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Sexual Abuse and the Girl Child
Sheila Campbell-Forrester Senior Medical Officer of Health - Jamaica
Child sexual abuse especially in the girl child has been with us for centuries and has become an important Public health problem over the past decade. Sexual abuse in the girl child accounts for approximately a third of all child abuse cases. Sexual abuse is defined as the exploitation of a child through violent or non violent molestation. This includes a spectrum of behaviour ranging from violent rape to inappropriate touching of the genitals or seduction. Data from the STD Control Programme of the Ministry of Health revealed a decreasing trend in the cases of Gonorrhoea seen in the 0-14 age group between 1991 and 1992, 9.2% and 4.6% cases respectively but the trend of more females than males continues to be seen. That is 8% of cases and 4.3% in 1991 and 1992 were females. The data suggests that 80 - 90% of sexual abuse occurs in the girl child which is corroborated by data from the Child Guidance Clinics. Similar findings are also reported from the United States where 90% of sexual abuse is to the girl child.
In a study done at the University Hospital in 1984 the youngest child was 9 months of age with a mean of age of 8 years. Children in this study were seen with a range of STD’s i.e.genital warts, trichomonas, herpes, all evidenced through sexual molestation. There appears to be an association between stability of home environment and sexual molestation with 60% mothers unemployed, one third having no stable residence and the highest incidence occurring during school holidays when supervision is minimal.
Characteristics of offenders vary and research has not been able to show any difference between the make up of a perpetrator and an ordinary man and sometimes sexual abuse is seen as an extension of male sexuality. A study of sexual abused cases seen at the child guidance clinic in 1987-88 showed that in 32% of cases sexual abusers were strangers, 25% were neighbours, 22% were male relatives, 11% were stepfathers and 2% fathers. A wide range of physical and behavioural consequences may occur as a result of sexual abuse in the girl child, although not confined to the girl child alone. In the study previously referred to done at the child guidance clinic the most common presentations were emotional - that of the child being sad and weepy, followed by physical problems (vaginal discharge) and then sleep disturbances, aggression, headaches and promiscuous or seductive behaviour. The history and medical evaluation is therefore of utmost importance and may be the only evidence available for the courts.
Current laws are grossly inadequate in the protection of children from sexual abuse particularly as it relates to exploitation of the young girl. The present age of consent is 14 years and should be raised to l6 years. The measure of punishment needs to be reviewed and the Justice Act needs to include proprietors of night clubs who employ girls under l7 years. Reformations of the law is necessary and needs to be more “friendly” in enabling the justice process in sexual abuse in any child.
Child sexual abuse especially in the girl child has been with us for centuries and has become an important Public health problem. It is quite common for newspapers to print letters or to report on some aspect of child sexual abuse (eg child hookers in Ocho Rios, Daily Gleaner May l4,1995) This is probably so because more persons are becoming more willing to report child sexual abuse and to share their experiences. This is further borne out by the increase in visits to institutions allowing the Central Registry and Child Guidance Clinics to record and report invaluable information on the child abuse.
Child sexual abuse has been defined as the exploitation of a child through violent or non violent molestation. This includes a spectrum of behaviour ranging from violent rape to inappropriate touching of the genitals or seduction. (Milourn 1993 p.1) It also includes the use of the child for pornographic purposes, prostitution, exhibitionism and exposure to erotic material for the purpose of stimulation of the child and gratification of the abuser (Horsham 1989,p.4)
EPIDEMIOLOGY Between 1987 and 1988 the Child Guidance Clinic at the Comprehensive Health Centre saw 55 cases of sexual abused children, 51 or 93% of which were females and 4 (7%) were males. At the child abuse clinic at the University Hospital 424 girls were seen with a vaginal discharge I 1984, 80 girls (14%) were confirmed as having gonorrhoea, which is considered to be evidence of sexual abuse. The age of youngest child was 9 months and the mean age was 8 years. Children were seen with genital warts, trichomonas, herpes, all evidence of sexual molestation (Task Force report April 1993, p.2) The 1993 data from the central registry which represents island wide data reported 243 cases of sexual abuse which was 60% of all child abuse cases. Sexual abuse was the most frequently reported type of abuse. Of the 243 cases, 237 or 97.3% were females and 6 were males which confirms the marked predominance of females in this kind of abuse. Child Guidance Clinic report 1994
The national data on sexually transmitted disease showed the following trend in gonorrhoea in the under fourteen age group; sexual abuse should always be considered in the girl child with an STD.Gonorrhoea cases in the girl child are therefore a sensitive indicator of sexual abuse although the data would not reflect whether or not the transmission may have been sexual or non sexual. Between 1991 and 1994 an average of 229 cases of gonorrhoea were reported in both males and females in the under 14 age group, 80% of which were females.
