PEDIATRICS Vol. 104 No. 2 August 1999, pp. 270-275

Addressing Sexual Abuse in the Primary Care Setting

Mary Ranee Leder, MD^*, S. Jean Emans, MD, Janet Palmer Hafler, EdD^§, and Leonard Alan Rappaport, MD^*

From the Divisions of ^* General Pediatrics and  Adolescent Medicine, Children's Hospital, Boston, Massachusetts; and the ^§ Office of Faculty Development, Harvard Medical School, Boston, Massachusetts.

	ABSTRACT

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Objective.  To describe factors that prompt pediatric practitioners to suspect child sexual abuse, the barriers to inquiry, and the approach to management of cases of possible abuse.

Design.  Qualitative, descriptive, and case-based.

Methods.  Six focus group interviews were conducted. Maternal and Child Health Bureau-sponsored collaborative office rounds groups nationwide participated in discussions of five vignettes. Each group interview lasted 1.5 hours and had 7 to 16 participants (n = 65). Audiotaped data were transcribed and analyzed independently for themes by two reviewers.

Results.  Five themes emerged from the group interviews: anticipatory guidance, red flags, approach to management, terminology used in discussions, and barriers to inquiry. All groups discussed giving anticipatory guidance about sexual abuse. Half (3/6) believed girls were more likely to be victimized, and some (2/6) gave more anticipatory guidance to girls for this reason. Although some groups reported giving anticipatory guidance about sexual abuse, many reported inconsistencies in their practice. All groups identified historical, behavioral, and physical red flags for sexual abuse but believed that they were not trained in residency to recognize these signs. There was no consensus regarding the approach to management of cases of possible sexual abuse, and many participants did not know the types of questions that they should be asking children when they suspect abuse. Members of all groups reported using imprecise terms when they discuss sexual issues with families. Most (4/6) believed that it was a practitioner's responsibility to inquire about abuse but believed that their discomfort with sexual topics was a barrier to inquiry. All believed that the most significant barrier to inquiry was inadequate training in the area of sexual abuse and that cases are missed because of lack of training.

Conclusions.  Highly motivated pediatric practitioners reported that they give anticipatory guidance about sexual abuse inconsistently, that they were not trained to recognize red flags for sexual abuse, and that they do not have a consistent approach to cases of suspected abuse. Additionally, they reported that they are not comfortable discussing sexual issues and that they miss cases of sexual abuse primarily because of lack of training. Educational interventions that target these themes are essential to improve the ability of pediatricians to screen children and to intervene when sexual abuse is identified.  Key words:  sexual abuse, primary care, psychosocial issues.

The true extent of child sexual abuse is unknown. There were an estimated 90 000 substantiated reports of child sexual abuse in 1996.¹ In a national survey conducted in 1985, 27% of women and 16% of men reported having been sexually abused before 18 years of age.² It is projected that ~1% of children will experience some form of sexual abuse each year.^3,4 Based on the last finding alone, a pediatric primary care provider with 2000 children in a practice panel could be expected to find as many as 20 children each year who have been sexually abused. Most pediatricians do not identify nearly this many cases of sexual abuse in their practices.

Recent studies show that sexual abuse can influence behavior significantly. In both males and females, a history of sexual abuse has been associated with higher rates of smoking, substance use, depression, and eating disorders.⁵ In adolescents, a history of forced or pressured sexual activity has been associated with higher rates of suicidal ideation, unprotected intercourse, pregnancy, and earlier onset of sexual activity.⁶ Pediatric primary care providers are in an important position to offer timely referral for additional evaluation, intervention, and treatment of sexual abuse.

From the perspective of the primary care provider, identifying victims of sexual abuse can be emotionally and intellectually taxing. Experts in the field of child abuse advocate that pediatricians ask questions about possible sexual abuse in situations in which there is a cause for concern, ie, a suspicious medical or behavioral complaint or a physical finding, such as a vaginal discharge, encopresis, or an abnormality of the hymen.⁷ Often there are no outward signs of abuse.⁸ Screening questions for routine visits have been proposed, such as, "Has anyone ever touched you in a way you didn't like?"⁹ Despite such guidelines, a Medline search did not reveal any studies that describe how pediatric practitioners in the primary care setting provide screening and anticipatory guidance for child sexual abuse.

