Increasing numbers of women will be asking their gynecologists to examine their daughters for signs of suspected sexual abuse.
With number of victims now reaching catastrophic proportions, even physicians accustomed to examining only adult patients need to familiarize themselves with the approach to this complex problem. Sexual abuse may be committed by a person under the age of 18 years, when that person is either significantly older than the victim, or when the abuser is in a position of power.
Abuse can represent any type of behavior such as disrobing, genital exposure. Molestation is a nonspecific term, sometimes used in a more polite setting, generally referring to nongenital or less violent contact. Incest is the term applied to a special subclass of sexual abuse that includes any sexual behavior inappropriate to a normal pre-existing family relationship. Relatives may be of various types and degrees. Various statistics are quoted, of which only the more recent implicate the monstrous extent of this crisis.
A typical child sex offender has abused an average of 68 victims. In other words, we are now seeing only the tip of the iceberg. Reports indicate that abuse occurs at all ages. Although average reported age is 8 to 11 years at the time of the first incident, it is now believed that younger children are at higher risk because of their physical vulnerability, trusting attitude, and moral ignorance regarding right and wrong behavior.
Younger victims are more likely to know the assailant especially incestuouslyto be victims of recurrent abuse, to report crimes not involving intercourse, and to present with abused siblings. The child knows the abuser in more than three fourths of the cases in which the victim is able to give a history. Almost invariably, the abuser is in a position of being the child's caretaker, thus being someone known and trusted in a position of authority over the child.
Abusers ordinarily have easy access to the child and have numerous opportunities to be left alone at home. The home situation frequently is such that the child lacks sufficient attention and affection; the abuser cultivates a warm, friendly relationship that Vaginal penetration with foreign object pics child values and wants to sustain. This sympathetic rapport progressively evolves from hugs, caresses, and nonerogenous kisses into seemingly innocent nudity Vaginal penetration with foreign object pics fondling; overt sexual acts follow.
He or she convinces the child that if any of these clandestine frolics come to light, it is the youngster and not the abuser who will be punished, removed from the home and prevented from seeing his or her family ever again.
Vaginal penetration with foreign object pics may also threaten harm will come to the child's parents or siblings. An elderly or widowed perpetrator may have no other carnal outlet; younger relatives may be the preferred prey precisely because of their virginal innocence and cleanliness, compared with a paid prostitute. When the father or a father figure is the perpetrator, the mother may actually be aware of the wrongdoing but be in a state of denial or be a victim of abuse herself.
This Vaginal penetration with foreign object pics especially true in households in which alcohol or drug abuse is commonplace. In addition to making use of a child for his own debauchery, a father figure may subjugate the victim into engaging in sex acts for other family members or even prostitution.
Youths who run away from home to escape this environment are at higher risk for continuation of prostitutional behavior or substance abuse in the future. Behaviorial indicators may be the first or only sign that sexual abuse has taken place.
A change from a normal pattern of behavior, especially if regressive, is most significant. A previously toilet-trained child may revert to enuresis; a formerly well-adjusted one may demonstrate sleep disturbances such as nightmares or demand to sleep with a night-light.
Older children may evince a deterioration of school performance or manifest sexualized behavior inappropriate for their developmental level. History taking in abuse cases is a true art and continues to be the most important part of any evaluation. Ideally it is conducted by a trained professional such as a therapist or social worker. Careful documentation of all details in the child's own words is vital and constitutes legal evidence.
Privacy and ample time are prerequisites: A child should not be made to repeat the story of the incident over and over. Unnecessary personnel in the room will only add to the child's embarrassment and so may hinder adequate information gathering. The original history obtained is usually the best one. Tape recording the initial interview has been recommended.
With younger children, use of anatomically correct dolls or picture drawings not only enhances rapport but also establishes the child's terminology for body parts. It is important that children's sense of guilt and fear be addressed in a way that will not make them feel responsible for any wrongdoing.
Reassurance that they will not be punished by either the system or the perpetrator will also engender a more supportive atmosphere. The disclosure sometimes is accidental, and the relationship may Vaginal penetration with foreign object pics yet have progressed to the point of any painful physical contact or emotional conflict. A child might recall pleasurable sensations from the encounters and now feel ambiguous or confused about the new aspect of immorality brought to awareness.
Therefore, a neutral approach is crucial so that a child does not hold back any information. A child's eventual disclosure almost never takes place after only one incident. The interviewer may attempt to date back to a singular experience suggesting seasonal clues such as occurrence around the time of a birthday, holiday, or school vacation.
Incredible vaginal penetration with foreign object pics sexy por pics
Other helpful particulars include hour of the day, exact locations, and the absence or proximity of other family members.
Historical factors that help validate the account include the occurrence of multiple episodes over time, a progression from fondling to penetration, an element of secrecy Vaginal penetration with foreign object pics by coercion, and explicit details of the abuse.
Children rarely anticipate the sequelae of the allegation. They confess in an effort to gain protection or an end to victimization and hardly ever expect the consequent police involvement or complex medical examination. Ambivalence may taint their feelings toward their abuser; in some cases, this may have been the only source of affection for an emotionally starved child. An understanding, unhurried approach obviously is critical.
A parental figure or guardian of the patient's choice should be present. The entire examination Vaginal penetration with foreign object pics is explained to the patient and parent. In addition to the history already taken, a physician must inquire about pain, bleeding, ejaculation, and the use of force or instrumentation.
If the most recent assault has occurred within the past 72 hours, the examination is conducted immediately. Otherwise, choose a time agreeable to the child, her or his caretaker, and the trained interviewer. The first visit sometimes is used to take the history and establish familiarity; the physical examination follows in 1 to 2 weeks.
A general physical examination reveals important information in terms of demeanor, affect, and general hygiene; overall neglect may be clear. Maintain modesty and decrease embarrassment by draping any part of the body not under immediate inspection. Note evidence of extragenital as well as genital trama: Documentation using diagrams 910 or sensitively taken photographs is essential.
In the absence of penetration, trauma is limited to the vulva and perineum and varies with the degree of force exerted by the abuser.
Note the presence of all physical findings, regardless of how innocuous or nonspecific they may seem initially. These encompass erythema, edema, excoriations, petechiae, bruises, and urethral inflammation. Because many milder injuries heal within a few days, 2 a careful search for old wounds must be carried out, and a magnifying lens or colposcope is especially helpful here. Long-standing abuse can manifest itself by seemingly innocent conditions such as nonspecific vaginal discharge or labial agglutination.
In cases of recent attack, any dried secretions, threads of clothing, or pubic hairs are collected as criminal evidence.
Great controversy exists over hymenal diameter and its relevance in sexual abuse cases. Better studies of normal hymenal anatomy have established that absolute diameter varies with the type of hymen circumferential, fimbriated, or posterior rimthe amount of tissue present, and the degree of patient relaxation, as well as with age, weight, examination position dorsolithotomy vs. Still, a hymenal diameter greater than 1.
Stronger emphasis is now placed on findings of disturbance of the normal clear lacy hymenal vasculature or loss of the velamentous delicate border, especially posteriorly from 9 to 3 o'clock. Asymmetric tears of the hymen in this area. Scarring and attenuation are unequivocal proof of penetration 14 Fig.