Recognizing Sexual Abuse

Sexual abuse includes any activity with a child for the sexual gratification of an adult or significantly older child (generally more than 4 years older). Sadly, the most common abuser is a family member or close family friend. Recognizing sexual abuse can be both tricky and heartbreaking.

Question

How can I recognize sexual abuse if it happened to my three-and-a-half-year-old daughter? About a month ago she told me a friend of ours touched her vagina. Since that time she has said nothing else and on gentle questioning she said it did not happen. There are no behavioral changes and her behavior towards the man in question has not changed at all. They've always had great times together. I have no idea why she said this and my feeling is that it is completely innocent. She is also at the stage where she is very interested in what a penis is and what a vagina is - she occasionally can be found on the floor probing her vagina. But, is there anything I should be concerned about and how do I recognize real abuse of a child?
Palo Alto, California

Dr. Greene's Answer

Some of the most poignant episodes of my pediatric training were long visits with children victimized by sexual abuse. I vividly remember sitting with tears streaming down my face after hearing how children had been scarred by those they trusted.

How sad that we need to be discussing this subject for a three-and-a-half-year-old! Unfortunately, there is no age at which a child is exempt from sexual abuse. About one-third of cases occur in kids younger than six years of age, about one third in children ages six to twelve, and one third in children ages twelve to eighteen. The Fourth National Incidence Study on Sexual Abuse estimated that 1.8 in 1000 children were victims of sexual abuse.  Unfortunately, many of these children do not disclose this abuse until they are adults.

Sexual abuse includes any activity with a child for the sexual gratification of an adult or significantly older child (more than about 4 years older). Children’s intense need for affection and nurturance from older figures makes them vulnerable. Adults and older children hold a position of tremendous power in their lives. It is the abuse of this power, and the abuse of children’s trust, that is so damaging.

Three Categories of Sexual Abuse

  1. Molestation, which is defined as the touching or fondling of the genitals of a child, or asking a child to touch or fondle an adult’s genitals, or using a child to enhance pleasure from sexual acts or pornography
  2. Sexual intercourse, which includes vaginal, oral, or rectal penetration
  3. Rape, unlawful sexual activity carried out with force against a person’s will or carried out with someone under a certain age or someone who is not able to consent fully.

Most abuse begins with innocent physical contact. A needy adult then makes this a routine. Once a routine is developed, it is not uncommon to progress to intercourse.

The most common perpetrator of sexual abuse is either a family member or a close friend of the family. Sexual abuse by a stranger is quite uncommon.

Sexual abuse commonly comes to light through the child’s disclosing the incident of sexual contact to a trusted adult. Historically, a child’s word was not taken seriously. Over the last twenty years, the pendulum swung to the opposite extreme; if a child described sexual contact, it was considered a fact, and the volunteering of such information was considered very strong legal evidence. Recently, the pendulum has returned to a more balanced position: take it very seriously whenever a child mentions sexual contact, but understand that not everything said necessarily mirrors physical reality. It is important to listen to your child and bring up any and all concerns to your pediatrician who can then take appropriate next steps. 

Determining a Child is a Victim of Sexual Abuse

The best way to clarify a situation, such as you have described, is to have your child examined by a sexual abuse specialist. Most children’s hospitals have a sexual abuse team or will be able to refer you to a specialist in your area. (The two hospitals that offer this service in your area are Santa Clara Valley Medical Center in San Jose and the Keller Center at San Mateo Medical Center). Your pediatrician can also help you navigate where best to take your child for an evaluation. 

A sexual abuse examination is comprised of two basic elements. First, and perhaps most important, your daughter would be interviewed by an expert who very gently elicits information from her about what might have happened. Efforts are made to minimize the number of times a child has to tell the story and the number of people visibly present during the interview. The interviewer will let your child set the pace and may use pictures or dolls to draw her out, without suggesting to her what might have occurred. 

This is generally followed by a physical examination of the external genitals, checking for any sign of trauma (such as bleeding, tears, or inflammation), laxity, or discharge. Sometimes this will be done with magnification, using an instrument called a colposcope. This will be done with a chaperone and often a parent in the room in order to ensure comfort for the child.  A parent or a loving caregiver by the child’s head can give them support and reassurance throughout the exam. 

Note that a physical examination cannot in and of itself confirm or rule out sexual abuse. In at least half of the cases of child abuse that are confessed by the abuser, there are no findings on physical exam.

Clues to Help Recognize Sexual Abuse

Children who have actually been abused will often recant their initial statement because they are afraid of their abuser or because their abuser convinces them that this is “their little secret.” And children who have never been sexually abused will, based on normal child development, go through phases of curiosity and misunderstandings about their genitals and about sexual activity.