The objectives of this study are to describe the factors that prompt pediatric primary care providers to suspect sexual abuse, to identify the barriers to inquiry, and to describe the approach to management of cases of possible abuse.

	METHODS

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Qualitative research methods were used to generate themes by analyzing narrative data obtained through detailed focus group interviews.

Sample

Collaborative office rounds (COR) groups were chosen as the sites of data collection in this study. These discussion groups, consisting of pediatric primary care providers and at least one child psychiatrist or psychologist, were developed in 1989 by the Health Resources and Services Administration's Maternal and Child Health Bureau. The COR groups emphasize the mental health aspects of primary health care for children and adolescents with the goal of promoting positive psychosocial development in patients and their families. Participation is voluntary. In a recently published study, COR group members indicated that the groups are remarkably stable and that members experience a sense of shared purpose that facilitates mutual trust and the open interchange of ideas.¹⁰ Such attributes made the COR group an optimal source of information about the pediatric primary care provider's perspective on the sexual abuse of children.

The methodology of focus group interviews was selected to allow discussion of sensitive information that might not be revealed in a written survey. These discussions lasted ~1.5 hours and were held during a regularly scheduled monthly or bimonthly COR group meeting. A pilot group of five pediatricians was used to develop a focus group interview guide. As shown in the "Appendix", the interview guide consisted of five vignettes depicting scenarios likely to be encountered in the office of a pediatric primary care provider. Each group discussion was guided by the same facilitator (M.R.L.) who visited each COR group site. The facilitator guided each discussion with open-ended questions to determine the factors that were most salient to the providers in their decision whether to inquire about sexual abuse in each vignette. To allow participation of the child psychiatrists and psychologists who attended these focus groups, they were asked to describe their perceptions of the practices of pediatric providers in their geographical areas. Field notes were made at the conclusion of each discussion. The audiotaped data from each interview were transcribed.

Participants

Ten Maternal and Child Health Bureau-sponsored COR groups were invited to participate in a focus group interview. Of the 10 groups, 6 agreed to participate. The primary reasons groups gave for declining participation included recent involvement in other research studies and an already established meeting agenda.

COR group members were sent letters describing the study and requesting their participation. From six COR groups, 65 providers agreed to participate. The study was approved by the Committee on Clinical Investigation, Children's Hospital, Boston, MA and was conducted between October 1996 and March 1997. Informed consent and permission to audiotape the discussion were obtained from each participant. The limits of confidentiality were also reviewed. Demographic information was obtained at the beginning of each interview using a one-page written questionnaire.

Of the 65 participants in the focus group interviews, 54 were general pediatricians, 8 were child psychiatrists, 1 was a pediatric nurse practitioner, 1 was a family practitioner, and 1 was a child psychologist. There were 32 men and 33 women in the study. Ages ranged from 29 to 78 years with a median of 46 years. The study groups were 94% white. Time in practice ranged from 5 months to 50 years with a median of 15 years. Of the participants, ~80% were either in group practice or hospital-based clinics, and nearly 60% practiced in either suburban or rural locations. Over half the participants reported some training in child sexual abuse, mostly in the form of continuing medical education courses.

Analysis

The data for this study were analyzed using qualitative methods.^11-13 First, multiple readings of the transcripts were completed to identify the major themes that emerged from the focus group discussions. Second, representative quotations for each theme were selected. Finally, the strength of concordance on particular points of view within each theme was noted. The COR group was the unit of analysis; therefore, all results are reported in terms of number of groups in which one or more participants endorsed a particular point of view.

Validity

At the beginning of each focus group interview, the facilitator emphasized that there were no right or wrong responses to the vignettes. Respondents were asked to be honest in their comments and to discuss not only what would be their practice but also that of their colleagues within the community. The facilitator was observed by an outside expert during the first focus group. It was noted that verbal and nonverbal cues from the facilitator did not influence responses from the participants. They adhered to the open-ended questions outlined in the interview guide, and all comments from the group interview were audiotaped and transcribed. For purposes of validity and reliability, the first three transcripts were examined by two different researchers (M.R.L. and J.P.H.) who independently identified similar themes.

	RESULTS

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Five major themes emerged from the six focus groups: anticipatory guidance, red flags, the practitioners' routine for approaching cases of possible abuse, terminology used during discussions, and barriers to inquiring about the possibility of sexual abuse.