Of all the reported cases of gonorrhoea in females 8% were in the under l4 age group in 1991, 4.3% in 1992, 6% in 1993, and 4.4% in 1994. Less than 1% of cases in this age group were males(STD Control Programme Annual Report 1992, Data 1993/94)
The data is corroborated by that reported from the United States where it is estimated that 90% of reported cases involve girls and that only between 2% to 10% of incidents are reported (Jong 1990, p.1) The1984 university study suggested a correlation between stability of home environment and sexual molestation as 60% of mothers of these children were unemployed; over one third had no stable residence and the highest incidence were seen in January and September when it is presumed that the children were left unprotected during the school holidays (Joint Task Force Report p.3) The data of the central registry also noted a seasonal variation in sexual abuse cases with an increase of cases occurring in May and October (Child Guidance Clinic report p.8) It is, however, difficult to explain this variation. All of the perpetrators of sexual abuse were men, and this has not changed since 1987/88. It is estimated that approximately a third of perpetrators are in the age group 20-34 years old.
Sexual abuse can occur in any family at any socio-economic level, however in the Jamaican situation one has to consider such factors as the transient union situation where mothers change boyfriends frequently and usually for economic gains. Very often it is the boyfriend who is the perpetrator. Step-parenting, marital breakdown and poor supervision of children may be other factors to be considered in child sexual abuse. There are also some fathers who think it is their right to have first intercourse with their girl child and the myth still exists that the cure for gonorrhoea is to have sexual intercourse with a virgin. The perpetrator - psychological, economic and demographic characteristics of offenders vary According to Emily Driver research has failed to find any fundamental difference between the make up of the child molester and men in general, and sexual abuse of children is seen by some as an extension of normal male sexuality. Sexual prowess is an important part of the male self image and by tradition involves conquest, domination and taking the initiative all of which are easier with children (Emily Driver 1989) In Jamaica strangers were 32% of perpetrators, relatives 25% cases and 25% of children were victimised by other individuals previously known to them(neighbours).(Millbourn 1991) In the child guidance clinic study of 1987/88 the following was found to be the profile of the sexual abuser:
Many perpetrators involved in repetitive abuse were usually themselves abused as children. In the case of the abusive father, he often has unfulfilled needs. Some are often wife abusers,maybe drug or alcohol abusers, unemployed or paedophilic.
