Child Sexual Abuse - Pitfalls in The Substantiation Process (2009) - Anna Aprile Et Al

Children's Issues, Laws and Programs Series
CHILD SEXUAL ABUSE: PITFALLS IN THE SUBSTANTIATION PROCESS
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CHILDREN'S ISSUES, LAWS AND PROGRAMS SERIES

Child Sexual Abuse: Pitfalls in the Substantiation Process Anna Aprile, Cristina Ranzato, Melissa Rosa Rizzotto and Paola Facchin 2009. ISBN 978-1-60741-427-8
Children's Issues, Laws and Programs Series
CHILD SEXUAL ABUSE: PITFALLS IN THE SUBSTANTIATION PROCESS
ANNA APRILE, CRISTINA RANZATO, MELISSA ROSA RIZZOTTO

AND
PAOLA FACCHINI
Nova Science Publishers, Inc.

New York
Copyright 2009 by Nova Science Publishers, Inc.

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LIBRARY OF CONGRESS CATALOGING-IN-PUBLICATION DATA Aprile, Anna. Child sexual abuse : pitfalls in the substantiation process / Anna Aprile, Cristina Ranzato. p. cm. Includes bibliographical references and index. ISBN 978-1-61728-181-5 (E-Book) 1. Child sexual abuse. I. Ranzato, Cristina. II. Title. HV6570.A67 2009 362.76'65--dc22 2009010236
Published by Nova Science Publishers, Inc. New York
CONTENTS
Preface About the Authors Chapter 1 Chapter 2 Chapter 3 Chapter 4 Chapter 5 Chapter 6 Chapter 7 References Index Introduction Sexual Abuse: A Bibliometric Analysis A Challenging Diagnosis: Its Normal to Be Normal! Published Case Reports Review Case Report Thank God It Wasnt that! Conclusion vii ix 1 5 49 61 73 77 89 91 103
PREFACE
Sexual abuse is a significant issue in child and youth health, often imposing an immediate and serious effect on child health and severe long term consequences on adulthood. The extreme variability of observable signs of child sexual abuse can range from the vague to the clear cut and this has led to the fact that allegations of sexual abuse are frequently contested. The great number of variables to be taken into consideration in the procedure of decision making renders the substantiation process very complicated for the cases of suspected child sexual abuse. This book explores all the aspects related to the problem of false allegations and misdiagnoses of Child Sexual Abuse (CSA). Starting from a bibliometric research exploring the main trends and characteristics of the international literature on CSA, a synthesis of current updated evidences and a review of all available case reports published, the issue is tackled considering all possible factors that may influence the professionals in arriving to a decision as to whether or not a child has been sexually abused and in integrating empirical research to help guide their decision-making process.
ABOUT THE AUTHORS

Prof. Anna Aprile, MD PhD Legal Medicine Institute, University of Padua Via Falloppio 50, 35121 Padova Italy Tel.: 0039 049 8272201, Mobile 0039 335 1425815 Fax: 0039 049 8215701 anna.aprile@unipd.it Dr. Cristina Ranzato, PhD Veneto Region Center for Child Abuse & Neglect Diagnosis Epidemiology and Community Medicine Unit, Paediatrics Department University of Padua, Via Giustiniani, 3, 35128 Padova Italy Tel.: 0039 049 8215700, Mobile 0039 347 8455626 Fax: 0039 049 8215701 ranzato@pediatria.unipd.it Dr. Melissa Rosa-Rizzotto, MD Veneto Region Center for Child Abuse & Neglect Diagnosis Epidemiology and Community Medicine Unit, Paediatrics Department University of Padua, Via Giustiniani, 3, 35128 Padova Italy Tel.: 0039 049 8215700, Mobile 0039 349 4624578 Fax: 0039 049 8215701
Anna Aprile, Cristina Ranzato, Melissa Rosa Rizzotto and Paola Facchin
Prof. Paola Facchin, MD PhD Veneto Region Center for Child Abuse & Neglect Diagnosis Epidemiology and Community Medicine Unit, Paediatrics Department University of Padua, Via Giustiniani, 3, 35128 Padova Italy Tel.: 0039 049 8215700 Fax: 0039 049 8215701 facchin@pediatria.unipd.it
Chapter 1
INTRODUCTION
Sexual abuse is a significant issue in child and youth health, often imposing an immediate and serious effect on child health and severe long term consequences on adulthood. It is defined by the World Health Organization as the involvement of a child in sexual activity that he or she does not fully comprehend, is unable to give informed consent to, or for which the child is not developmentally prepared and cannot give consent, or that violate the laws or social taboos of society. Child sexual abuse is evidenced by this activity between a child and an adult or another child who by age or development is in a relationship of responsibility, trust or power, the activity being intended to gratify or satisfy the needs of the other person. This may include but is not limited to: the inducement or coercion of a child to engage in any unlawful sexual, activity, the exploitative use of child in prostitution or other unlawful sexual practices, the exploitative use of children in pornographic performances and materials [1]. For the last 20 years, reports of Child Sexual Abuse (CSA) have been constantly increasing. A recent study by Finkelhor and colleagues, using telephone surveys of a nationally representative sample of households in the United States, found prevalence rates for sexual victimization of 96/1 000 for girls, and 67/1 000 for boys between the ages of 2 and 17 years [2]. Because of the high prevalence and the potential for short and long-term adverse outcomes, all health providers caring for children and adolescents must be familiar with the problem of sexual abuse and with the type of evaluation needed for these children [3,4]. There are many indicators of CSA and these can be divided into three categories: physical [5,6], behavioral [7] and psychiatric signs [8]. In terms of physical indicators, according to the most recent evidences, few are diagnostic of
Anna Aprile, Cristina Ranzato, Melissa Rosa Rizzotto et al.
sexual abuse, such as the presence of a sexually transmitted disease in a young child or the presence of sperm in or on the body of the victim, and in many cases, definite physical findings of child sexual abuse are absent, even when the history is confirmed by perpetrator confession. CSA is also associated with a wide range of psychological and behavioral problems, including fear, anxiety, depression, anger and hostility, aggression, sexually inappropriate behavior, self-destructive behavior, poor self-esteem, suicidal ideation, behavior problems, posttraumatic stress disorder, somatization, delinquency, and feelings of isolation and stigma [9,10,11,12,13]. The extreme variability of observable signs of a suspected case of child sexual abuse can range from the vague to the clear cut and this has led to the fact that allegations of sexual abuse are frequently contested [14]: in other words, a claim of abuse often sparks a counter-claim, suggesting the allegation is false [15] and often confusing the diagnostic process. Current international guidelines recommend that a case with a suspicion of child sexual abuse should be immediately referred for a full medical examination and a global assessment [16,17,18,19]. The recommendations of the Committee on Child Abuse and Neglect of American Academy of Pediatrics [20] offer an outline of suggestions for taking a history from the child and caretakers, performing the physical examination and interview, and obtaining laboratory specimens as indicated. It also lists guidelines for making the decision to report suspected cases of sexual abuse to child protective services agencies and broadly reviews treatment, follow-up and legal issues. A comprehensive evaluation of a child who may have been sexually abused requires a specific set of skills and body of knowledge. Several agencies and professional may be involved in the referral of children for sexual abuse evaluation [21]. Child protection agencies, law enforcement (both police and prosecuting attorneys), physicians, mental health workers, and parents may all seek further delineation of the problem. These agencies and individuals are likely to have varying agendas and aims for the evaluation. Some may seek evidence to initiate prosecution, others to determine need for services, and still others to provide a second opinion on a physical examination [22]. In any case, in the US, once a child protection agency is notified that a child may be a victim of sexual abuse, each suspect is first screened for appropriateness and then investigated in case the suspect is well-grounded. Surveys of the outcome of investigations indicate that 41% to 53% of such concerns subsequently become confirmed as cases of sexual abuse [23,24]. These concerns range from the tentative or poorly formed, through to the clearly abusive or those which appear to have little substance. Confirmed cases are also named as
Introduction
substantiated or founded cases, the remainder are classified as unsubstantiated or unfounded cases. Researchers, professionals and the lay public have all expressed reservations about errors in classification because of the worry that among the substantiated cases, some may be wrongly categorized, resulting in a false allegation of CSA. In the above mentioned papers, references are made to the serious consequences which ensue for the child and adults involved following substantiation of a case when no sexual abuse has occurred [25]. These may include separation of child and parent, imprisonment, loss of job and reputation, and major psychological stress for all concerned [24]. According to the international literature, sources of false allegations are for example an incompetent professional using faulty investigative and interviewing techniques or benefiting of financial aid when substantiating a case of child abuse, or unscrupulous or vindictive, prevaricating adults for example parents involved in separating and/or custody disputes [26], or again inaccurate memories of children and their suggestibility or mistaken, programmed, lying, or fantasizing. This last case however is very rarely observed [24,27]. Nonetheless, although quite scary, the phenomenon of false allegations is fairly uncommon according to many studies [28], or at least probably not as common as the underestimation of cases of CSA. This book will explore all the aspects related to the problem of false allegations and misdiagnoses of CSA. Starting from a bibliometric research [29,30,31] exploring the main trends and characteristics of the international literature on CSA, a synthesis of current updated evidences and a review of all available case reports published and the report of a new case, the issue will be tackled considering all possible factors that may influence the professionals in coming to a decision as to whether or not a child has been sexually abused and in integrating empirical research to help guide their decision-making process.
Chapter 2
SEXUAL ABUSE: A BIBLIOMETRIC ANALYSIS