Several clues are associated with sexual abuse (but often the only clues are a child’s verbal statement):

  • Genital infections, redness, or discharge
  • Burning with urination
  • Urinary tract infection
  • The new onset of either bed-wetting or stool problems
  • Sudden increased sexuality with peers, animals, or objects
  • Seductive behavior
  • Age-inappropriate sexual knowledge
  • Regression
  • Other dramatic behavior changes

Hopefully, nothing significant happened to your little girl, but if my daughter came to me with the same story, I would not let the situation go uninvestigated. The scenario you have described is the most frequent way actual sexual abuse is detected.

Whatever turns out to be true, it’s important to prepare our children to protect themselves against sexual abuse. Begin by teaching them the proper names and significance of their private parts as soon as they are able to understand (about age 3). This will help to teach them that although these parts of their body are private, it is ok to talk about them and ask questions. Then they will be ready to understand and communicate what has happened to them.

Three Key Messages Children Should Understand

  • Say no if somebody tries to touch your nipples, rectum, or genitals.
  • Tell a trusted adult if someone tries to touch you.
  • Don’t keep secrets — if somebody tells you to keep a secret, let your parents know right away.

Parents need to be careful about who spends time alone with their children – where and when.  Parents should also be ready to listen and take seriously when their child has a question or concern.  Open lines of communication are incredibly important for children in order for them to feel comfortable talking about confusing or scary experiences.  

For a parent or caregiver, recognizing sexual abuse is just the beginning of the healing process — but it’s a very important first step.   Studies have shown that the long term outcomes of children who have been abused are much better if they are believed and taken seriously at the time of disclosure. Abuse should be treated by a supportive team of experts.

You have the power to make a big difference. 

References and Resources

Jenny C, et al. The evaluation of children in the primary care setting when sexual abuse is suspected. Pediatrics. 2013; 132(2):e558-e567.  

Finkel  MA, et al. Medical Evaluation of Child Sexual Abuse: A Practical Guide. Elk Grove Village, IL: American Academy of Pediatrics; 2009.

Last medical review on: July 15, 2020
About the Author
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Dr. Greene is a practicing physician, author, national and international TEDx speaker, and global health advocate. He is a graduate of Princeton University and University of California San Francisco.
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when I was around 4 or 5 years old I remember my brother and I would lay in bed and watch tv with my dad. I remember he would put his hands down the back of pants. I remember thinking how uncomfortable I was but I was afraid to push him away so I would adjust in certain ways hoping he’d have to move his hand. I remember he started putting his hand down the back of my pants and underwear and I didnt like it but I was afraid if i pushed him away he’d get mad (he was always flip flopping and either your best friend or worst enemy)
Coincidentally, after picking us up from school, on the way home, my mom told me and my siblings “if any one ever touches you and you dont like it you can tell me, even if its your dad”
and thats when i told her exactly what was making me uncomfortable.

That night, right infront of me… my dad and mom were arguing and my dad said i was a “vicious liar” and that it never happened at all.
The fact that my dad denied it was so confusing for me because I didnt actually think he was doing anything wrong, i just didnt like it. My mom just told me he was probably checking to see if i pee’d or something but I remember regretting I ever said anything. Nothing ever happened and I never cuddled with my dad or mom or anyone ever again and I turned into the worst child in the family. my dad always said im always lying, spying, or crying.

My relationship with my parents and my dad nowadays, 25 years later, is good. I dont know if what happened to me was sexual and i dont know if other sexual stuff had happened that i didnt remember. (because I was very very sexually inappropriate from as long as i can remember)
Its hard for me to think that my dad sexually abused me and im really conflicted if that is what happened?

what scarred me the most is that i trusted my mom and felt safe telling her what i did and it backfired and made me realize that i couldnt trust anyone

I need serious advice please anyone who can help…. it started when my daughter was 16 months old… I had a gut feeling that my husband (her dad) had touched her inappropriately. There wasn’t any reason to think this.. just a sudden gut feeling. Weeks later, I walked into the room and she was sitting down with her baby dolls face in her crotch area and she was making a sucking sound. When I asked her was she was doing she made the sound again and then stopped. Her dad and I separated for a while shortly after that incident and were on and off for a bit but he was never alone with her and she never had issues.