Date rape or acquaintance rape situations in which a male forces or pressures a peer into sexual activity while others involve misrepresentation of power or authority to engage younger children in sexual contact. If these acts are not disclosed or reported then the perpetrator will abuse other children. Case history: Adolescent Date Rape -15 year old Gem obese female, who has a low self esteem meets boy whom she thinks she likes. He invites her to his home. She goes, no one else is home. He tells her to take off her clothes, she refuses, he locks her in and rapes her. Afterwards he tells her to leave. Gem cannot tell mother as mother is very strict and does not allow her to go out with boys. The child guidance clinic study of 1987/88 noted that 7 teenagers were male perpetrators. Three of the group were part of gang rape attacks on three girls. This is a disturbing fact when it is recognised that there is such “disrespect and disregard for females by boys in our community” (Milbourn 1991, p.7)
The Victim -Children are taught to be obedient and obey the requests of adult without questioning. They are also vulnerable because they believe in and fear the threats of perpetrators. under 5 years of age they are not always able to distinguish between right and wrong and their emotional growth and development is hinged on love - i.e. hugging, touching and cuddling. These qualities make them vulnerable to sexual abuse and continuing abuse(Horsham 1989
The Mother In the Jamaican context it has been observed that mothers whose children have been sexually abused were seen to be passive, disconnected from their daughters and accepting the sexual abuse almost as if it were inevitable. They often bow to pressure from family and neighbours “to drop the case” and pay little attention to follow up of the child (Milbourn 1991, p.7)
Behavioural consequences and perpetrators methods - The initial and long term physical and emotional symptoms of sexual abuse vary with the trauma resulting from the abuse and the age and sex of the child. Infants and toddlers may have general irritability from oral and rectal abrasions that cannot be localised by parent or physician. Dysuria from genital trauma may suggest a urinary tract infection. Trauma resulting in laceration to the vestibule, anus or hymen should be associated with bleeding; however, an anal fissure from penetration may be misdiagnosed. Symptoms vary with age and sex of the child. Some may be overt such as fear and avoidance of the perpetrator or general and non specific.Symptoms may present in adulthood and can include medical complaints including alcoholism, sexual compulsiveness, identity and relationship confusion. The older child may be able to relate about the abuse but may be reluctant because of fear of reprisals, guilt associated with the act of acceptance of bribes or fear of dissolution of the family (Garfinkel, Carlson, Weller 1990) In the Child Guidance Study 1987-88 the presenting characteristics of sexual abuse were:
Powerlessness or disempowerment results because the girl child’s needs and will are made subservient to the perpetrator’s. The sense of powerlessness and hopelessness is associated anxiety, fear, phobias, hyper-vigilance, perception of self as victim, somatic complaints school problems, vulnerability to future abuse or becoming an abuser. Stigmatisation occurs because the child is given a message of being responsible or to blame for the abuse. This results in feelings of guilt, shame, isolation, lowered self esteem, suicidal ideation, criminal behaviour and self injuring behaviour such as drug or alcohol abuse.
Masked presentations of sexual abuse are common. These cases are characterised by initial physical or behaviour complaints other than sexual abuse. Masked presentation may make up approximately 19-60% of diagnosed sexual abuse cases. Typical masked complaints are genital symptoms, abdominal pain, constipation or rectal bleeding, straddle injury, pregnancy and other somatic and behavioural problems (De Jong 1990,p.4)
MEDICAL EVALUATION OF SEXUALLY ABUSED CHILD History of sexual abuse Sexual abuse of children usually follows a predictable sequence of events. Historical details corroborated by specific physical findings provide the strongest evidence of sexual abuse. Statements made to the physician may be particularly important in validating the allegations and may be admissable in court as an exception to the hearsay rule. The child’s statements are important as they may be the only evidence that abuse has occurred and it is critical that the interview be carried out with the same attention to detail as with collecting forensic evidence.
A sensitive, non threatening, non leading, unhurried approach is essential. It is usually painful for children to discuss their experiences and can be quite difficult for professionals to listen. Children are extremely sensitive to the reactions of those to whom they disclose the abuse. The interviewer must be open and objective and not presume that the child was psychologically damaged, embarrassed or hurt. Nor should the interviewer presuppose the child’s feelings about his or her abuser; such feelings may be complex and ambivalent.
When conducting the interview, the physician should: 1. Inform the child of what will happen during the interview and physical examination. 2 Acknowledge how difficult it is for the child to talk, give support but not promise what cannot be delivered 3. Encourage the child to ask questions 4. Determine child’s name for body parts and names and nicknames of family members, use these terms during the interview. 5.Obtain a medical history particularly of the gentio-urinary system or gastro-intestinal complaints 6.Reassure child that she is not to blame 7.Avoid using negative words. 8.Be non judgmental, matter of fact or casual. 9.Supplement a direct questioning approach with the use of communication aids such as drawing activity, puppets or anatomically detailed dolls.