In recent years, a growing body of scientific literature devoted to sexual abuse in children has been published filling in the pages of numerous journals of various areas and discipline and representing a large part of the whole literature on child abuse and neglect [32]. Together with physical abuse, CSA has immediately represented one of the most predominant interests for all researchers involved in the field of violence against children. The aim of this chapter is to explore the characteristics of the specific literature on CSA in order to outline the main past and current research fields and areas of interest, and possibly argue the future trends, as well as to understand the profile of researchers and authors involved. Two retrieval systems were utilized: SilverPlatter Information Retrieval System Webspirs (SilverPlatter WebSPIRS) for PsycINFO data base, and PubMed data base, the service of the U.S. National Library of Medicine. All available years were chosen and searched. Two free text search was performed for each data base per each year, selecting all the records containing: a. the words child sexual and abuse and b. the quoted phrase child sexual abuse. Per each retrieved record, information was extracted on author/s, title, journal name, year of publication, volume, issue, page number, ISBN/ISSN code, and abstract, if available. Subsequently information on selected journals was gained from various sources, retrieving a detailed description of each journal on language, country and continent of publication. According to the classification of scientific disciplines, 6 main areas of content have been identified core journals, medicine, psychology, psychiatry, pediatrics, social science, and law, and each journal was examined and
classified according to the main theme it dealt with (i.e. BMJ, medical area; Journal of Psychopathology and Behavioral Assessment, psychological area). A descriptive bibliometric analysis [29,30] was performed. Each search retrieval was analysed separately and then data were merged and studied together. Considering the data-base resulting from the union of PubMed and PsycINFO, all double records were excluded from the final analysis. To perform a qualitative analysis on titles, several string searches were subsequently performed utilizing a series of keywords (classification/definition, age, gender, intervention typology). The analysis was carried out with the SAS software. The whole analysis was performed separately for PsycINFO (Box 1) and PubMed (Box 2) and merging together all records (Box 3). Several aspects need to be highlighted.
BOX 1. PSYCINFO AND CHILD SEXUAL ABUSE

PsycINFO is an electronic bibliographic database of literature in psychological, social, behavioral, and health sciences fields. PsycINFO contains more than 2.2 million records spanning 1806 to 2007. The data base was searched for the keywords child sexual and abuse with the Boolean expression: CHILD (and) SEXUAL (and) ABUSE. This search retrieved 11 573 records in the range years period from 1908 to 2007. The result lowers to 11 262, when excluding the duplicates, distributed per year as shown in figure B1.1. The figure shows a peak in manuscripts publication from 1995 to 1999 and from 2004 to 2006, before 1995 publication trend increased till earlier 2000, characterized by a plateau, and a renewal of publication in the range period 20042006. Only 10 records have been published before 1970 ranging from 1908 to 1968 (1908, 1913, 1927, 1933, 1936, 1937, 1946, 1960, and 2 in 1968). 2007 papers are partially represented, but it results interesting to highlight that in June 2007 the amount of retrieved manuscripts is less than 1/6 if compared to 2006. The typology of publication distribution (table B1.1) shows a great majority of journal papers, followed by book chapters.
Sexual Abuse: A Bibliometric Analysis

800 700 600 500 400 300 200 100 0 before 1970 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
Figure B1.1. Distribution per year of retrieved records searching for CHILD (and) SEXUAL (and) ABUSE.
Table B1.1. Publication typology

Typology Book (Chapter) Dissertation-Abstract Electronic-Collection Encyclopedia Journal Article Total N 1 927 1 625 175 1 7 534 11 262 % 17.11 14.43 1.55 0.01 66.90 100.00
The manuscripts count for 352 756 pages (approximately more than half a ton of knowledge). Narrowing criteria and searching for quoted phrase child sexual abuse, 3 987 records are retrieved, 3 878 excluding the duplicates. All the manuscripts retrieved with the narrow search result to be included in the wider one, previously described, and they count for 129 650 pages. Manuscripts distribution per year of publication is shown in figure B1.2.
8
250
200
150
100
50
0 1913 1974 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
Figure B1.2. child sexual abuse papers: distribution per year of publication.
The distribution per year of retrieved manuscripts shows the same trend of the wider one illustrated above. Adding a trend line (mobile average) the observedexpected quantitative gap in 2007 is highlighted. For the record, the start-up manuscript was published in 1913 [Whipple GM. Psychology of testimony and report. Psychological-Bulletin, 1913; 10(7):264-268] and it regards a review of the literature on sexual offence and victims psychology.
Journal 65%
Book 20% ElectronicCollection 2% DissertationAbstract 13%
Figure B1.3. child sexual abuse publication typology.
In figure B1.3, the distribution of publication typolgy is in 65% represented by journal papers is shown, followed by book chapters and dissertation abstracts. The last ones are Graduation and PhD thesis abstracts from the US and European Universities belonging to all scientific areas. They generally constitute approximately 12% of the PsycINFO database, and, in this case, they belong to medical, psychiatric, psychological and social areas. The leading language of publication, among 17 different languages, is English with more than 97% of manuscripts (table B1.2) and 98% of written pages (figure B1.4). Table B1.2. Language distribution (manuscripts)
Language English German French Spanish Norwegian Italian Japanese Portuguese Chinese Polish Czech Danish Turkish Dutch Korean Serbo-Croatian Swedish Total N 3 766 30 26 21 6 5 4 4 3 3 2 2 2 1 1 1 1 3 878 % 97.11 0.77 0.67 0.54 0.15 0.13 0.10 0.10 0.08 0.08 0.05 0.05 0.05 0.03 0.03 0.03 0.03 100.00
Authors & corporate authors (if indicated as an acronym counting as 1) are 7 350, more than 50% of manuscripts are written by a single author, 25% by 2 authors, and choral operas result an unpopular choice as shown in figure B1.5.
10

German Spanish French Dutch Norwegian English 98% other 2% Japanese Italian Polish Chinese Czech Portuguese Serbo-Croatian Danish Turkish Swedish Korean
Figure B1.4. Language distribution (written pages).
1 au 52%
2 au 25%
10 au 0% 9 au 0% 8 au 0%
Figure B1.5. Authorship.
5 au 4% 7 au 6 au 1% 1%
4 au 5%
3 au 12%
Single authors prefer to write manuscripts in form of articles (52%) followed by the publication of dissertation abstracts (23%) and book/book chapter (20%). Articles are preferred (75%) also in case of 2 authors, and for more than 8 authors (9 manuscripts) the favourite way of publishing remain journals articles.
11
Rating the number of pages of each manuscripts per number of authors it is possible to group manuscripts indexing them in 6 different classes (figure B1.6): <=1: 1 or less page per author, with dissertation abstract as the leading publication typology (80%) and the more frequent index is 1 (88%); <=5: from more than 1 to 5 pages per author, with journal as the leading publication typology (91%) and 4 the more frequent index (13.6%); <=10: from more than 5 to 10 pages per author, with journal as the leading publication typology (82.5%) and 6 the more frequent index (15.5%); <=100: from more than 10 to 100 pages per author, with journal as the leading publication typology (64%) and 11 the more frequent index (11%); >100: from more than 100 to 800 pages per author, with book as the leading publication typology (78.3%) with 178 different indexes; nd: when no pagination indicated with Electronic Collection as the leading publication typology.
1000 900 800 700 600 500 400 300 200 100 0 nd nd <= 10 <=1 >100 >100 <=100 <=100 <=100 <=100 <= 10 <= 10 <= 10 <=1 <=1 >100 >100 <=5 <=5 <=5 <=5 nd
Book
DissertationAbstract
ElectronicCollection
Journal
Figure B1.6. Publication typologies: rating pages per authors.
12
Considering manuscripts edited in Journals (65% of the whole), at least 30% of them are child and adolescent specifically targeted even if general targeted journals have parts minors-oriented, as shown in figure B1.7. Excluding almost the 20% of manuscripts represented by books, the journals main areas, figure B1.8, shown a clear prevalence of core journals (34.7%) involved in the field of child abuse and violence. The leading journals among core ones are Journal of Child Sexual Abuse and Child Abuse and Neglect, 43% and 30% of core journals respectively. Psychology journals counts for the 30% and at least 11% are therapy addressed. The 12% of journals belong to medicine and include legal medicine, public health and nursing.
all 68%
adolescent 0.5% women 0.7% family 2.2%
child 26.5% child+adolescent 1.6% child+women 0.2% child+family 0.3%
Figure B1.7. Journals tags.

