INTRODUCTION

Sexual abuse of a child is defined as using a psychosocially and sexually incompetent child for sexual desire and needs through force, threat or deception (1). Among the factors increasing the risk of being exposed to sexual abuse can be listed as: growing up in a disintegrated family, the presence of a psychiatric disorder, sexual abuse history and lack of social support (2). The sexually abused-sexual abuser hypothesis of child posits that persons, in particular males, who were exposed to abuse in childhood are particularly at risk of becoming an abuser (3).

The aim of this case report is to present a pediatric patient who was abused by a babysitter with a history of abuse in her adolescence.

CASE

A three-year-old girl was referred to child psychiatry clinic for forensic evaluation, with the claim of her babysitter hit her genital organ and buttocks. Before the child psychiatry admission her family reported that she showed her genital organ and buttocks, and said that they were hurting because of her babysitter did something bad. They went to an emergency service after her mother visually inspected her body and saw a rash on her buttocks. At the emergency service, a pediatrician performed a physical examination then called a pediatric surgeon. The surgeon decided to carry out a physical examination under general anesthesia upon the request of the family, because he thought that the child might be afraid of genital examination. The surgeon detected fissures in child’s anus, trauma in her hymen, and ecchymoses on the buttocks. After these findings, the family contacted the police department. The family was admitted to the Department of Forensic Medicine of the university hospital in company with the police officer. During the examination in the forensic medicine clinic, the physician found that her hymen was intact, and there were superficial fissures at the position of face, a fissure in her anus, and an ecchymosis at the back. It was realized that the 20-year-old babysitter, daughter of the paternal uncle of the child, who had cared for her for the previous three months, abused her. Her family said that they could not know how many times the child was abused by her.

The family learned that 10-year-old elder daughter of the family was also exposed to sexual abuse. Two weeks after the employment of the babysitter, the elder sister said that the babysitter touched her breasts. When parents talked about that incident with the babysitter, she denied it. Unfortunately, the family thought that their daughter was lying.

Furthermore, the family said that the babysitter had been involved in a legal case previously and they did not know the details about. Her court file was requested by the Department of Forensic Medicine. It was found out that a relative of the babysitter raped her three years ago. After this event, she became pregnant at the age of 17 and was forced to abortion by abuser. According to the case file, she was diagnosed with acute stress disorder (ASD) but did not receive any support or treatment.

During the interview with the family, it was discovered that the child did not want diaper changing, her sleep and appetite are decreased, and she had nightmares for the last month. She did not want to go to recreational areas or participate in any social activity. At the baseline evaluation, she appeared in stated age and had normal self-grooming. Consciousness and orientation were intact. She gave some pictures to the child psychiatrist that she drew in the waiting room with other children. She seemed defensive, unhappy and remarkably anxious. She did not make any eye contact. She held her mother’s hand incessantly and did not want to sit in the room. She took a glance at the toys in the room and wanted to go outside. Then, she agitated suddenly and had a tantrum in the room. During the interview, she attempted to reject communication. Play therapy sessions and 10mg/day hydroxyzine HCl were recommended for her anxiety and other symptoms.

The first play therapy session was scheduled for the week after her visit. At the first session, she did not want to enter therapy room and had another tantrum at the hall. Her mother stated that her appetite and sleep were better than the previous week, and she started to go to the nursery. The second visit was planned in the following week. The child started to communicate with the child psychiatrist in the session and seemed cheerful. She could stay at the therapy room approximately fifteen minutes then got anxious and called her family into the room. Her family explained that she was gradually getting better and enjoyed to go to the nursery. Maintaining of 10mg/day hydroxyzine HCl therapy was decided. Unfortunately, she participated merely two times in the play therapy sessions, because her family decided to move to another city for a new beginning. She was directed to another child psychiatrist in their new settlement. She has been still followed up by child psychiatrist, and she has a good mood.

DISCUSSION

The rate of sexual abuse has been found to be 3 to 37% in boys and 7 to 53% in girls. The majority of abused individuals are girls while the majority of abusers are males. Females may also become sexual abusers but those cases are more infrequent (4,5). Role modeling and social learning theory may explain this finding since children who are abused may take the individuals in their traumatizing experiences as role models (6). In our case, the abusive babysitter had been abused. The determination of victim or offender is contradictive.