Theme 1: Anticipatory Guidance

Members of all groups discussed giving anticipatory guidance about sexual abuse. Many reported discussing "good and bad touch" during preschool well-child visits as part of the child's genital examination. One participant said, "I tell them, "It's part of your examination. No one should be looking or touching these parts except for the doctor when your parents are in the room, and if anyone ever does, you need to tell your parents."

However, another group member admitted, "but it [discussion of good and bad touch] still doesn't come natural to me, and I don't do it as often as I probably should."

Half (3/6) of the groups believed that girls were more likely to be victimized, and some (2/6) reported giving more anticipatory guidance to preschool girls than to boys. Although some clinicians reported giving anticipatory guidance about sexual abuse, many reported inconsistencies in their practice.

Theme 2: Red Flags

As shown in Table 1, members of all groups identified red flags that they believed would likely trigger them to inquire about the possibility of sexual abuse. Behaviors believed to be signs of abuse included: sexualized behavior (6/6); anxious, depressed, or withdrawn behavior (5/6); and precocious sexual knowledge (4/6). Fewer groups mentioned sleep, appetite, or toileting difficulties (2/6) or drinking to drunkenness (2/6) as a sign of sexual abuse. Respondents indicated that in many cases behavioral symptoms were of more concern than were certain anogenital complaints. One participant said, "I would be more likely to ask about sexual abuse because [the child] didn't want to go to the baby-sitter's as opposed to she [only] has a vaginal discharge."

All groups said that the child's presentation during the office visit was very important. Nearly all groups (5/6) said that an unusual reaction to the physical examination, particularly the genital examination, was worrisome and that unusually passive, sad, or combative behavior from the child would make them suspicious.

Many groups (5/6) mentioned that parental concern about a child's behavior or anogenital complaints would trigger them to ask questions about possible sexual abuse. One member said, "You need to find out from the parent, because a lot of times parents will come in and that [sexual abuse] is their first concern ... "

Nearly all groups (5/6) mentioned social factors that might lead to inquiry about possible sexual abuse particularly when accompanied by behavioral changes. These factors included a young mother, a mother with a boyfriend, teenage males in the home, and a child in foster care.

Providers identified multiple red flags that they believed would trigger them to inquire about the possibility of sexual abuse. These red flags ranged from behavioral symptomatology and abnormal physical findings to historical and social factors.

Theme 3: Approach to Management

There was no consensus regarding the approach to management of cases of possible child sexual abuse among the groups surveyed. Members of several groups (4/6) said they preferred the parent to raise the issue of possible abuse. However, they acknowledged that it was often difficult for parents to do this, and they believed that the inquiry is the responsibility of the medical provider. One member stated, " ... it is very unusual, I think uncommon, for people to come in and say, "I think my child has been abused.' ... so it really puts it on you to really have to ask the question ... or listen very carefully to figure out that's the complaint."

Most groups (5/6) reported that they would ask specific questions about sexual abuse to both the parents and the child when the previously listed red flags were present, even if the parent did not raise the issue of possible abuse. Participants reported approaching the parents first without the child present in the room. One member reported saying to the parent, "You appear to be concerned," followed by, "What are you thinking about?," and then, "Is there any possibility ... that there could be sexual abuse?"

Members emphasized the importance of initiating the discussion with open-ended questions and then following up with more direct inquiry depending on the parent's response.

Some providers indicated that they would also direct questions to the child either with or without the parent present. One member reported using the following words, "I just tell them [the children] that I am concerned that there is a problem going on. "I know you have been complaining to your mom that it hurts down there ... Has anything happened that made you hurt down there?' and eventually ... "Did you fall?' and "Did anyone touch you there?"

Members acknowledged the possibility that the parent could be the perpetrator but were reluctant to question a young or anxious child without the parent in the room. Other participants discussed the difficulty of getting a complete disclosure and expressed concern about asking the child leading questions and contaminating the child's disclosure. One provider summed it up by saying, "If there is a story, I am always positive that I am not the right person to get a subtle story from a small child ... I think you just confuse the really good collection of data ... "

In these situations, many participants reported referring the child to a mental health provider or to a child abuse team at a tertiary care center for additional evaluation and a disclosure interview.

Members of several groups (4/6) reported focusing their attention on the medical evaluation, even though they acknowledged that the presence of physical findings of sexual abuse is very low. Half of these groups expressed reluctance to evaluate children with suspicious complaints further unless the medical evaluation was abnormal.