psychology 30% medicine 12%
core 34%
psychiatry 9% pediatrics law social science 1% 9% miscellaneous 1% 4%
Figure B1.8. Journals main areas of interest.
13
Affiliation countries, when indicated, are prevalently OCSE countries, but not all of them are English-speaking countries, even if only the 2.8% of the manuscripts are written in a different language than English. Table B1.3. Countries of affiliation
Country US UK Canada Australia Germany South Africa New Zealand Israel Netherlands Sweden nd Total N 2 616 309 272 99 34 30 27 24 19 19 429 3 878 % 67.5 8.0 7.0 2.6 0.9 0.8 0.7 0.6 0.5 0.5 10.9 100.00
Table B1.4. Countries collaboration

Country Canada+US Australia+China Australia+UK New Zealand+Australia Australia+Canada Canada+UK Ireland+Tanzania Italy+US New Zealand+Australia+UK Sweden+Norway UK+Nigeria+Zimbabwe+South Africa+Netherlands US+China US+Israel US+New Zealand US+UK N 6 4 3 3 1 1 1 1 1 1 1 1 1 1 1
14
At least the 5% of authors affiliations belong to non English speaking countries, although almost 7% of affiliation countries are not indicated. 10 most frequent authors countries of affiliation per manuscripts number are shown in table B1.3. Collaborations among researchers of different countries exist not only in case of neighbouring countries such as Australia & New Zealand, or in case of countries sharing the same background (UK & Australia), but also unexpected links as Ireland & Tanzania (table B1.4). The typology of affiliation result not determinable in more than 7% of cases (table B1.5). The Universities represent the leading writers, alone (69.5%) as department or unit, as university-hospital (1.7%), and in 72.5% of the manuscripts university appear as affiliation typology of at least one of manuscripts authors. Private practitioners, attorneys and specialized centres are grouped in services and represent the 7.9% of the whole, the tag organizations groups NGO, international and governmental organizations, and institutions as FBI, police, health offices, and so on. Table B1.5. Affiliation typology
Typology University Services Not indicated Hospital Organizations University-Hospital University + Hospital University +Services University +Organizations University + UniversityHospital University + Hospital +Services University-Hospital + Hospital University-Hospital +Services Hospital +Services Total N 2 694 307 287 302 167 65 22 14 9 6 2 1 1 1 3 878 % 69.47 7.92 7.40 7.79 4.31 1.68 0.57 0.36 0.23 0.15 0.05 0.03 0.03 0.03 100.00
Considering affiliation specialties (table B1.6), a great amount (33.5% of the whole) is not indicated by authors and/or journals, as shown in the following table. The remaining 76.5% is distributed as shown in figure B1.9. Affiliation
15
areas grouped as CORE are related to specifically department/unit/services/organizations involved in child sexual abuse, sexual abuse, child abuse and neglect, sexual assault, child protection and violence prevention. Table B.1.6. Affiliation specialty
Affiliation specialty not indicated psychology psychiatry social science medicine core law paediatrics Total
core 8% psychology 35%
N 1 299 899 433 399 360 201 147 139 3 878
% 33.5 23.2 11.2 10.3 9.3 5.2 3.8 3.6 100.0
social science 15%
law 6% pediatrics 5% medicine 14% psychiatry 17%
Figure B1.9. Authors affiliation main area.
Manuscripts titles counts for 44 991 words, the quoted phrase child sexual abuse appears in 1 682 records, more than 43% of the whole retrieved manuscripts, and the quoted phrase sexual abuse, excluding the retrievals of the previous search, appears in 664 manuscripts titles (17%).
16
Anna Aprile, Cristina Ranzato, Melissa Rosa Rizzotto et al. Table B1.7. Words in titles
Word child sexual abuse therapy victim treat family adult survive woman case study prevent effect assessment trauma behaviour factor self approach symptom survey system association anatomic attribution attachement affect video suicide suggestion acceptance advocacy acknowledge N 3 070 2 990 2 933 481 374 324 300 288 260 258 235 230 182 178 165 154 129 129 83 82 66 61 50 48 36 34 26 24 22 18 10 7 7 4 Whole % 6.8 6.6 6.5 1.1 0.8 0.7 0.7 0.6 0.6 0.6 0.5 0.5 0.4 0.4 0.4 0.3 0.3 0.3 0.2 0.2 0.1 0.1 0.1 0.1 0.1 0.1 0.1 0.1 0.0 0.0 0.0 0.0 0.0 0.0 % 9.8 9.6 9.4 1.5 1.2 1.0 1.0 0.9 0.8 0.8 0.8 0.7 0.6 0.6 0.5 0.5 0.4 0.4 0.3 0.3 0.2 0.2 0.2 0.2 0.1 0.1 0.1 0.1 0.1 0.1 0.0 0.0 0.0 0.0
17
The words in titles showing higher frequency are related to child and abuse, prevalent words and their frequencies (whole %), excluding articles, conjunctions, etc. (%) are shown in table B1.7. 3 725 manuscripts (96% of the whole) present a related abstract. All the abstracts count for 513 504 words, the quoted phrase child sexual abuse appears 5 181 times (0-4 per manuscript), and the quoted phrase sexual abuse (0-6 per abstract), excluding the retrievals of the previous search, appears 4 219 times. Words with higher frequency, grouped per main area (i.e. father and mother were grouped in parents), are: child 13 177 (2.6% of the whole, 4.2% excluding articles, conjunctions, etc.), abuse 13 441 (2.6%, 4.3%), sexual 12 224 (2.4%, 3.9%).
BOX 2. PUBMED AND CHILD SEXUAL ABUSE

PubMed is an electronic bibliographic database of literature and it is a service of the U.S. National Library of Medicine that includes over 17 million citations from MEDLINE and other life science journals for biomedical articles back to the 1950s. It was developed by the National Center for Biotechnology Information (NCBI) at the National Library of Medicine (NLM), located at the U.S. National Institutes of Health (NIH). The database was searched for the keywords child sexual and abuse with the Boolean expression: CHILD (and) SEXUAL (and) ABUSE. This search retrieved 6 346 records in the range years period from 1978 to June 2007 (figure B2.1). The figure shows 3 peaks in manuscripts publication: in 1994-1995, in 2001-2002 and in 2005-2006. Before the first peak, analysing the distribution chronologically, publication trend increased more than 5 times from 1985 to 1986 and almost 3 times from 1986 to 1987. The manuscripts count for 57 685 pages. All the manuscripts are journal articles, the typology of publication distribution (table B2.1), when specifically indicated (excluding the general tag journal article), shows a great majority of review studies (12.2%) and case reports (12%).
18
450 400 350 300 250 200 150 100 50 0 1978 1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
Figure B2.1. Distribution per year of retrieved records searching for CHILD (and) SEXUAL (and) ABUSE.
Table B2.1. Publication typology

publication typology case report clinical trial editorial letter review meta-analysis practice guideline comment classic journal article Total N 757 170 121 760 772 23 21 404 3 318 6 346 % 11.9 2.7 1.9 12.0 12.2 0.4 0.3 6.4 52.3 100.0
Narrowing criteria and searching for quoted phrase child sexual abuse, 1 242 are the retrieved records. All the manuscripts retrieved with the narrow search result to be included in the wider one, previously described, and they count for 12 717 pages (for 3 manuscripts pages numbers result missing), with a mean of pages per article of 10.7 (range 1-194) and a mode of 6. Manuscripts distribution per year of publication is shown in figure B2.2.
2007