She potty trained herself at 2 years old and had no accidents. 1 year after being potty trained, she’s now 3 (around the time everything got shut down from covid) her dad started coming over to watch her while I went grocery shopping. After the 2nd or 3rd time, she started peeing her pants all the time. And we were always home so there was no obvious reason for it. She started to space out and kind of just check out mentally and pee her pants. I thought she was just being lazy so I began doing potty breaks to avoid accidents. She fought me about pulling down her pants. She did not want to to pee or to take a bath and she’d would cry. I thought she was just being a typical 3 yo and giving me a hard time. But the accidents persisted for about 5-6 weeks. It seemed to begin improving but then began again.. then, she started to smell like fish down there.. NOTHING helped. From diet to more water,, to bathing/no soap/soap.. nothing.. I called the ped and she was negetive for UTI and bacterial infection. I obviously told her dad about this and it seemed to all just stop after she cried out of nowhere one night and said she doesnt want me to leave her with daddy. She wants to go to the store with me so I stopped leaving her with him. All was well for almost 2 months until last week. He’s been taking her regularly for 2 days the past couple weeks.. I had a bad gut feeling again when I went to pick her up from the house he’s staying at.. I can read him well and he seemed nervous. She was watching TV and out of nowhere he just randomly asked me what ever happened last time with her peeing her pants and the smell….. my heart sunk because it was so out of the blue and I already had a bad feeling… I said “remember, I told you… everything was negetive and it all just cleared up so I let it go”…. then I took her to the bathroom before we left and she had discharge on her underwear for the first time ever…. she started smelling like fish again the next day and scremed crying holding on to me so tightly that she doesn’t want to go with him. She always says she doesn’t want to but he tells her she has no choice. He always buys her stuff almost like an attempt to make her forget she didn’t want to be with him… I took her in to the ped right away… urine was positive for nitrates and white blood cells. The results came back today that she has a UTI. Same symptoms.. except last time she was negetive for everything and this time she has all of this going on… I have had this gut feeling for so long but I don’t know what to do….I’ve caught her trying to put things in her vagina before all of this happened… so she was only 2 and to me, that’s so young for that… people say its normal though. My gut instinct has been eating me up for years at this point and now to see this happening I am so torn. She is my miracle baby and It’s killing me to think I have to just allow this if it is happening. She acts like she resents me already… any time I tell her that he’s coming to get her, she starts acting like she doesn’t love me anymore… becomes really mean towards me… I’m so hurt. I don’t know what to do…

My 4 year old granddaughter adamantly insists that an 8 year old neighbor boy took her to the bathroom, gave her his camera and asked her take a picture of her vagina. He showed her how to pull down her pants, put the camera between her legs and snap the picture. His parents say it never happened and my granddaughter is lying. Do I call the police?

I caught my husband for 11 years with putting his hand down my 16 month old baby’s nappy. He had previously tried to be alone with her al lot and once I walked in on him whilst carrying her and he immediately dropped his hand from under her skirt. I reported the whole thing and he was arrested. I fled to a refuge with my kids and we went to court. I lost the case and he has now been granted overnight stays with her and my son starting this weekend. I am terrified that the thing I feared had now happened. I cannot be there to protect her and if I don’t take her for the visitation, I risk losing her entirely.
She has already had some unsupervised time with him in the community as ordered by the court and came back refusing I change her nappy saying no no no. her brother was there as well. The thing is when I saw him doing these things to her, it was in public because I didn’t allow him acces to her in private due to my suspicions. Now, he will potentially have access to her in private. I feel really helpless and don’t know what to do. She is non-verbal at 2 and won’t be able to tell me if anything bad happens to her. What do I do?

I just left a 6 month relationship where I was elated to date a man who was a great dad to his 6 year old daughter. He has been divorced one year.
Now that we have been broken up one month, I am trying to logically decide if some of the behavior I witnessed is enough to report to child services. I have felt off about him and our relationship since what I began to see a few months ago, and what I saw only escalated.
The things that have been happening are more psycho-sexual in nature. My ex-boyfriend has 50/50 custody of his daughter and sleeps with his daughter every night he has her in his underwear, and draws on her back to put her to sleep. He says that she refuses to sleep in her own room and always wants to touch him and be close to him at night, but isn’t this the adult’s decision and not the child’s? She actually began removing her clothing in the middle of the night saying that she wanted to be ‘skin to skin’, and wanted to sleep naked (in underwear) like her father. The child displays behavior that is very unlike other 6 year olds I know. She has a total emotional breakdown if her father’s attention is taken away from her for even several seconds, to the point of crying. He seems to be giving her a very intense level of attention and physical contact that is more akin to a spouse than a little girl. Since I found out about the co-sleeping nightly, I suggested that it was probably time for her to sleep in her own bed, but he kept sleeping with her. They go on month-long trips alone together out of the country, without the ex/wife obviously, and co-sleep in hotels as well. For me it feels like the little girl’s physical boundaries are not being respected properly, and her behavior is showing that she is being groomed to act in sexual ways. Not to mention her emotional instability. I know of several times when she has expressed to him ‘stop touching me’ or ‘stop rubbing my leg’.
Another detail that could come into play – my ex engaged in sexual behavior with me at night once and told me he didn’t remember. So he was either dreaming, or lying, but that shows he does not have sexual control while he sleeps or he is, well – a liar. What if this behavior ever happened with his daughter?
So as you see, I don’t think he’s engaging her in sexual acts with her, but there is inappropriate contact. I want to protect this little girl, because I trust my gut instincts, and I have always felt off about what I’ve seen. Since she is 6, he will obviously have to help her dress and bathe to some extent, but most of the touching I have witnessed is more out of his own desire than anything a kid needs adult help with.
I’m quite happy to be without my ex, since he has officially creeped me out, and I wouldn’t say I’m heartbroken or even angry with him. But I just don’t think these actions are enough to report. Thoughts?

