discussed.     

The associations between abuse characteristics in child sexual abuse: a meta-analysis

Child sexual abuse (CSA) is a general term describing a wide range of events that vary in characteristics such as the victim’s age of onset, relationship to the perpetrator, abuse quantity, degree of contact, and use of force. To investigate correlations and provide information on the clustering of these characteristics, the present meta-analysis included data from 14,494 sexually abused individuals from 62 empirical peer-reviewed studies and doctoral theses. The results showed that victims of intrafamilial abuse were younger than victims of extrafamilial abuse. More force was used in abuse including higher degrees of physical contact. Intrafamilial abuse and early onset of abuse showed no statistically significant associations with either use of force or closer physical contact. Abuse was more frequent and/or committed over a longer time period when it (a) featured more contact or force, (b) involved a relative as a perpetrator, or (c) commenced when the child was younger. The associations were weak to moderate in strength.     

Characteristic Features of Severe Child Physical Abuse—A Multi-informant Approach

Minor child physical abuse has decreased in Sweden since 1979, when a law banning corporal punishment of children was passed, but more serious forms have not decreased. The aim of this study was to examine risk and background factors in cases of severe child abuse reported to the police. Files from different agencies (e.g., Social services, Adult and Child psychiatry and Pediatric clinic) for 20 children and 34 caretakers were studied. An accumulation of risk factors was found. It is concluded that when the following four factors are present, there is a risk for severe child abuse: 1) a person with a tendency to use violence in conflict situations; 2) a strong level of stress on the perpetrator and the family; 3) an insufficient social network that does not manage to protect the child; 4) a child that does not manage to protect him or herself. Thus, multiple sources of information must be used when investigating child abuse.     

Alleged Biological Father Incest: A Forensic Approach

Paternal incest is one of the most serious forms of intrafamilial sexual abuse with clinical, social, and legal relevance. A retrospective study was performed, based on forensic reports and judicial decisions of alleged cases of biological paternal incest of victims under 18 years old (n = 215) from 2003 to 2008. Results highlight that in a relevant number of cases: victims were female; the abuse begun at an early age with reiteration; the alleged perpetrator presented a history of sexual crimes against children; sexual practices were physically poorly intrusive, which associated with a forensic medical evaluation performed more than 72 h after the abuse, explain partially the absence of physical injuries or other evidence—these last aspects are different from extrafamilial cases. In conclusion, observations about paternal incest are likely to exacerbate the psychosocial consequences of the abuse and may explain the difficulty and delay in detect and disclose these cases. Few cases were legally prosecuted and convicted.     

The spectrum of sexual abuse in daycare: An exploratory study

Findings from an exploratory study of 48 children sexually abused in daycare centers and daycare homes are presented. About two thirds were female and one third male. Approximately half of victims were maltreated by a single perpetrator and about half by more than one perpetrator, in the latter instance almost always by both men and women. On average, the children were subjected to 5.3 types of sexual abuse, experienced 2.1 different sorts of threats to obtain their cooperation or prevent disclosure of their victimization, and suffered from 3.7 symptoms regarded as sequelae of sexual abuse. Differences in the characteristics of offenders, victims, the sexual abuse, threats, and sequelae were found based upon the daycare context, that is, whether children were victimized in a center with multiple perpetrators, a center with a single perpetrator, or a daycare home.     

The correlation of childhood physical abuse history and later abuse in a group of Turkish population

Domestic violence is passed from one generation to the next, and it affects not only the victim but also the psychological states of the witnesses, and especially the psychosocial development of children. Studies have reported that those who have been the victim of or witnessing violence during their childhood will use violence to a greater extent as adults in their own families. This research examines the relationships between a history of childhood physical abuse, likelihood of psychiatric diagnoses, and potential for being a perpetrator of childhood physical abuse in adulthood among women who received psychiatric treatment and in the healthy population from Turkey. Estimates of the prevalence of childhood physical abuse vary depending on definition and setting. The frequency of witnessing and undergoing physical abuse within the family during childhood is much higher in the psychiatrically disordered group than the healthy controls. Childhood physical abuse history is one of the major risk factors for being an abuser in adulthood. The best indicator of physically abusing one's own children was found to be as physical abuse during the childhood period rather than psychiatric diagnosis. There is a large body of research indicating that adults who have been abused as children are more likely to abuse their own children than adults without this history. This is an important study from the point of view that consequences of violence can span generations. Further studies with different risk factor and populations will help to identify different dimensions of the problem.     