80
19
70
60
50
40
30
20
10
0 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
Figure B2.2. Child sexual abuse papers: distribution per year of publication.
The per year distribution of retrieved manuscripts shows the same general trend of the wider one illustrated above, but the most fruitful year of publication result 2001 instead of 1995. Adding a trend line (mobile average) the observedexpected quantitative gap in 2007 results less wide than in the previous search, in fact the search using the quoted phrase child sexual abuse at the end of June 2007 retrieved almost of the expected manuscripts for the 2007 year. Table B2.2. child sexual abuse publication typology
publication typology case report clinical trial editorial letter review meta-analysis practice guideline comment classic journal article Total N 81 16 19 66 199 14 4 48 795 1 242 % 6.5 1.3 1.5 5.3 16.0 1.1 0.3 3.9 64.0 100.00
20
Considering the typology of publication (table B2.2), excluding classic journal article, a great majority of reviews (16%) is shown, followed by case reports (6.5%) and letter (5.3%). The leading language of publication, among 12 different languages, is English with the 97% of manuscripts (figure B2.3).
German 0.8%
English 97%
other 3%
French 0.7% Spanish 0.3% Chilean 0.2% Polish 0.2% Czech 0.2% Italian 0.2% Dutch 0.1% Hungarian 0.1% Japanese 0.1% Swedish 0.1%
Figure B2.3. Language distribution.
Almost all of the 333 journals are published in North-America and Europe (figure B2.4). The American journals are mostly from US (184), 6 journals are Canadian, 1 from Chile and 1 from Brazil. The greatest part of the European journals is from UK (60%) and Germany (9%) (table B2.3). Authors & corporate authors are 2 982, 9 manuscripts have only a corporate author and 15 manuscripts, newspaper articles and news, have no authors listed. More than 36% manuscripts are written by a single author, 27% by 2 authors, 17% by 3, and choral operas, 4-10 authors, represent less than 20% of the whole manuscripts amount (figure B2.5).
Sexual Abuse: A Bibliometric Analysis Table B2.3. Journals countries of publication

Publication continent Africa Country of publication Egypt Israel Kenya South Africa Total Africa Brazil Canada Chile United States Total Americas China India Japan Philippines Total Asia Austria Belgium Czech Republic Denmark England Finland France Germany Hungary Ireland Italy Netherlands Norway Poland Scotland Spain Sweden Switzerland Total Europe Australia New Zealand Papua New Guinea Total Oceania TOTAL Journal N 1 1 1 2 5 1 6 1 184 192 3 1 1 1 6 1 2 2 1 67 2 3 11 1 4 1 4 2 3 3 2 3 5 117 11 1 1 13 333 Journal % 0.3 0.3 0.3 0.6 1.5 0.3 1.8 0.3 55.3 57.7 0.9 0.3 0.3 0.3 1.8 0.3 0.6 0.6 0.3 20.1 0.6 0.9 3.3 0.3 1.2 0.3 1.2 0.6 0.9 0.9 0.6 0.9 1.5 35.1 3.3 0.3 0.3 3.9 100.0
21
Americas
Asia
Europe
Oceania
22

Oceania
Europe
Asia
Americas
Africa 0 50 100 150 200
Figure B2.4. Journal distribution per continent.

2 au 27% 3 au 17% 1 au 37% 10 au 9 au 8 au 1% 5 au 5% 6 au 3%
4 au 8%
7 au 2%
Figure B2.5. Authorship.
At least 50% of manuscripts are child & adolescent specifically targeted. This figure was obtained consulting the NIH Journal Data Base files. General targeted journals (i.e. BMJ) had parts minors oriented (figure B2.6).
23
all 48%
child 45%
adolescent 1% women
child+adolescent 4% family child+adolescent+all 1% 1%
Figure B2.6. Journals tags.
Journals main areas (figure B2.7) show a clear prevalence of core journals (37%) involved in the field of child abuse and violence. The leading journals among core ones are Child Abuse and Neglect (71.5%), Journal of Child Sexual Abuse (13%) and Child Maltreatment (5%). Psychology and Psychiatry journals count for the 13% of manuscripts, and the 25% of journals belong to medicine and include legal medicine, public health and nursing. The 10 journals publishing most of the manuscripts on CSA are shown in table B2.4.
medicine 25% psychiatry 13%
core 37%
pediatrics 11% law social science 1% psychology 13%
Figure B2.7. Journals main areas of interest.
In a great amount of manuscripts, 22.1% (274), the field of affiliation is not fulfilled. When indicated, Countries of affiliation result to be OCSE, but not all of
24
them are English-speaking countries, even if only the 3% of the manuscripts are written in a different language than English. For example 0.1% of manuscripts are published in Swedish instead of the 1.2% of manuscripts with Author/authors belonging to institutions of Sweden. Countries of authors affiliation distributed per number of manuscripts (table B2.5). Table B2.4. TOP 10 Journals
manuscripts N % 321 25.8 58 4.7 25 2.0 23 1.9 22 1.8 18 1.4 17 1.4 15 1.2 14 1.1 14 1.1 527 42.4
Journal Child Abuse & Neglect Journal of Child Sexual Abuse Pediatrics British Medical Journal Child Maltreatment J Am Academy of Child & Adolescent Psychiatry British Journal of Psychiatry Child Welfare Journal of Traumatic Stress Lancet Total TOP 10
Table B2.5. 10 mostly represented countries of affiliation

Country US UK Canada Australia New Zealand Sweden China Israel South Africa Ireland N 587 96 66 52 22 15 12 11 11 10 % 47,3 7,7 5,3 4,2 1,8 1,2 1,0 0,9 0,9 0,8
The Universities represent the leading writers (54.4%) as department or unit, and as university-hospitals (4.8%). Private practitioners, attorneys and specialized centres are grouped in services and represent the 4.6% of the whole,
25
organizations groups NGO, international and governmental organizations, institutions as FBI, police, health offices (4.5%) and hospital authors affiliation is 9%. The typology of affiliation result not indicated in 22.6% of cases (figure B2.8).
University 53% services 5% organizations 5% University-Hospital Hospital 5% 9%
Figure B2.8. Affiliation typology.
not indicated 23%
Considering affiliation specialties (figure B2.9), those grouped as CORE are related to specifically department/unit/services/organizations involved in child sexual abuse, sexual abuse, child abuse and neglect, sexual assault, child protection and violence prevention. Medical sciences grouped in medicine, paediatrics and psychiatry, represent more than 50% of indicated authors institutions of provenance. In the 29.2% of cases this characteristic is not indicated by authors and/or journals.
core 6%
social science 15%
psychology 24%
law 1%
pediatrics 14%
psychiatry 14% medicine 26%
Figure B2.9. Authors affiliation main area.
26
Anna Aprile, Cristina Ranzato, Melissa Rosa Rizzotto et al. Table B2.6. Words in titles
Word child sexual abuse women victim study adult treatment survivor parent prevention health behavior history perpetrator anogenital assessment HIV Investigation community violence PTSD N 1 214 1 161 1 130 132 105 90 74 65 60 59 55 51 40 39 38 34 34 29 28 25 24 14 Whole % 8.7 8.3 8.1 0.9 0.8 0.6 0.5 0.5 0.4 0.4 0.4 0.4 0.3 0.3 0.3 0.2 0.2 0.2 0.2 0.2 0.2 0.1 % 14.7 14.1 13.7 1.6 1.3 1.1 0.9 0.8 0.7 0.7 0.7 0.6 0.5 0.5 0.5 0.4 0.4 0.4 0.3 0.3 0.3 0.2
Manuscripts titles counts for 13 906 words, the quoted phrase child sexual abuse appears 797 folds in 795 records, as the 64% of the whole retrieved manuscripts, and the quoted phrase sexual abuse, excluding the retrievals of the previous search, appears 171 folds in 169 manuscripts titles (14%). The words in titles showing higher frequency are related to child sexual abuse, prevalent words and their rates are shown in table B2.6. 995 manuscripts (80% of the whole) have a related abstract. More than half of the 247 manuscripts without abstract are comment, letter, editorial and news. All the 15 articles without authors listed have no abstract as well, and the 66% of manuscripts without abstract are written by single author. All the abstracts count for 162 207 words. The quoted phrase child sexual abuse appears 1 853 folds in 582 manuscripts (0-5 per manuscript), and the quoted phrase sexual abuse 1 065 folds in 821 manuscripts (0-4), excluding the
27
retrievals of the previous search. Words with higher frequency, grouped per main area (i.e. father and mother were grouped in parents), are: child 5 088, abuse 4 681, sexual 4 137 and victim 858.
BOX 3. MERGING PSYCINFO AND PUBMED DATABASES

