Background: Studies and surveys show that sexual abuse and exploitation of children is becoming bigger, and now there is not a problem involving only developing countries in Asia and Africa. The phenomenon of sexual abuse and exploitation of children is a very old global phenomenon that is perpetuated. Nurses, in cooperation with a multidisciplinary team, can provide important services to children who are victims of sexual abuse. Aim: The presentation based on international literature review, of the role of nurses in child sexual abuse in USA. Material and Methods: Method was used is to search electronic databases (MEDLINE, CINAHL) for a review of international literature until 2009 and became selection of books, articles and studies from libraries. Results: Nurses meet abused children and their families in emergency departments, urgent care centers, clinics and offices. Nurses can play a vital role in helping these children and their families by activating a team of people who will respond to the child’s disclosure. The most important role for a nurse is to ensure the health and safety of the child. At times, nurse with proper training can also collect and preserve forensic evidence. Conclusion: Nurse can play a very important role in the health and welfare of children who have experienced sexual abuse. All cases of suspected child abuse should be reported to the appropriate authorities.
Nurses, child , abuse, care.
The federal definition of child sexual abuse is “any recent act or failure to act which results in death, serious physical or emotional harm, sexual abuse or exploitation” . It is well known that the incidence of reported child sexual abuse is increasing. Whether or not the actual incidence is increasing is open to debate.
According to The National Child Abuse and Neglect Data System, in Αmerica 2,9 million referrals alleging child abuse or neglect were investigated by Child Protective Services (CPS) . From these referrals 906.000 children were substantiated to be victims of abuse. Sixty percent were victims of neglect, twenty percent were physically abused, ten percent were sexually abused, five percent emotionally abused and 17% were victims of other maltreatment. Some children were the victims of several types of abuse.
Nurses can provide important services to children who are victims of sexual abuse. Nurses’s skills including interviewing and physical examination can be vital for investigation and prosecution in these cases.
The physical and psychological effects of child sexual abuse can be permanent and life threatening. The nurse in cooperation, with a multidisciplinary team, can assist in providing adequate protection and services for the child, as well as optimizing chances for a successful legal outcome .
People who are sexually attracted to children may choose to act on their sexual fantasies. People who intend to engage children in sexual activity must first select a victim. Strangers to the offender are rarely chosen as victims. Usually the chosen is someone to whom the offender has access. The victim is usually a relative and/or someone living in the offender’s household.
After the offender has chosen the child, a grooming process takes place. The offender begins by developing a non sexual relationship with the child and over time, becomes an important part of the child’s life. The offender becomes a “special” friend showering the child with gifts and attention. Eventually the offender gradually introduces sexual activity into the relationship.
Offenders discourage the child from disclosing or reporting the crime. This is indeed a difficult task. On one hand, the offender wants the child to believe that the sexual activity is normal and may refer to it as “our little game”. Frequently, perpetrators of these crimes show the child pornography that depicts children involved in sexual activity.
On the other hand, the activity must be presented as a secret, this is “our little game” but also “our little secret”. The offender must convince the child that two seemingly opposite ideas are both true.
As difficult as this is many offenders are successful in convincing a child that he/she should not tell anyone about the sexual activity. The offender may threaten to hurt the child or the child’s siblings, parents, or pets if they tell anyone about the sexual activity. It is unknown how many children never disclose their sexual abuse. Formal and informal surveys indicate that the number of people who never disclose may be quite high.6
Despite threats, however many children do disclose, which generally occurs in one of three ways. The first is intentional disclosure. For reasons known only the child, the child tells someone that the sexual behavior is occurring.
The second, is accidental disclosure, which is very common. The child says something that alerts a family member or acquaintance that something sexual is happening to the child.
The third type of disclosure is discovery. In these cases, someone witnesses a behavior that may be associated with sexual behavior between an adult and a child.Disclosure and the Nurse
The law enforcement community, the social service community, and the healthcare community are trained to respond to sex crimes against children. In most communities these systems function efficiently. However, the ability to navigate through these systems can be very difficult for children and their families.Law Enforcement
The role of law enforcement is to investigate crimes using tools such as interviews and evidence collection. A team of people including a trained forensic interviewer, law enforcement and victim advocacy professionals conducts an interview of the child who disclosed the abuse.