Post-mortem radiological examination in infants:: Evidence of child abuse?

We examined the value of post-mortem radiological examination of infants who were brought in for medico–legal autopsy. Twenty children between the age of 1 month and 15 months died under the picture of SIDS. No radiological or other signs of previous child abuse were seen in our autopsy material. A fatal case of child abuse with several metaphyseal fractures is reported. Some fractures were not visible on gross examination, but could be demonstrated by radiography and histology. In our material no association between SIDS and child abuse was found. In suspected cases of child abuse, particularly rib fractures and metaphyseal fractures should be sought. We recommend that post-mortem radiography is performed in such cases. If fractures are demonstrated, they should be verified by histologic examination.     

Influence of Perpetrators' Account on Nurses' Recognition and Reporting of Child Abuse

Suspected perpetrators may attempt to influence the professional's recognition and reporting of child abuse by providing an account that explains or justifies their behavior or the child's injury. A factorial survey design was employed in which a random sample of nurses (N = 1038) judged vignettes that included systematic variations of types of accounts and selected case characteristics. In comparison to the other characteristics of the case, perpetrator accounts had little impact on nurses recognition and reporting of child abuse. Only two types of accounts influenced the nurses' responses, and from the perspective of the suspected perpetrator they backfired, resulting in greater recognition and reporting of abuse. Interaction terms constructed of accounts and situational variables had little impact on nurses' judgments when sexual abuse was involved, but resulted in both higher and lower recognition and reporting scores when physical and emotional acts were judged.     

The violent female perpetrator and her victim

The aim of the present study was to examine the relationship between violent female offenders and their victims as well as the putative differences in the motives and specific psychological factors among three groups of female offenders: women who have victimised someone closely related to them, those who have victimised an acquaintance and lastly women who have victimised a stranger. More than half (N=61) of all violent female offenders hospitalised or incarcerated in Finland during the year of study were interviewed and assessed by Structured Clinical Interview II for DSM-IV (SCID-II) and Hare's Psychopathy Checklist-Revised (PCL-R). In 34% of the cases the victims were persons close to the offender, in 41% the victims were acquaintances and in 25% strangers. The victims in homicide offences were more often both male and closer to the perpetrator than in assault offences. Although motives were related to interpersonal problems, self-defence and long-term physical or psychological abuse were reported by only a few women, even for the small proportion of women whose victims were intimate partners. The most frequent reason for offences stemmed from confrontational situations in connection with alcohol use. Women who victimised acquaintances and strangers were also more likely to have a history of criminality and substance abuse than women who victimised those in close personal relationships. The latter were also more likely to have an antisocial personality disorder (PD) and psychopathic characteristics. There were, however, no significant differences found between those who had experienced physical or psychological abuse in childhood or adulthood and those who had no adverse experiences. These findings suggest that the violent behaviour by females leads more often to the death of the victim, when the victim is closely related to the perpetrator. The commonly-held view that violent female offending occurs primarily as a consequence of precipitation by the victim was not supported.     

Children of Alcoholism: Implications For Juvenile Justice

Alcoholism and drug addiction affects the entire family. At least 22 million Americans have been raised in an alcoholic environment. Parental alcoholism and/or addiction can have profound emotional and psychological scars on the children. These homes are often characterized by emotional and or physical insecurity, loneliness, terror and inconsistency. The children from these homes often are extremely insecure have low self-esteem, and have a variety of emotional problems. Adolescents from addictive homes are over-represented in juvenile court as status offenders, delinquents and abuse and neglect cases. This article will discuss this issue and implications for the juvenile justice system and personnel working with these youth     

Elder homicide: a 20-year study

A subcategory of elder maltreatment is the fatal outcome, or elder homicide. Some cases of elder homicide result from chronic abuse and/or neglect, while others appear to be sudden, with no pertinent history. The research and literature of elder homicide are lacking, making the investigation of each case difficult; the typical victim, perpetrator, scenario, and cause of death are not known. Components of homicide such as sexual assault and toxicology also lack study. We analyzed all elder deaths over a 20-year period. Cases included those with victims greater than or equal to 65 years of age. These deaths totaled 2137: natural = 1506, accident = 344, suicide = 139, homicide = 127, and undetermined = 21. Focusing on homicides, variables analyzed were age, race, gender, cause of death, location of death, time of year, motive, perpetrator, toxicology, and sexual assault component. By identifying the typical victim, perpetrator, scenario, and autopsy findings, these cases can be more completely investigated and possibly prevented.