The search for the quoted phrase child sexual abuse in PsycINFO and in Pubmed databases retrieved 3 778 and 1 242 records, respectively, leading to a whole amount of 5 120 manuscripts. Books (765 manuscripts are book chapters) and dissertation abstract international (512 manuscripts) are exclusively linked to PsycINFO database, but considering the performed searches several journals result to be db-specific. The journals are 711, 136 are covered by both the databases, instead of 575 databasespecific. Considering database-specific journals 192 (384 manuscripts) are covered by Pubmed and 383 (1 135 records) by PsycINFO. Database-specific journals main characteristics are shown in figure B3.1. Comparing journal target, it appears evident that pubmed-specific journal child-adolescent oriented are the 20.3% instead of the 11% of PsycINFO. It results evident the great gap considering the main area journals: 58% of psychology journals and 17% of medical field (medicine, psychiatry and paediatrics) in PsycINFO instead of 3% of psychology journals and 72% medicine, 17% paediatrics and 4% of psychiatry journals. The higher number of manuscript per journal are shown in table B3.1: PsycINFO 309 records (27% of the whole database-specific journal records), Pubmed 115 manuscripts (30%). Moreover, data shown in table B3.1 highlight the gap considering journal main area of interest between the two databases, Pubmed and PsycINFO, medicine and psychology, performing exactly the same search. The overlapping area of the two databases consists of 397 manuscripts with same title, same authors, same journal, same publication year and different database of affiliation. Other two different phenomenon need to be underlined: firstly there are 38 manuscripts (19 couples) that show same title, same authors, same year of publication but different journal of publication; and, secondly, there are 96 manuscripts (48 couples) that show same title, same authors.
28
Figure B3.1. Database-specific journals tags and main area: PsycINFO vs Pubmed.
Table B3.1. Database-specific journals top 15: PsycINFO vs Pubmed

PsycINFO Journal PsycCRITI QUES Child Abuse Review British Journal of Social Work Journal of Family Violence Psychology, Public Policy, and Law Jo tag all Jo main area psychology rec ord 76 PubMed Journal Pediatrics American journal of diseases of children New Zealand medical journal Archives of disease in childhood Archives of pediatrics & adolescent medicine Jo tag child Jo main area pediatrics rec ord 25
child
core
48
child
pediatrics
all
social science
20
all
medicine
family
core
19
child child+ adoles cent
pediatrics
all
psychology
17
pediatrics

PsycINFO Journal Professional Psychology: Research and Practice Aggression and Violent Behavior Feminism and Psychology Journal of Child and Youth Care Psychology, Crime and Law Child and Adolescent Social Work Journal Journal of Sexual Aggression American Journal of Forensic Psychology Arts in Psychotherapy Applied Cognitive Psychology Jo tag Jo main area psychology rec ord 16 PubMed Journal Journal of clinical forensic medicine Journal of pediatric and adolescent gynecology Acta paediatrica Australian family physician British journal of nursing Health visitor Journal of pediatric health care New directions for mental health services Acta paediatrica Scandinavica Current opinion in obstetrics & gynecology Jo tag Jo main area medicine
29
rec ord 7
all
all
all
core
15
child+ adoles cent
pediatrics
all
psychology
15
child
pediatrics
child
psychology
14
family
medicine
all
psychology
13
all
medicine
child+ adoles cent
social science
12
all
medicine
all
core
12
child
pediatrics
all
psychology
11
all
psychiatry
all
psychology
11
child
pediatrics
all
psychology
10
all
medicine
30
The Overlapping Area

Manuscripts distribution per year of publication considering the overlapping area between PsycINFO and PubMed is shown in figure B3.2.
30
25
20
15
10
0 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
Figure B3.2. Overlapping area between PsycINFO and Pubmed databases: distribution per year of publication.
The range period of the overlapping area is from 1983 to 2007, even if the starting year result to be 1913 for PsycINFO and 1978 for PubMed. Moreover, the years with the higher numbers of papers are 1994 and 2000, as in Pubmed are 1994 and 2001, and in PsycINFO 1995 and 1997. 2007 shows only 3 manuscripts in common, as the 9% of PsycINFO 2007 manuscripts and the 13% of PubMed ones. The typology of publication distribution (table B3.2) shows, excluding classic journal article, a great majority of clinical trials (13.4%). 395 manuscripts are written in English (99,5%), 1 in Polish and 1 in Czech. The 98% of the 103 overlapping area journals are published in North-America and Europe (table B3.3), Asia and Africa are completely uncovered.
Sexual Abuse: A Bibliometric Analysis Table B3.2. Overlapping area publication typology
publication typology case report clinical trial editorial letter review meta-analysis comment classic journal article total N 14 53 2 9 13 17 1 288 397 % 3.5 13.4 0.5 2.3 3.3 4.3 0.3 72.5 100.0
31
Table B3.3. Overlapping area Journals countries of publication

continent of publication Americas Total Americas Czech Republic England France Germany Netherlands Norway Poland Australia country of publication Canada United States
Jo N 1 74 75 1 18 1 2 2 1 1 26 2 2 103
Jo % 1.0 71.8 72.8 1.0 17.5 1.0 1.9 1.9 1.0 1.0 25.2 1.9 1.9 100.0
Europe
Total Europe Oceania Total Oceania TOTAL
Authors & corporate authors (if indicated as an acronym count as 1) are 959, more than 31% of manuscripts are written by single author, 30% by 2 authors, 21% by 3, and choral operas, 4-10 authors, represent at least the 17% of the whole manuscripts amount as shown in figure B3.3.
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2 au 30% 3 au 21%
1 au 32% 5 au 4% 10 au 0% 9 au 1% 7 au 2% 6 au 1%
4 au 9%
Figure B3.3. Overlapping area Authorship.
In a great amount of manuscripts, 11.6% (46), the field of affiliation is not fulfilled. When indicated, Countries of affiliation result to be OCSE, but not all of them are English-speaking countries, even if only the 0.5% of the manuscripts are written in a different language than English. Authors countries of affiliation per manuscripts number is shown in table B3.4. It results interesting to underline authors displacement in order of publishing. In the case of not indicated affiliation, the 70% of manuscripts are published in US and the remaining in Europe, US authors publish the 36% of their articles in Europe (England 98% and Netherlands), UK authors publications move to US only in the 17% of cases, and authors from Argentina, Botswana, China, Israel, Korea, Malaysia and South Africa have published their manuscripts in different continent than the affiliation ones. The typology of affiliation result not indicated in 12.3% of cases (figure B3.4). The Universities represent the leading writers (66.8%) as department or unit, and as university-hospitals (3.5%). Private practitioners, attorneys and specialized centres are grouped in services and represent the 4.3% of the whole, organizations groups NGO, international organizations, governmental, and institutions as FBI, police, health offices, etc. (5%) and hospital authors affiliation is 8%. University affiliation seems to be advantageous to be selected by both databases, or better by the journals involved in the selection, in fact data for each database are 71% and 58%, PsycINFO and PubMed respectively.
Sexual Abuse: A Bibliometric Analysis Table B3.4. Countries of affiliation considering the overlapping area
affiliation country US Not indicated UK Canada Australia Ireland China New Zealand Norway Finland Sweden Denmark Israel Netherlands South Africa Argentina Botswana Czech Republic Greece Korea Malaysia Poland Switzerland Total N 238 46 36 24 14 5 4 4 4 3 3 2 2 2 2 1 1 1 1 1 1 1 1 397 % 59.9 11.6 9.1 6.0 3.5 1.3 1.0 1.0 1.0 0.8 0.8 0.5 0.5 0.5 0.5 0.3 0.3 0.3 0.3 0.3 0.3 0.3 0.3 100.0
33
University 67%
services 4% UniversityHospital 4% Hospital 8% organizations 5%
not indicated 12%
Figure B3.4. Affiliation typology: overlapping area.
34
Considering affiliation specialties (table B3.5), a great amount (22% of the whole) is not indicated by authors and/or journals, as shown in the following table. Table B3.5. Affiliation specialty: overlapping area
affiliation specialty psychology not indicated medicine psychiatry social sciences pediatrics core law Total N 103 87 60 54 53 20 15 5 397 % 25.9 21.9 15.1 13.6 13.4 5.0 3.8 1.3 100.0
The remaining 78% is distributed as shown in figure B3.5. Affiliation areas grouped as CORE are related to specifically department/unit/services/ organizations involved in child sexual abuse, sexual abuse, child abuse and neglect, sexual assault, child protection and violence prevention. Medical sciences grouped in medicine, paediatrics and psychiatry, represent more than 41% of indicated authors institutions of provenance.
core 5% psychology 34%
social science 17% law 2% pediatrics 6% medicine 19%
psychiatry 17%
Figure B3.5. Authors affiliation main area: overlapping area.
35
Manuscripts titles counts for 4 671 words, the quoted phrase child sexual abuse appears 265 folds, and the quoted phrase sexual abuse, excluding the retrievals of the previous search, appears 54 folds. The words in titles showing higher frequency are related to child sexual abuse, prevention, health, victim, and women. 358 manuscripts (90% of the whole) have a related abstract. All the abstracts count for 16 647 words, the quoted phrase child sexual abuse appears 286 folds in 199 manuscripts (0-5 per manuscript), and the quoted phrase sexual abuse 101 folds in 99 manuscripts excluding the retrievals of the previous search. Words with higher frequency, grouped per main area (i.e. father and mother were grouped in parents), are: child, abuse, and sexual.
The Union DB: The Merge of Psycinfo and Pubmed