The child is often best interviewed in the absence of the parents although this is not always possible. When taking the child’s history the physical should obtain answers to the following questions. Who is the perpetrator? Is he or she a stranger or known to the child? How did the alleged perpetrator gain access to the child, have opportunity for private interaction and how were the activities presented to the child? Was this a single episode or recurrent abuse? Was there a progression of increase in intimacy of contact? How did the child describe his or her feelings during the activities? What were the circumstances surrounding the disclosure and was it accidental or purposeful? When was the last abuse? What has happened since the last episode? What type of sexual contact was attempted? (DeJong 1990,p.5-6)
SEXUALLY TRANSMITTED DISEASES -The sexually abused girl child or any other abused child is at risk of an STD. This may be the only physical evidence of sexual contact and sexual abuse. The matter of STDs has to be handled with care to determine non sexual or sexual transmission. HIV disease poses a challenge in the case of the sexually abused girl child. Testing for HIV disease is indicated in all cases especially where the perpetrator is a known case or there is no baseline knowledge about the perpetrator. In acute molestation recognition of the window period requires that baseline testing be done and the test repeated in three months. The HIV positive child in addition to facing the stresses of abuse has to face new challenges of stigmatisation and of becoming an outcast on society.
Case: Marina aged 7 was sexually abused. She tested positive for HiV and the perpetrator apprehended. Marina had to be removed from the area in which she lived because she would not have been accepted by the community and school. Father wanted to have nothing to do with her and mother was left to support her. This is only one tragedy of an HIV infected child who has been abused.
SEXUAL ABUSE - THE GIRL CHILD AND THE LAW -The Joint Task Force on Child Abuse stated in its report that “Current laws do not appear to be adequate in the protection of children from sexual abuse, particularly from the point of view of exploitation of young girls”.The present age of consent is l6 years having been changed in 1988.There is anomaly between the Incest Act which provides maximum punishment of ten years for a father who abuses his child under 12 years of age and the Offences Against the Person Act which provides a penalty of life imprisonment for carnal abuse of a young girl of the same age who is not related. The Task Force recommends equal punishment for abusers of children under 12 years whether or not they are related plus - 1.Mandatory reporting of child abuse cases. Medical practitioners, social workers and the police are required by law to report cases to the Registry 2.Mandatory counselling and psychiatric treatment for sexual abusers in a family situation. 3.Empowerment of the court to remove the child or offender from the home in the case of incest involving a girl under l7 years while trial is pending, whichever is in the best interest of the child. 4.It is also recommended that provision should be made under the Juvenile Act to prosecute a)the proprietor of a nightclub who employed a girl under l7 b)the owners of premises who knowingly rent their premises for use as a brothel where girls aged l7 are used as prostitutes. c)the persons who watch girls perform indecently or are present at such performances. Reformation of the law is necessary and needs to be more “friendly” in enabling the justice process in sexual abuse of any child. The Convention on the Rights of the Child (Art 34,1989) states that the State shall protect children from sexual exploitation and abuse, including prostitution and involvement in pornography. What should be society’s vision of our children? It should be one where are children are happy, healthy, wholesome, protected, loved and cared for to enable them to achieve their full potential and certainly not abused. Acknowledgements to Dr Pauline Milbourn, Dr Beryl Irons, Joint Task Force,Dr Alfred Braithwaite, Phylis Smikle REFERENCES 1.Horsham Patricia M.D.Practical Guidelines to the assessment of the sexually abused child 2.Report on the Task Force on Child Abuse 3.DeJong A.R. Child Sexual Abuse, Pediatrics and Nutrition Review Exerpta Medic vol.4.No2.p 1-8 4.Sexually transmitted disease control programme report 1991-92 5.Emily Driver and Audrey Droisen, Child Sexual Abuse, Feminist perspectives 6.Garfinel, Carlson & Weller Psychiatric disorders in children and adolescents, 341-343 7.Child Abuse in Jamaica - COJ UNICEF Review of Children in extremely difficult circumstances 8.Child Guidance Clinic annual report 1994 9.Unpublished data STD 1992-94 10.Pauline Milbourn, Fernanda DiTullio, Valerie Beckford - Child Abuse in a child guidance clinic setting
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