It is known that childhood sexual abuse history may lead to many psychiatric disorders in the future (1,7). In our case report, the abuser had ASD due to sexual abuse, did not receive any psychiatric treatment at that time and alienated by her family, then subsequently abused two children. It seemed to be forgotten that she was an adolescent who became pregnant after the sexual abuse three years ago. All similar cases who are exposed to sexual abuse should receive an obligatory psychiatric evaluation and follow-up program. Psychiatrists should monitor these cases closely in terms of preventive psychiatry.

Right now, necessary interventions have been processed for this case and our team follow her progress remotely by contact her current physicians. Additionally, the Ministry of Justice and Ministry of Health is monitoring the process.

It has been stated that sexual abuse cases report their experiences at the rate of approximately 15% (1). The most important cause of this secrecy is that the concern that family would not believe him or her. In addition to this, young children may perceive the abusive event as a normal behavior, consider it as an indicator of love and interest, especially if the abuser is a family member (1). Families that know the abuse are also not willing to report it to the legal authorities because of the fear of social rejection and religious pressure (1). Therefore, children should receive sexual education to protect themselves and ask for help in such circumstances.

Another important point in our case was that a pediatric surgeon carried out genital examination under general anesthesia without legal request. In Article 287 of Turkish Criminal Code, it is stated that physicians cannot carry out genital examination without a decision of authorized judge or public prosecutor (8). In Article 76 of Criminal Procedure Code, it is stated that after victim’s consent, examinations can be carried out without the decision of judge or public prosecutor in order to collect evidence regarding a crime. Hovewer, it is also stated that this examination should not be a surgical examination and should not endanger health of the victim (9). There are case reports in the literature reporting that genital examination has been carried out under general anesthesia upon the suspicion of sexual abuse (10). However, the family declared that the procedure was not explained to them in detail and they became aware of the genital examination after the procedure had already been processed. If we evaluate the current case, the legal authorities should have been informed before the examination. If this is not possible, obtaining informed consent from the family after explaining all the positive and negative aspects of examination and anesthesia would have been more convenient.

For early recognition of sexual abuse, treatment of developing psychiatric disorders, and minimization of abused-abuser vicious cycle, sexual abuse victims should undergo a comprehensive psychiatric evaluation and follow-up program. In addition, it is important to inform health care professionals in such sexual abuse cases in order to carry out proper forensic evaluations regarding health legislation, children rights, legal obligations and rights. Teams composed of child psychiatrists, forensic medicine doctors, pediatricians, emergency service physicians, and social workers should be established for the management of legal processes in order to make interventions, which are most beneficial for the patients. These teams should offer information to health professionals and prepare forensic evaluation training programs.

Conflict of Interest: Authors declared no conflict of interest.

Financial Disclosure: Authors declared no financial support.

REFERENCES

1.Iseri E. Sexual Abuse. In: Coskun A, Iseri E, Miral S, Motavalli N, Pehlivanturk B, Turkbay T, Uslu R, Unal F (editors) Textbook of Child and Adolescent Psychiatry. Ankara: Hekimler Yayin Birligi, 2008, 470-477. (Turkish)

2.Davies EA, Jones AC. Risk factors in child sexual abuse. J Forensic Leg Med 2013; 20:146-150. [CrossRef]

3.Leach C, Stewart A, Smallbone S. Testing the sexually abused-sexual abuser hypothesis: A prospective longitudinal birth cohort study. Child Abuse Negl 2016; 51:144-153. [CrossRef]

4.Salter D, McMillan D, Richards M, Talbot T, Hodges J, Bentovim A, Hastings R, Stevenson J, Skuse D. Development of sexually abusive behaviour in sexually victimized males: a longitudinal study. Lancet 2003; 361:471-476. [CrossRef]

5.Finkelhor D. The international epidemiology of child sexual abuse. Child Abuse Negl 1994; 18:409-417. [CrossRef]

6.Felson RB, Lane KJ. Social learning, sexual and physical abuse, and adult crime. Aggress Behav 2009; 35:489-501. [CrossRef]

7.Jumper SA. A meta-analysis of the relationship of child sexual abuse to adult psychological adjustment. Child Abuse Negl 1995; 19:715-728. [CrossRef]

8.Turk Ceza Kanunu http://www.mevzuat.gov.tr/MevzuatMetin/1.5.5237.pdf. Date of access: 26.06.216

9.Ceza Muhakemesi Kanunu http://www.mevzuat.gov.tr/MevzuatMetin/1.5.5271.pdf. Date of access: 26.06.2016

10.Harari MD, Netzer D. Genital examination under ketamine sedation in cases of suspected sexual abuse. Arch Dis Child 1994; 70:197-199. [CrossRef]