It can be difficult to spot signs of abuse in a child as there are not always physical signs that are obvious. In this chapter, we will look at signs of sexual abuse, particularly child sexual exploitation, emotional abuse and neglect as these are examples of abuse that can be difficult to identify.
Sexual Abuse
There are very few absolutely diagnostic signs of sexual abuse on examination. This is because often sexual abuse of children is by touching or kissing or other activities that do not involve significant physical force. Furthermore the genital area heals very quickly in young children: no signs may be present a few days after quite significant trauma. Forensic material also decays rapidly.
Examination of children suspected of having been sexually abused requires a doctor with specific expertise and training, facilities for photo documentation, sexually transmitted infection screening and management, and (where indicated) forensic testing. Forensic material (e.g. DNA from sperm) may be found on the child or his/her clothing/bedding.
Child sexual exploitation is a hidden crime. Young people often trust their abuser and don't understand that they're being abused. They may depend on their abuser or be too scared to tell anyone what's happening.
What can be involved?
It can involve violent, humiliating and degrading sexual assaults, including oral and anal rape. In some cases, young people are persuaded or forced into exchanging sexual activity for money, drugs, gifts, affection or status. Child sexual exploitation doesn't always involve physical contact and can happen online.
Child sexual exploitation (CSE) is a type of sexual abuse. Children in exploitative situations and relationships receive something such as gifts, money or affection as a result of performing sexual activities or others performing sexual activities on them.
Children or young people may be tricked into believing they're in a loving, consensual relationship. They might be invited to parties and given drugs and alcohol. They may also be groomed and exploited online.
Some children and young people are trafficked into or within the UK for the purpose of sexual exploitation. Sexual exploitation can also happen to young people in gangs.
Child trafficking and modern slavery
Child trafficking and modern slavery are child abuse. Children are recruited, moved or transported and then exploited, forced to work or sold. Children are trafficked for:
Child sexual exploitation
Benefit fraud
Forced marriage
Domestic servitude such as cleaning, childcare, cooking
Forced labour in factories or agriculture
Criminal activity such as pickpocketing, begging, transporting drugs, working on cannabis farms, selling pirated DVDs and bag theft
Many children are trafficked into the UK from abroad, but children can also be trafficked from one part of the UK to another.
Gangs and young people
Children and young people involved with, or on the edges of, gangs might be victims of violence or they might be pressured into doing things like stealing or carrying drugs or weapons. They might be abused, exploited or put into dangerous situations.
For lots of young people, being part of a gang makes them feel part of a family so they might not want to leave. Even if they do, leaving or attempting to leave can be a really scary idea. They might be frightened about what will happen to them, their friends or their family if they leave.
Grooming
Grooming is when someone builds an emotional connection with a child to gain their trust for the purposes of sexual abuse, sexual exploitation or trafficking.
Children and young people can be groomed online or face-to-face, by a stranger or by someone they know - for example a family member, friend or professional.
Groomers may be male or female. They could be any age.
Many children and young people don't understand that they have been groomed or that what has happened is abuse.
Child sexual abuse online
When sexual exploitation happens online, young people may be persuaded, or forced, to:
Send or post sexually explicit images of themselves
Take part in sexual activities via a webcam or smartphone
Have sexual conversations by text or online
Abusers may threaten to send images, video or copies of conversations to the young person's friends and family unless they take part in other sexual activity.
Images or videos may continue to be shared long after the sexual abuse has stopped.
It is a criminal offence to meet a child online and engage in a sexual conversation, or to arrange to meet the child in person for the intent to sexually abuse or exploit them.
Child sexual exploitation (CSE) is a type of sexual abuse where the child/young person receives something (for example, money, food, shelter, drugs) in return for sexual activities. There is a power imbalance between the perpetrator and victim. Staff in GUM clinics, GPs, CAMHS and Emergency Departments are well-placed to consider whether a young person might be subject to CSE. The difficulty is that most victims do not recognise that they are being exploited.
Vulnerability factors include:
Previous abuse
Young people in foster/residential care
Young people who are missing (from education/home)
Drug/alcohol use
Poor self-esteem
The child or young person may be difficult to engage and display challenging behaviour. Local GUM and Emergency Department services should be able to signpost to local services that offer support and intervention as they work closely with the police and children's social care.
Test your Knowledge
How might concerns about sexual abuse arise in a healthcare setting?
A child may:
Think of four options and check the answer.
Be identified in indecent images
Be pregnant
Have mainly older friends
Have a sexually transmitted infection with no clear explanation
Be sexually active at a young age
A child may:
Be identified in indecent images
Be sexually active at a young age
Be pregnant - by legal definition this is due to sexual abuse if the girl is under the age of 13 years
Have a sexually transmitted infection without explanation - note that some sexually transmitted infections can be passed from the mother to the baby during pregnancy or birth
Physical symptoms are rarely diagnostic. Concern arises in children who present with vaginal bleeding, itching, discharge or rectal bleeding, although these may have other non-abusive causes.
What are the physical symptoms of sexual abuse?
Think of three options and check the answer.
Vaginal bleeding
Scratches on the torso
Vaginal itching
Discharge or rectal bleeding
What are the behavioural symptoms of sexual abuse?
Think of one or more options and check your answer.
Soiling, secondary enuresis
Self-harm
Aggressive or sexualised behaviours
Regression and poor school performance
Running away from home or care
Behavioural symptoms are rarely diagnostic and there are other non-abusive causes but concern arises in children who present with:
Soiling, secondary enuresis
Self-harm, aggressive or sexualised behaviours, regression and poor school performance
Running away from home or care
Neglect
This component displays an image gallery with accompanying text. Use the next and back navigation controls to work through the narrative.
When should you consider the possibility of neglect?
When the child:
Consistently misses medical appointments
Lacks needed medical/dental care, immunisations or glasses
Seems ravenously hungry
Is dirty
Is wearing inadequate clothing for cold weather
Is abusing alcohol or other drugs
Says there is no one at home to provide care
When the parent or other adult caregiver:
Appears to be indifferent to the child
Seems apathetic or depressed
Behaves irrationally or in a bizarre manner
Is abusing alcohol or other drugs
Dental neglect
Dental neglect can be defined as “the persistent failure to meet a child’s basic oral health needs, likely to result in the serious impairment of a child’s oral or general health or development.
Poor oral health can impact on a child’s ability to eat, sleep, speak and socialise as well as potentially causing pain, infection, poor nutrition or impaired growth and development.
Concerning features or behaviours to be aware of once dental problems have been highlighted to parents or carers may include:
Failure to take a child for dental care leading to severe untreated dental problems
Missing appointments and not completing recommended dental treatment
Failure to provide basic dental care at home (e.g. toothbrushing twice daily with fluoride toothpaste)
Repeated general anaesthesia to remove teeth
Emotional Abuse
Emotional abuse is the hardest form of abuse for anyone in a healthcare setting to detect. It is very damaging and can cause severe, long-term harm to a child's intellectual and emotional development.
Some clues may be found by considering the status of the child for the parent or caregiver. Is the child the 'wrong' gender, born at a time of parental separation or violence, or seen as 'ill' or 'difficult'? Is the parent/carer overprotective?
Is there a suspicion of bullying, not only by a parent/carer but by others in the child's life, for example at school or online?
Babies
Apathetic, delayed development, non-demanding. The mother describes the baby as 'spoiled, attention seeking, in control, not loving her’.
Toddlers and pre-school children
Violent, clingy, apathetic.
School children
Wetting, soiling, relationship difficulties, non-attendance, anti-social behaviour.
Self-harm, substance misuse, depression, oppositional, aggressive and delinquent behaviour