Frequently, the forensic interviewer conducts the interview behind a one-way mirror while law enforcement listens from the other side and provides input to the interviewer via a microphone and headset. Law enforcement also interviews the child’s family and others who may have information about the case, interrogates the person or persons accused, and collects evidence from the crime scene(s).Healthcare
The most important role for a nurse is to ensure the health and safety of the child. At times, nurse with proper training can also collect and preserve forensic evidence.
When a family member believes that sexual abuse of a child has occurred, the family moves into a crisis mode. The most common place to seek help for children and their families is a health care setting. Nurses meet abused children and their families in emergency departments, urgent care centers, clinics and offices. Nurses can play a vital role in helping these children and their families by activating a team of people who will respond to the child’s disclosure.Social Work
Social workers also conduct an investigation. In many countries the professional who conducts the social work investigation depends on the relationship between the accused and the victim. Due to issues, of jurisdiction, if the accused is a family member, the investigation is conducted by a different group than if the accused is not a family member or a caregiver. Social workers evaluate the child’s situation and make important suggestions, such as whether or not the child or the accused should be removed from the home. Social workers are well aware of local resources that may assist children and their families. Caseworkers are assigned to children in need, and social workers help families and children navigate through the system to secure the necessary assistance (monetary or counseling).Evidence Collection
If the child reveals that a sexual encounter occurred within the last few days, evidence collection may be possible. The science of DNA permits identification of sexual offenders and provides evidence of sexual activity. DNA can be retrieved from any cell that has a nucleus and can be retrieved from saliva, blood, semen, dandruff, and skin cells.
Collection of clothing is critical in cases of child sexual abuse. DNA can be retrieved from underwear, bedding, and the child's clothing. If the child is wearing the clothes that he/she had on during the sexual encounter, it should be collected. Place each piece of clothing into a separate paper bag, which will reduce transfer of evidence from one piece of clothing onto another. Clothing must be kept in the presence of the Nurse until law enforcement takes possession of it. The Nurse may want to keep a closet of children's clothing in various sizes to replace the collected clothes. The child will be leaving the healthcare setting wearing replacement clothing.
It is possible that the offender left semen on the child. Semen can be on the child's clothing, but it can also be on his body. An alternate light source, such as a lamp, can be helpful in finding semen. However, history from the child is the most effective tool for locating semen. Age appropriate questions should assist in the location of semen and saliva.
All evidence collected must be kept in plain sight of the Nurse during and after the collection process. After the evidence is collected and air dried, law enforcement will assist the nurse in packing the clothing and will assist with appropriate labeling of evidence.
The nurse must carefully look for fingertip bruising on the child around the neck and on the extremities. Injury captured with a camera is a very important part of the investigative process. Minor injuries heal quickly and must be documented as soon as possible. Injuries that require medical intervention must be documented in the medical record. Injuries that do not require medical intervention are frequently missed in child abuse cases but may be crucial to the investigation process and should be documented.
If the assault(s) occurred days prior to the disclosure and evidence will not be present on the child's body. However, there may be evidence on the child's clothing. It may be present on the clothes the child is wearing at the time or on clothing left at home [3,7].
Law enforcement should be called in all cases of suspected child abuse. In many areas of the country a special law enforcement team responds to child sexual abuse cases. The nurse can also call law enforcement. Law enforcement will respond with a visit to the hospital and will begin directing the investigation.
It is mandatory in every state that nurse’s report child abuse to law enforcement .Suspicion of Sexual Abuse
If a nurse suspects that a child has been sexually abused, the child should be asked age-appropriate questions about sexual activity. If the child is forthcoming with a disclosure, appropriate referrals should be made and forensic evidence collected if the timing of the disclosure permits.
If the child denies sexual activity but the nurse continues to suspect sexual abuse, based upon physical evidence or the child's behavior or both, social agencies should be notified. Evidence should be collected if possible. Social agencies will conduct an investigation of the home, the family, and the circumstances. Nurses should not be fearful of requesting investigation in cases in which suspicions are not founded or proven. More than one-half of all cases reported to CPS are unsubstantiated via investigation . It is better to consider the health and safety of the child first .Conclusions
Nurse can play a very important role in the health and welfare of children who have experienced sexual abuse. All cases of suspected child abuse should be reported to the appropriate authorities.
Nurses can acquire more information on child sexual abuse and evidence collection by participating in a sexual assault nurse examiner course with a pediatric focus.
At times, children require protection from adults. Child sexual abuse is one of those times. The nurse can provide a critical role in identifying victims of child sexual abuse, referring these children for care, and protecting them from further physical and psychological harm.