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.
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.
Sexual abuse falls into three different categories:
- 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;
- sexual intercourse, which includes vaginal, oral, or rectal penetration;
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.
The best way to clarify a situation such as you have described is to have your child examined by a sexual abuse specialist in. 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.)
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 daughter set the pace and will 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, laxity, or discharge. Sometimes this will be done with magnification, using an instrument called a colposcope. 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.
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 as opposed to normal development (but many children give no clues except what they say):
- 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
- 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 abuse is detected.
Whatever turns out to be true, we must 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). Then they will be ready to understand the three key messages:
- 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.