Manuscripts distribution per year of publication considering the newly created database obtained merging data from PsycINFO and PubMed databases and excluding duplicates is shown in figure B3.6. The resulting database firstly shows a wide range of manuscripts distribution per year (1913-2007) covering almost a century of literature on child sexual abuse issue, it is constitutes by 4 723 manuscripts, 845 from PubMed, 3 481 from PsycINFO and 397 in common to PsycINFO and PubMed. The figure B3.6 shows a peak in manuscripts publication from 1995 to 1999, from 2001 to 2002 and from 2004 to 2006, before 1995 publication trend increased till earlier 2000, characterized by a plateau, and a renewal of publication in the range period 2004-2006. The more fruitful years, counting for more of the 50% of the whole are summarized in table 6. Adding a trend line (mobile average) the observed-expected quantitative gap in 2007 the amount of retrieved manuscripts is 1/3 if compared to 2006. The typology of publication distribution (figure B3.7) shows a great majority of journal papers (71.4%), followed by book chapters and dissertation abstracts (Graduation and PhD thesis abstracts from US and European Universities belonging to all scientific areas).
36
300
250
200
150
100
50
0 1913 1974 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
Figure B3.6. The Union DB: distribution per year of publication.
Table B3.6. Leading publication years: Union DB

Publication Year 1995 1997 2001 1998 2006 2004 1996 1992 2002 1999 Subtotal 10 years whole N 293 273 270 265 252 248 238 237 236 229 2 541 4 723 % 6.2 5.8 5.7 5.6 5.3 5.3 5.0 5.0 5.0 4.8 53.8 100.0

Journal 71%
37
ElectronicCollection 2%
Book 16% DissertationAbstract 11%
Figure B3.7. Child sexual abuse publication typology: Union DB.
Looking to journal articles, the typology of publication distribution is shown in table B3.7. Table B3.7. Journal articles typology in Union DB
publication typology classic journal article clinical trial letter comment review case report editorial meta-analysis practice guideline total N 3045 122 53 36 35 33 22 19 5 3370 % 90.4 3.6 1.6 1.1 1.0 1.0 0.7 0.6 0.1 100.0
Manuscripts pages count for 137 460 as an estimation, considering that about the 2% of the retrieved manuscripts had no specific pagination indicated. The leading language of publication, among 18 different languages, is English in 97% of manuscripts (table B3.8) and 98% of written pages (figure B3.8).
38

German Spanish French Dutch Norwegian Japanese English 98% other 2% Italian Polish Chinese Czech Portuguese Serbo-Croatian Danish Turkish Swedish Korean
Figure B3.8. Language distribution (written pages) of Union DB.
Table B3.8. Language distribution (manuscripts) of Union DB

Language English German French Spanish Italian Chinese Norwegian Japanese Polish Portuguese Czech Danish Dutch Swedish Turkish Korean Serbo-Croatian Hungarian Total N 4 576 40 35 25 7 6 6 5 5 4 3 2 2 2 2 1 1 1 4 723 % 96.89 0.85 0.74 0.53 0.15 0.13 0.13 0.11 0.11 0.08 0.06 0.04 0.04 0.04 0.04 0.02 0.02 0.02 100.00
39
Almost all the 711 journals are published in America (55.6%) and Europe (35.9%), the American journals are mostly from US (91%) and Canada (6%), the greatest part of European journals is from UK (50%) and from Germany (12%). 765 records are books or books chapters leading to a total amount of 520 books published in United States (88%) and Canada (0.5%), 10,2% in Europe (88% in UK and the remaining 7 books in the Netherlands), 5 books in South Africa and 1 in Australia. All the 512 manuscripts from Dissertation Abstracts International, constituting approximately 12% of PsycINFO database, and belonging to medical, psychiatric, psychological and social areas retrieved with the already described search are from US universities. Authors & corporate authors (if indicated as an acronym count as 1) are 9 362, 9 manuscripts have only a corporate author and 15 manuscripts, newspaper articles and news, no authors listed. Looking at manuscripts with listed authors at least the 50% are written by single author, 24.9% by 2 authors, 12.3% by 3, 5.3% by 4, and choral operas, 5-10 authors, represent the 7.5% of the whole manuscripts amount as shown in figure B3.9. At least the 39% of 3 958 manuscripts, excluding 765 books or books chapters for which the age tag is not determinable, are child & adolescent specifically targeted. This figure was obtained consulting the NIH Journal Data Base files. General targeted journals (i.e. BMJ, JAMA) had, in any case, parts minors-oriented (figure B3.10).
2 au 25%
1 au 50%
no author listed 0.5% 10 au 0.1%
5 au 4% 8 au 0.4% 7 au 0.8% 6 au 1.5%
4 au 5.5%
3 au 12%
9 au 0.2%
Figure B3.9. Authorship in Union DB.
40

all 57%
child 35% adolescent 1% women 1% child+women 0.2% child+adolescent 2.5% family 3% child+family 0.3%
Figure B3.10. Journals tags: Union DB.
Journals main areas, figure B3.11, shown a clear prevalence of core journals (33.5% as 1 326 manuscripts) involved in the field of child abuse and violence. This is one of the most important result obtained merging the searches conducted on the 2 different databases: not only an increasing in the range period, not only an enlargement of fields involved, but also the terrific increasing in manuscripts from the 23 core journals, picking up different articles performing the same search in different databases, and a reached equilibrium between manuscripts from medical disciplines and psychological ones. The leading journals among core ones are Child Abuse and Neglect and Journal of Child Sexual Abuse (37.6%) and Child Maltreatment (5%).
medicine 17%
psychiatry 9% pediatrics 4%
core 34% miscellaneous 3% law 1%
psychology 25% social science 7%
Figure B3.11. Journals main areas of interest: Union DB.
41
In the 10% of records (N=482) the field of affiliation is not fulfilled. Moreover, for other 8 manuscripts the affiliation indicated (i.e. e-mail address not belonging to official institution as university) doesnt allow to the determination of the Country. At least the 70% of manuscripts are written by authors US affiliated, 9% of UK and 7.5% of Canada. Authors of 1 of the manuscripts [Lachman P, Poblete X, Ebigbo PO, Nyandiya-Bundy S, Bundy RP, Killian B, Doek J. Challenges facing child protection. Child-Abuse & Neglect, 2002; 26(67): 587-617] result to be strongly multi-countries affiliated: UK, Nigeria, Zimbabwe, South Africa, Netherlands; this choral opera, public health targeted, examines the achievements in the field of children's rights that underpin all programs aimed at protecting children and future need. The typology of affiliation result not indicated in 13% of cases, as shown in table B3.9. The Universities represent the leading writers (64%). Private practitioners, attorneys and specialized centres are grouped in services and represent the 8% of the whole, organizations groups NGO, international organizations, governmental, and institutions as FBI, police, health offices, etc. (5%) and hospital authors affiliation is 7%. Table B3.9. Affiliation Typology in Union DB
affiliation typology University Not indicated Services Hospital Organizations University-Hospital University+Hospital University+Services University+Organizations University+University-Hospital University-Hospital+University Organizations+University University+Hospital+Services Hospital+Services Hospital+University-Hospital University-Hospital+Services Total N 3015 609 383 323 225 112 22 14 7 6 4 2 2 1 1 1 4 723 % 63.84 12.89 8.11 6.84 4.76 2.37 0.47 0.30 0.15 0.13 0.08 0.04 0.04 0.02 0.02 0.02 100.00
42
Considering affiliation specialties, a great amount (36.5% of the whole) is not indicated by authors and/or journals, as shown in table B3.10. Table B3.10. Affiliation specialty: the Union DB
affiliation specialty not indicated psychology medicine psychiatry social science core paediatrics law Total N 1 722 978 484 473 460 239 233 134 4 723 % 36.5 20.7 10.2 10.0 9.7 5.1 4.9 2.8 100.0
The remaining 63.5% is distributed as shown in figure B3.12. Affiliation areas grouped as CORE are related to specifically department/unit/ services/organizations involved in child sexual abuse, sexual abuse, child abuse and neglect, sexual assault, child protection and violence prevention. Medical sciences grouped in medicine, paediatrics and psychiatry, represent the 40% of indicated authors institutions of provenance, and psychology the 33%.
pediatrics 8%
core 8%
law 4%
social science 15%
psychiatry 16% medicine 16%