Participants did not agree on a uniform approach to the management of cases of possible sexual abuse. Providers focused on the medical evaluation despite acknowledging that a normal or nonspecific examination is common in victims of sexual abuse. Many practitioners did not know the types of questions that they should be asking children when they suspect abuse.

Theme 4: Terminology Used in Discussions with Families

Members of all groups used a variety of terms to describe the genitalia, sexual abuse, and masturbation in the focus group interviews as described in Table 2. They also reported using many of these same terms in their discussions with families. Imprecise terminology such as "down there" and "this/that area" were often used to refer to the genitalia. Phrases such as "that sort of stuff" were used to refer to both sexual abuse and masturbation.

Group members reported difficulty with using the words "sexual abuse" when discussing this issue with families. One participant summed it up by saying, " ... the question is how do you get into this thing of sexual abuse. I don't actually say [those words]. I actually try to couch it as "inappropriate touching' because then the parent feels much more comfortable with that."

One group member acknowledged the problem with using such vague references for sexual abuse in discussions with children by saying, "I have always been bothered by these euphemisms. [when saying to the child] "Has anybody touched you in a way that you didn't like?' The child has to translate that into "Has somebody touched you in your vagina?' to make a meaningful answer and as long as they have to translate it, you might as well ask them."

Many practitioners found it difficult to use precise language in their discussions of sexual topics with families despite acknowledgment that use of such vague references can be problematic.

Theme 5: Barriers to Inquiry

A number of barriers to inquiry were identified as described in Table 3. Members of all groups reported that lack of training in sexual abuse was the major barrier to inquiry and that cases of abuse are missed because of inadequate training. One participant said, "It [the decision to inquire about possible sexual abuse] is a major decision and nothing in residency prepared me for the decision when I first started practice."

Another pediatrician said, "I have missed it [sexual abuse]. There is no way that [of] the 2000 kids I have seen in the past 9 months, [that] one of them hasn't been abused ... "

Most groups (5/6) reported lack of time and loss of alliance with the family as barriers to raising the issue of possible sexual abuse. As one provider said, "There's the risk that if you suspect it [sexual abuse] and start evaluating it ... you can really even make it worse for the family."

Members of several groups (4/6) candidly admitted the existence of internal barriers by saying, "I think there are two barriers [to inquiry] that come from within us. One is a lot of providers have some discomfort with some sexual issues and secondly, what I think I'm hearing is, "Do we really want to know this information and then [have to] deal with it?"

Members in half of the groups (3/6) discussed fear and uncertainty as barriers to inquiring about possible sexual abuse. They used the metaphor "letting the cat out of the bag" to describe this loss of control. One participant said, " ... you don't know what you are uncovering and where it is going to take you" and "once you "let the cat out of the bag,' you have no control over it."

Participants in half the groups (3/6) also expressed frustration about the lack of appropriate referral services for children whom they believed to be at risk and in need of additional evaluation for possible sexual abuse. Clinicians in half the groups (3/6) cited their belief that child protective services are inadequate or counterproductive as a barrier to inquiry.

Members of only one group discussed the concern regarding false accusations as a barrier to inquiry about possible sexual abuse. Participants identified multiple barriers to inquiring about possible sexual abuse with the most significant barrier being inadequate training.

	DISCUSSION

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We found that highly motivated pediatric providers do not routinely give anticipatory guidance about sexual abuse. They do not believe that they are equipped adequately to address suspected sexual abuse for a number of reasons. They do not feel that they were trained adequately during residency to recognize the signs of child sexual abuse. They were not taught a consistent approach to such cases, including the types of questions they should be asking children when they suspect abuse and the agencies within their communities to which they might refer a child for additional evaluation. They do not feel comfortable discussing sexual topics with children and families. Consequently, they believe that they have failed to identify children who may have been sexually abused, and they have been unable to intervene on their behalf.

Previous studies support these findings. A recent nationwide survey of pediatric residency program directors found that child abuse, particularly sexual abuse, is an area that is not covered adequately during training.¹⁴ Woolf et al¹⁵ found that residents who reported more formal exposure to child abuse training performed better on a questionnaire assessing knowledge of child abuse. Ladson et al¹⁶ found that limitations in knowledge of the social and medical aspects of sexual abuse decreases pediatricians' recognition and reporting of abuse.