My son is 4 years old, a month ago he told me his friend who’s my neighbor’s son put his penis in his his anus. i was utterly shocked. sometime when my son was 3 he had told his dad that this same child (who’s 11yrs old now) touched his penis but he didn’t mention it to me, and then he always accused everyone of touching his penis apparently we were teaching him about his body parts and when to scream if someone is touching him inappropriately, so i didn’t think much of the first accusation he made though i questioned the other child and he said he had never touched my son’s penis. but this second accusation was alarming and so we took him to hospital and the doctor said there was no penetration but after asking my son different manipulative questions his answer was still the same. but about a week ago my 4 year old son came to me and said “mummy Samuel did not put his penis in my bombom (anus) Samuel is a good boy” so i asked him why did he say that the boy put his penis in his anus in the first place? but he kept saying he’s sorry and he wouldn’t do that again I then asked him who told him to lie about it? he said it was his dad, but i asked him so many times after but his answer was not consistent what he kept saying though was that the other child had never touched his penis or put his penis in his anus. right now i’m so confused cos i don’t know what to think, i and his dad are separated and the dad has reported this case to the social workers and there are threats of the child likely to be withdrawn from me. Please i need advice.

Dana,

I’m so sorry your granddaughter is going through this. And what a tough position you are in. You may be the only person in the situation that has all this information and the ability to process that information. Her mother may have clues, but it’s very difficult to believe that a man you love would hurt your child.

It would be ideal for you to take her to a pediatrician and tell them the story. Pediatricians are bound by law to call Child Protective Servies if they suspect abuse. The child’s mother may lash out at you if you take her to the doctor without her permission. This may leave you no choice and you may need to call CPS yourself. While calling seems extreme, it may be the only option you have.

I hope that helps.
Best, @MsGreene
Note: I am the co-founder of DrGreene.com, but I am not Dr. Greene and I am not a doctor. Please keep that in mind when reading my comments and replies.

Again, I’m so sorry.

I really need help. My granddaughter at 2 always said her butt hurt. She would bend over and point at her butt for no reason. She got a UTI. I a former CNA knew she had one from the smell. About 5 months after that her step dad got indecent exposure charges on him. Somehow they were changed to trespassing while my son was going for full custody. I don’t see my GC that often, now at age 3 her mom asked when was her dad curious of his privates. Not at 3. She said she was trying to insert a mermaid doll in her in the tub. Not normal! Then she says she has a UTI 4 days later. I offer to take her, but she hanged her mind but let her come to spend the night. We caught he cutting her baby dolls throat with a plastic knife and stabbing in the privates. She also scratched her in the privates saying she wanted to cut and hurt her. I asked did someone do that to her. She said yes. I said do you tell your Mom. She said Yes. What do I do? I told my son

Dana,

I’m so sorry your granddaughter is going through this. And what a tough position you are in. You may be the only person in the situation that has all this information and the ability to process that information. Her mother may have clues, but it’s very difficult to believe that a man you love would hurt your child.

It would be ideal for you to take her to a pediatrician and tell them the story. Pediatricians are bound by law to call Child Protective Servies if they suspect abuse. The child’s mother may lash out at you if you take her to the doctor without her permission. This may leave you no choice and you may need to call CPS yourself. While calling seems extreme, it may be the only option you have.

I hope that helps.
Best, @MsGreene
Note: I am the co-founder of DrGreene.com, but I am not Dr. Greene and I am not a doctor. Please keep that in mind when reading my comments and replies.

Again, I’m so sorry.

Wow. Sexual abuse is a LOT worse than I thought. On a scale from 1 to 100 of how bad it was, I thought it was a 90. Now I KNOW it’s a 100!😨

Lucee,

I’m so sorry for what you’ve gone through. No 14 year old should be afraid of their mom’s boyfriend.

You should report this to the authorities.

@MsGreene
Note: I am the co-founder of DrGreene.com, but I am not Dr. Greene and I am not a doctor. Please keep that in mind when reading my comments and replies.