Figure B3.12. Authors affiliation main area: the Union DB.
psychology 33%
Manuscripts titles counts for 53 004 words, the quoted phrase child sexual abuse appears 2 213 folds, and the quoted phrase sexual abuse, excluding the retrievals of the previous search, appears 779 folds in 775 manuscripts titles. The
43
words in titles showing higher frequency are related to child sexual abuse: child (as child, children, girl, boy, son, daughter, etc.), sexual, and abuse (as harassment, rape, etc.). 4 367 manuscripts (92.5% of the whole) have a related abstract and all the abstracts count for 621 632 words. More than half of the manuscripts without abstract are characterized by specific manuscripts typology as comment, letter, editorial and news. All the articles without authors listed are also without abstracts, and the 64% of manuscripts without abstract are written by single author. Words with higher frequency, grouped per main area (i.e. father and mother were grouped in parents), are: child, abuse, sexual, victim, and women.
BOX 4. FALSE ALLEGATION/S AT GLANCE

The databases were searched for false allegation/s in titles and abstracts: the results are presented below.
PsycInfo
Searching for
Allegation/s in Titles 75 manuscripts as the 2% of the whole, counting for 1 978 published pages 13 books, counting for 1 383 pages; published in US from 1989 to 2006 (70% published 1991-1996, 31% 1995); written in English by 19 authors (1-3; mode 1); author/s in 23% of manuscripts are from Canada, and the remaining from US; authors affiliations are: 54% universities, 39% services, 7% organizations, 40% medicine, 23% psychiatry, 15% law, 15% not indicated, 7% psychology; main theme is allegation assessment and evaluation in legal contexts. 4 dissertation abstracts, written in English published in US (1992-1997) by single author, on Judgement and allegations. 58 journal articles, counting for 595 pages ranging from 1986 to 2007 (median 1995, mode 1994 with 8 articles); written by 121 authors (ranging 1-5; mean, mode and median 2); written in English in 96.5% of cases and 2 manuscripts in French are published in 32 journals; journals area of interest are psychology (36.2%), psychiatry (22.4%), social science (3.4%), law and medicine (1.7%), the remaining are core journals (34.5%); articles are published in journals from US (77.6%), England (15.5%), France (3.4%), Canada and Ireland (1.7%);
44
journals age tags are child&adolescent (36.3%) and all ages (63.7%); author/s in 73% of manuscripts are from US, 9% from UK, 5% from Canada, 3.4% from Israel, 1.7% from Australia, France, Ireland, and the remaining not indicated; authors affiliations, when indicated, are: 60% universities, 12% services, 10% hospital, 9% organizations, 10% medicine, 12% psychiatry, 14% law, 31% not indicated, 16% psychology, 11% law, 4% paediatrics, 2% core; main theme is allegation assessment, evaluation, examination in legal context highlighting child role & credibility.
False Allegation/s in Titles 14 manuscripts (0.4%) counting for 484 pages 3 books, counting for 405 pages; published in US (1989, 1991,1995), written in English by single authors, 2 from US and university affiliation and 1 from Canada and services but from different area of affiliation: medicine, child psychiatry and psychology; main theme is false allegation assessment and practice. 11 journal articles, counting for 79 pages, ranging from 1991 to 2006 with 3 manuscripts published in 1995; written by 20 authors (ranging 1-4, mode 1, median 2); 9 articles written in English (82%) and 2 in French published 1 per journal; journals area of interest are psychiatry (45.5%), psychology (27.3%), law (9.1%) and the remaining are core journals (18.2%); articles are published in journals from US (72.7%), France (18.2%) and Ireland (9.1%); journals age tags are child&adolescent (36.4%) and all ages (63.6%); author/s in of 7 manuscripts are from US (64%), 1 from UK, Ireland, France and 1 not Indicated; authors affiliations, when indicated, are: 45.5% universities, 2 manuscripts from hospitals and organizations, and 1 from services, law 3 manuscripts, psychiatry 2, psychology and medicine 1, and 46.4% not indicated; main theme is false allegation assessment and child custody. False Allegation/s in Abstracts 14 manuscripts (0.4%) only 3 of them overlap with the group retrieved searching for false and allegation/s in titles (2 books and 1 article) but all are included in the wider search looking for allegation/s (75 retrievals), counting for 771 pages 5 books, counting for 701 pages; published in US (2 in 1989, 2 in 1995, 1 in 1998), written in English by 6 authors; authors affiliation is almost from US and 1 from Canada, 2 manuscripts are written by authors affiliated within university, 2 from services and 1 from hospital, with a 60% of affiliation area of psychology
45
and the remaining 40% of medicine; main theme is child sexual abuse investigations and impact of bias. 9 journal articles, counting for 70 pages, ranging from 1986 to 2004; written in English by 12 authors (ranging 1-2, mode 1); 8 articles are from journals published in US and 1 in Europe; journals age tags are child (55%) and all ages; journals main area of interest is psychology (44%), followed by 2 manuscripts form core journals, and 1 from journals dedicated to psychiatry and social science; psychiatry (45.5%), psychology (27.3%), law (9.1%) and the remaining are core journals (18.2%); author/s in 7 manuscripts are from US, 1 from UK and 1 from Australia; authors belong to universities in 2/3 of cases, 1 manuscripts from hospitals, organizations, and services; 3 manuscripts are written by authors affiliated to medical institutions, and 2 from psychology and law, and in other 2 cases the affiliation area is not indicated; main theme is false allegation and child sexual abuse in child custody cases: fabricated charge as by parents as by children.
Pubmed
Searching for
Allegation/s in Titles 20 journal articles as the 1.6% of the whole, counting for 239 published pages ranging from 1986 to 2007 (median and mode 1994 with 4 articles); written by 44 authors (ranging 1-4; mean 2.2, mode and median 2); all written in English and half of them (N=10) published in US, 1 in New Zealand, and 9 in Europe, 1 in Sweden and the remaining in England and they are published in 10 different journals (with a max value of 7 manuscripts in child abuse and neglect); 4 journals are targeted to child&adolescent publishing 11 manuscripts, and the remaining 10 journals are targeted to all ages and published 9 articles; journals area of interest are psychiatry (40%), specifically dedicate to child abuse and/or violence as core journals (35%), psychology and medicine (10%), and paediatrics (5%); author/s of the 60% of manuscripts are from US, while in the 20% of manuscripts the country of affiliation is not indicated, and 1 article from UK, Sweden, Israel an New Zealand; authors affiliations, 20% not indicated in case of affiliation typology and 40% in case specialty of affiliation, are: 65% universities, and 5% services, hospital and University-Hospital, 20% psychiatry, 15% psychology, 10% medicine and paediatrics, 5% social sciences; main theme is child sexual abuse allegations: evaluation & validation.
46
False Allegation/s in Titles 2 journal articles, both review from US and included in wider search above; 2 particular issues: The frequency of false allegations of sexual abuse by children and adolescents examined in a large sample of Child Protective Services (CPS) cases; A literature review regarding Munchausens syndrome by proxy in relation to allegations of child sexual abuse, problems in Munchausens syndrome by proxy diagnosis can be the result of a failure to consider that the allegations may be false, legal issues surrounding the child's testimony, and other biases in professional and legal attitudes towards allegations of sexual abuse. False Allegation/s in Abstracts 6 journal articles, 3 of them included in the wider search (allegation/s in titles) and only 1 in the previous performed search (false allegation/s in titles); 10 authors with university psychiatry/psychology background; 38 pages written in English and 11 in German in the range period 1988-2000; main theme is false allegation and investigation: memory and interviews. Focusing on the 3 records not included in any previous search one results particularly interesting: children credibility switch to child sexual accuse syndrome or sexual abuse allegation in divorce syndrome: the authors intent to stressing the importance only of false positives in child sexual abuse questions, an attempt is made to describe reasons for false negatives.
MAIN RESULTS
Started within the psychological literature, CSA has progressively gained the pages of the medical literature for the clinical aspects related to diagnosis and physical examination, but also on law and social sciences journals as well as economical and policy literature. This multidisciplinary temperament has rapidly awarded the subject with a shared popularity that allowed a quick diffusion among the professionals involved as well as deep repercussions on public opinion, mass media and arts (for example the wide utilization of this subject in the movie industry). Focusing on the medical literature, published clinical research included studies on genital anatomy in children selected for non-abuse [33], and reports on anatomical variations in children referred for possible sexual abuse. In addition, there have been few reports of healing trauma [34]. Based on these studies, recommendations for diagnostic criteria or standards as well as classifications
47
schemes have been developed [16,17,18,19]. Another important trend in the literature on CSA regards the psychological research dealing particularly with interviews and child testing, memory and episodes recollection, adulthood psychological consequences and recovery [35]. The two databases searched store a considerably different number of manuscripts on CSA (3 878 PsycINFO vs 1 242 PubMed) and the overlap is represented only by 397 manuscripts (32% in PubMed and 10% of PsycINFO), belonging to few selected journals (mostly Child Abuse & Neglect). The first record retrieved dates 1913 in PsycINFO and 1978 in PubMed. These data could explain a different tradition in the involvement of the two disciplines, Psychology and Medicine, in CSA field. More than 1/3 of the manuscripts are published in core journals, specifically addressed to CSA, Sexual Abuse, child maltreatment, child protection. This is observed in both databases (PsycINFO 34%, PubMed 37%, Union DB 34%). The authors affiliation area is mostly Psychology and Psychiatry working within Universities, and this datum is confirmed in all the 3 analysis. Words in titles and abstracts reveal an overall tendency to think to CSA in retrospective terms, focusing on recovery and trauma outcome. Among the most frequent words in fact we find victim, women, adult, survivor and history. Collected data show an visible decline in the number of manuscripts on CSA during 2007. This phenomenon is more pronounced in PsycINFO then in PubMed (Box 1 and 2). The partial datum may suggest a decreasing interest from the psychological editing or authoring in the field. There are 96 manuscripts (48 couples) that show same title, same authors published at a distance of 2-3 years, probably demonstrating the presence of a group of experts constantly updating the information on this topic. Summarizing the results of the text mining for false allegation/s (Box 4) in titles and abstracts performed on the searches previously described: according to PsycINFO database, papers containing the term false allegation/s are quantitatively poor, exclusively in English, extremely drifted to a US point of view, focused on false allegations in child dispute cases and the diagnostic method based on a psychological basis, no manuscripts on false negative cases, performing the search in two different fields, title and abstract, the results are unexpectedly different.
48
Anna Aprile, Cristina Ranzato, Melissa Rosa Rizzotto et al. In PubMed, the search retrieves a poorer amount of papers, all in English, psychiatric oriented, not published in recent years, leading to suppose an interest breakdown. The two databases, performing the same search on the overlapping area, show to have in common only 1 record based on the evaluation of child sexual allegations facing Munchausens by proxy syndrome.
Chapter 3
A CHALLENGING DIAGNOSIS: ITS NORMAL TO BE NORMAL! [36]

