Charles Felzen Johnson

Child sexual abuse

Child sexual abuse is a worldwide concern. It is an insidious, persistent, and serious problem that, depending on the population studied and definition used, affects 2-62% of women and 3-16% of men as victims. Pain and tissue injury from child sexual abuse can completely heal in time, but psychological and medical consequences can persist through adulthood. Associated sexually transmitted diseases (such as HIV) and suicide attempts can be fatal. All physicians who treat children should be aware of the manifestations and consequences of child sexual abuse, and should be familiar with normal and abnormal genital and anal anatomy of children. This aim is best accomplished through training and routine examination of the anus and genitalia of children. Because as many as 96% of children assessed for suspected sexual abuse will have normal genital and anal examinations, a forensic interview by a trained professional must be relied on to document suspicion of abuse.

Sex abuse prevention programs: Offenders' attitudes about their efficacy

Little scientific basis exists for the content of school-based programs which are intended to help children protect themselves from sexual abuse. Children are taught about protecting themselves from a stereotypical old male stranger, yet perpetrators are most frequently young, known to the victim, and use a variety of methods to gain access to children. Programs generally include concepts of body ownership, acceptable touching, good vs. bad secrets, saying no, telling, and trusting ones intuition. Seventy-two prison inmates incarcerated for child sexual abuse were surveyed to evaluate their attitudes about the effectiveness of topics intended to prevent abuse. Offenders described the ideal victim and the modus operandi they used to involve children. Inmates indicated which topics in prevention programs they believed were efficacious and which topics would have little value in preventing abuse. Responses of incestuous and nonincestuous abusers were compared. Inmates indicated that parents could help prevent child abuse and that they must be involved if programs are to be effective. Information from abusers is useful and can be incorporated into programs if the potential for prevention of abuse is to be improved.

Inflicted injury versus accidental injury

The morbidity and mortality that are associated with child abuse is a serious concern for the practicing pediatrician. If abuse is to be prevented, physicians must become skilled in recognizing factors that place a child at risk for abuse. Early and minor signs of abuse and neglect must be recognized and reported to assure services if more serious abuse and neglect are to be prevented. Instruments that are used to strike children or burn them leave their imprint on the child. Marks on the skin may signal the existence of internal injuries. Nonaccidental injuries may be difficult to distinguish from accidental injuries. Physicians must approach an injury as a symptom requiring a diagnosis of cause. This is best accomplished by careful examination and documentation of each injury. If the injury is not in keeping with the history given or the childs level of development, abuse must be considered as a cause. A suspicion of abuse should result in a report.

Comparing Female and Male Perpetrators' Modus Operandi Victims' Reports of Sexual Abuse

Although a sizable percentage of all sexual abuse in the United States is perpetrated by females, until recently the subject of sexual offending by this population has been largely overlooked. In this study, reports of child sexual abuse by 53 victims of female perpetrators were compared with reports by a group of 53 victims of male perpetrators. Victims were matched for age, race, and sex. The purpose of this investigation was to gain information about similarities and differences in the modus operandi of female and male offenders. Females were more often involved with males in co-offender situations. They were also more likely to exploit their victims than males. Male offenders were reported to be more sexually invasive in their abuse and were more likely to use bribes to obtain victim cooperation than females.

The sexual abuse of children: A comparison of male and female victims

Although estimates of the incidence of reported child sexual maltreatment vary greatly, most authors agree there is a predominance of female to male victims. Yet studies of sexual offenders suggest afar greater proportion of male victims than is reported. This study compared circumstances surrounding the abuse for boy and girl victims. A total of 81 reported cases of male sexual abuse over a 3 year period were matched to 81 females sexually abused during the same period. Although it was hypothesized that there would be significant differences between boy and girl victims of sexual abuse, this study revealed surprisingly few differences between factors associated with the abuse. The sex of the victim was not related to the relationship of the abuser, who referred the child, the number of abusers, the incidence of sexual abuse of other children or siblings, chronicity of abuse, the use of bribes or threats, or concurrent physical abuse. There was a greater incidence of physical evidence of sexual abuse amon...