The barriers to the recognition and intervention for domestic violence, as opposed to sexual abuse, have been identified in previous studies.^17,18 Physicians reported that exploring domestic violence is analogous to opening Pandora's box and that barriers to inquiry included lack of comfort, fear of offending the patient, powerlessness, loss of control, and time constraints.¹⁸ Indeed, similar barriers seem to affect recognition and intervention for child sexual abuse.

We believe that the current study has implications for residency training. Previous studies have distinguished normal childhood sexual behavior from behavior that may be concerning for sexual abuse.^19,20 Guidelines for questioning children appropriately when sexual abuse is suspected also exist.^21-23 Other studies have shown that most children who have been abused sexually have normal or nonspecific genital examinations.^24,25 Our study suggests that this information should receive greater emphasis during pediatric residency training. Additionally, residents should be encouraged to examine children's genitalia routinely at each well-child visit to become familiar with normal variations at all ages.

There are limitations to this study. It provides rich information about how a small, select sample of pediatric providers approaches cases of possible sexual abuse. Attendance of COR meetings presumes a certain level of motivation and interest in psychosocial topics that might not exist in the general population of pediatric medical providers. For these reasons, the results of this study may not be generalizable to other populations of medical providers but provide important insights worthy of additional study. Our impression is that the barriers to addressing child sexual abuse are even more daunting for pediatricians who have less training and who are less motivated to address issues related to child development and behavior.

This study provides new information, because it examines with more detail the reasons pediatricians believe that they are not equipped adequately to address child sexual abuse and the implications for patient care. This study also yields clinically useful information, because these themes provide a foundation to design and test educational interventions in residency training and continuing medical education courses.

	CONCLUSIONS

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In summary, highly motivated pediatric providers reported that they inconsistently give anticipatory guidance about sexual abuse, that they were not trained to recognize red flags for sexual abuse, and that they do not have a consistent approach to cases of suspected abuse. Additionally, they reported that they feel uncomfortable discussing sexual issues with families and that they believe they miss cases of sexual abuse primarily because of lack of training. We believe that new educational programs can be designed from this study that focus on screening questions for patients and families, physical examination guidelines, and intervention strategies.

	APPENDIX 1: Focus Group Interview Guide

Vignette 1: Genitourinary Complaint

Mrs Jones and her 7-year-old daughter present to your office for additional evaluation of a vaginal discharge. The mother seems concerned. The child has no other complaints but has been reluctant to go to the baby-sitter's house after school. The physical examination is remarkable for a moderate amount of purulent vaginal discharge. The remainder of the examination is normal.

Vignette 2: Sexualized Behavior

Mrs Mann and her 4-year-old son come to your office. The mother is concerned, because her son has been masturbating openly. She has reminded him that this activity is to be performed in private, but the behavior persists. There are no other complaints, and the physical examination is normal.

Vignette 3: Routine Visit

Mr Smith and his 8-year-old son present to your office for a routine check up. Neither the parent nor the child raises any concerns. The physical examination is normal.

Vignette 4: Nonspecific Complaint

Mr Greene and his 14-year-old daughter present to your office for additional evaluation of recurrent midabdominal pain for the last several months. There are no other associated symptoms. She has missed a significant amount of school. The physical examination is unremarkable.

Vignette 5: First Gynecological Examination

A 16-year-old girl requests information about birth control. She admits that she drinks to drunkenness on the weekends. Her physical examination, including a pelvic examination, is normal.

	ACKNOWLEDGMENTS

Dr Leder's participation in this project has been supported by the Maternal and Child Health Bureau Developmental and Behavioral Pediatrics Training Grant 6-T77 MC0011, the Von Meyer Award, and the Milton Fund.

We thank the members of the COR groups who agreed to participate in this study. We also thank Dr David Schonfeld and Robert Heroux for their review of the manuscript. The abstract of this study was presented in a poster session at the Ambulatory Pediatrics Association meeting on May 4, 1998.

	FOOTNOTES

Received for publication Jun 30, 1998; accepted Jan 8, 1999.

Address correspondence to Mary Ranee Leder, MD, Children's Hospital, Timken G-352, 700 Children's Drv; Columbus, OH 43205. E-mail: lederr{at}pediatrics.ohio-state.edu

	ABBREVIATIONS

COR, collaborative office rounds.

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