Sexual Assault-or Mimic?

A 7-year-old girl was brought to the Child Advocacy Center (CAC) for a sexual assault examination. The newly assigned Child Protective Services (CPS) worker reported only what the child had disclosed to a friend’s grandmother the evening before the visit.

The child had indicated that her stepfather had sexually assaulted her. She told the forensic interviewer at the CAC that she had been “raped” by her stepfather. When asked what rape meant, she giggled and shrugged her shoulders. She offered no other detail of the alleged assault.????

The physical examination was completed and the child cooperated for the entire examination. She was not clean and was intellectually fairly low–functioning but was otherwise healthy. The examination showed no indication of any genital injury. There was very minimal erythema on the perineum, which was consistent with her poor hygiene.

The initial report to the CPS worker was that the examination was normal and that the child appeared to have been coached.

Do you suspect actual abuse?  ?????

(Discussion on the next page.)

The next day, a victim advocate called with grave concerns about the child. The following are the facts that had not been relayed during the CAC visit:????

1. The child had been taken to the emergency department and a “rape kit” had been performed by an adult ED doctor the night before she was seen at the CAC. Minimal history had been obtained from the child. It was feared that her terminology had originated with this ED visit.????
2. The child’s younger brother had disclosed a year earlier to a teacher that his mother “fiddles” with his private parts. CPS had gone to the child’s home and questioned him, but did not get confirmation of this disclosure. The children were left in the home.?
3. The brother had been expelled from school several times recently because he had been drawing graphic sexual and violent pictures.?
4. The mother had been cutting her arms with increasing frequency within the past 6 months.?
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The week following the CPC visit, the police and CPS had gone to the house to see the mother. The child recanted her story, and her mother supported her recantation. The police officer then interviewed the child’s stepfather at the police station, who confessed that he had shown the young girl how to have “safe sex.” He further bragged that his penis was too large to fit inside the child’s vagina. He then went on to explain that he and the mother had tied the child to the bed but that she had willingly participated in the incident.?
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The stepfather pled guilty to first-degree sexual assault and sexual assault involving a minor and was sentenced to 10 to 20 years in prison. The mother was never charged. The children were removed from the home and adopted by caring parents.?????
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????Lessons Learned
This case illustrates 2 key points in doing abuse examinations and 1 frequently encountered point.

1. A good history is critical when doing abuse exams. This case could have easily been dropped for lack of corroborating history and physical findings if it had not been for persistent individuals looking for more details. The CAC group effort and sharing of information brought closure to this case.

2. The second point cannot be stated too frequently. Sexual abuse exams are non-diagnostic of abuse in 95% of cases. Too often the statement is made that the determination to pursue a case depends on the medical examination. The information from the medical component pales in comparison with the historical/social work component in most cases.

3. When a child’s story changes, some professionals question the necessity of pursuing his or her case. We have to assume that some children may lie about their abuse, but we also know that some (between 3% and 23%) will recant their allegations of abuse.^1-3 Sorensen and Snow² found that 96% of sexually abused children made an active disclosure of abuse; 22% of those recanted, and 93% then reaffirmed their allegations. A more recent article has duplicated these statistics. Malloy and colleages³ found a 23.1% recantation rate. The wide variation in recantation rates may be due to the definition of recantation, the length of follow-up, the population of children studied, or the family’s influences on the child.
 
References:
1. Bradley AR, Wood JM. How do children tell? The disclosure process in child sexual abuse. Child Abuse Neglect. 1996;20:881-891.
2. Sorensen T, Snow B. How children tell: the process of disclosure in child sexual abuse. Child Welfare.1991;70:3-15.
3. Malloy LC, Lyon TD, Quas JA. Filial dependency and recantation of child sexual abuse allegations. J Am Acad Child Psychiatry. 2007;46:162-170.    ?