Do physicians have adequate knowledge of child sexual abuse? The results of two surveys of practicing physicians, 1986 and 1996

The objective of this study was to to determine if physician knowledge of and biases regarding child sexual abuse (CSA) have changed since 1986. A questionnaire, previously used in 1986, was mailed to 370 physicians who see children in Columbus, Ohio. More respondents in 1996 correctly denied an association between specific sociologic factors and the likelihood of CSA. Seventy-two percent of physicians indicated that they check the genitalia of prepubescent females more than 50% of the time, versus 77% in 1986. Physicians who see more than 25 pediatric patients per week were significantly more likely to check the genitalia (p < .001), whereas physicians with more than 10 years experience were less likely to check genitalia (p < .05). Physicians surveyed in 1996 were more knowledgeable about socioeconomic and behavioral aspects of CSA but continued to be deficient in identifying prepubescent female genital anatomy and in reporting suspected abuse. Education is necessary to correct these deficits.

Child abuse diagnosis and the emergency department chart

Failure to uncover and report nonaccidental injury may have serious consequences for the child and the physician. To determine if the information recorded in the emergency department record was adequate to eliminate the possibility of nonaccidental injury, the charts of 333 children under five years of age were reviewed. No charts contained all the information deemed necessary; in 12.6% a diagnosis of nonaccidental injury could not be eliminated. In three cases, the injury was inconsistent with the history. Missing historical information included where the injury occurred, the presence of witnesses, notation of previous injuries, and old chart review. Information regarding size, color, and age of the injury was incomplete. A complete examination was recorded 22.3% of the time. The private-pay category charts and those recorded by staff were most complete. Remedial actions, guided by periodic chart reviews, are suggested.

The Hand as a Target Organ In Child Abuse

The authors reviewed the abuse reports submitted by the staff of The Childrens Hospital, Columbus, Ohio, to determine the incidence and types of injuries inflicted to childrens hands. The authors did not study hand injuries in children who were not reported as physically abused. The authors examined two time periods to ascertain changes in injury severity. Of the 631 abuse reports submitted from 1980 to 1982, there were 52 injuries (8.2%) involving the hands. From July 1987 to July 1988 there were 42 hand injuries (13.4%) among 313 reports. In the 94 total cases, 19 (2%) children sustained injury to the hand only, including eight with burns, two with bruises, two with human bites, two with erythema, two with fractures, and one with a laceration. Children with burns to the hand alone were significantly younger than those with other types of injuries. Of the 94 children with hand and other injuries, 18 (20%) required hospital admission. Of the 19 with injuries to the hand only, five required hospital admission. A variety of instruments were used to injure these children. The hand is a delicate organ, and it is frequently the primary or incidental target of child abuse. Familiarity with the patterns and types of hand injury suffered in child abuse is essential for early recognition, reporting, and child protection.

Child abuse as a stressor of pediatricians.

A survey of: 1) sources of perceived stress, 2) stress management, and 3) burnout among members of the American Academy of Pediatrics Sections on Child Abuse and Emergency Medicine indicates that child abuse physicians are stressed by the history, physical examination, and court appearances in abuse cases. Rarely did physicians indicate that this stress adversely affected their sexual life or family life. Both groups considered courtroom appearances most stressful. Both groups claimed to recognize their stressors and use a variety of approaches to decrease stress. Formal training in child maltreatment was unusual among Abuse Section members, whereas Emergency Section members tended to receive this training in Fellowships. Emergency Medicine Section members reported increased perceived levels of stress. Despite recognition of stress, there was no indicated desire to leave either specialty before an average of 11 to 15 years. Emergency Medicine Section members indicated that 5% of their patients are abused. It is important that emergency medicine residency programs include child abuse education. Formal training programs for individuals who wish to limit their practice to child abuse are needed. Stressors need to be recognized and appropriately managed. Stress recognition and management techniques that have been shown to be effective should be taught and used, beginning in medical school and continuing throughout medical practice. This is necessary if the highest quality of professional personal and patient care is to be maintained.

Walker-related burns in infants and toddlers

During one year, four (6.5%) of the 61 children who were hospitalized for burns at a childrens hospital sustained their injuries in a walker. Records from a total of nine children hospitalized with walker burns were compared to those from other hospitalized burned children. Patients who were burned while in a walker had a greater body surface area burned (11.6%) than those with burns from abuse (1.7%), neglect (2.5%), or other accidents (6.2%). A higher percentage of males were burned, and the burn patterns differed among all four groups. Seven of the nine walker burns resulted from scalds, with three scalds from hot grease. Walker-related burn patients required more physical or occupational therapy and a longer mean hospital stay. Social histories of infants with walker and other accidental burns differed from those associated with abuse or neglect. Walkers expose infants to unnecessary hazards, including potentially serious burns; their use should be discouraged.