As outlined in the previous chapter, the idea of considering child maltreatment and child sexual abuse as a issue of the medical discipline is a relatively recent achievement. This awareness has broadly expanded the dedicated clinical research. In the present chapter, the Authors sum up the current international guidelines for the examination and diagnosis of CSA. The diagnostic process requires the analysis of a wide spectrum of differential diagnosis, the search of shared specific criteria, an objective assessment of the signs and symptoms, the examination of focused laboratory data, a deep understanding of the patterns and mechanisms of observed injury, the study of the mechanics and dynamics of the abuse, and the evaluation of the consistency between the history and the medical findings. Clinicians conventionally identify cases of abuse on the basis of physical findings, but only occasionally, the child presents with clear evidence of anogenital trauma due to sexual abuse. Physical examination alone, in fact, is infrequently diagnostic, since many types of abuse leave no physical evidence and physical findings are often absent even when the perpetrator admits the penetration of the child's genitalia [37]. The medical assessment is only a part of the whole, since a clear and consistent history and/or specific laboratory findings are usually needed to state the diagnosis, and in some cases the diagnosis of child sexual abuse often can be made based only on the child's history. In other cases, the evaluation can be instrumental in establishing that a worrisome physical sign or symptom was in fact caused by something other than abuse.
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The physician, the multidisciplinary team evaluating the child, and the courts must establish a level of certainty about whether a child has been sexually abused. Adams and colleagues have recently updated the 5 classes of likelihood of abuse (tables 1 and 2) [16]. Table 1. Approach to Interpreting Physical and Laboratory Findings in Suspected Child Sexual Abuse
Findings documented in newborns or commonly seen in non-abused children: (The presence of these findings generally neither confirms nor discounts a child's clear disclosure of sexual abuse) Normal variants 1. Periurethral or vestibular bands 2. Intravaginal ridges or columns 3. Hymenal bumps or mounds 4. Hymenal tags or septal remnants 5. Linea vestibularis (midline avascular area) 6. Hymenal notch/cleft in the anterior (superior) half of the hymenal rim (prepubertal girls), on or above the 3 o'clock 9 o'clock line, patient supine 7. Shallow/superficial notch or cleft in inferior rim of hymen (below 3 o'clock 9 o'clock line) 8. External hymenal ridge 9. Congenital variants in appearance of hymen, including: crescentic, annular, redundant, septate cribiform, microperforate, imperforate 10. Diastasis ani (smooth area) 11. Perianal skin tag 12. Hyperpigmentation of the skin of labia minora or perianal tissues in children of color, such as Mexican-American and African-American children 13. Dilation of the urethral opening with application of labial traction 14. Thickened hymen (May be due to estrogen effect, folded edge of hymen, swelling from infection, or swelling from trauma. The latter is difficult to assess unless follow-up examination is done) Findings commonly caused by other medical conditions: 15. Erythema (redness) of the vestibule, penis, scrotum or perianal tissues. (May be due to irritants, infection or trauma*) 16. Increased vascularity (Dilatation of existing blood vessels) of vestibule and hymen. (May be due to local irritants, or normal pattern in the non estrogenized state) 17. Labial adhesions. (May be due to irritation or rubbing) 18. Vaginal discharge. (Many infectious and non-infectious causes, cultures must be taken to confirm if it is caused by sexually transmitted organisms or other infections.) 19. Friability of the posterior fourchette or commissure (May be due to irritation, infection, or may be caused by examiner's traction on the labia majora) 20. Excoriations/bleeding/vascular lesions. These findings can be due to conditions such as lichen sclerosus, eczema or seborrhea, vaginal/perianal Group A Streptococcus, urethral prolapse, hemangiomas)
A Challenging Diagnosis: Its Normal to Be Normal!
51
21. Perineal groove (failure of midline fusion), partial or complete 22. Anal fissures (Usually due to constipation, perianal irritation) 23. Venous congestion, or venous pooling in the perianal area. (Usually due to positioning of child, also seen with constipation) 24. Flattened anal folds (May be due to relaxation of the external sphincter or to swelling of the perianal tissues due to infection or trauma*) 25. Partial or complete anal dilatation to less than 2 cm (anterior-posterior dimension), with or without stool visible. (May be a normal reflex, or may have other causes, such as severe constipation or encopresis, sedation, anesthesia, neuromuscular conditions) INDETERMINATE Findings: Insufficient or conflicting data from research studies: (May require additional studies/evaluation to determine significance. These physical/laboratory findings may support a child's clear disclosure of sexual abuse, if one is given, but should be interpreted with caution if the child gives no disclosure. In some cases, a report to child protective services may be indicated to further evaluate possible sexual abuse.) Physical Examination Findings 26. Deep notches or clefts in the posterior/inferior rim of hymen in pre-pubertal girls, located between 4 and 8 o'clock, in contrast to transections 27. Deep notches or complete clefts in the hymen at 3 or 9 o'clock in adolescent girls. 28. Smooth, non-interrupted rim of hymen between 4 and 8 o'clock, which appears to be less than 1 millimeter wide, when examined in the prone knee-chest position, or using water to float the edge of the hymen when the child is in the supine position. 29. Wart-like lesions in the genital or anal area (Biopsy and viral typing may be indicated in some cases if appearance is not typical of Condyloma accuminata) 30. Vesicular lesions or ulcers in the genital or anal area (viral and/or bacterial cultures, or nucleic acid amplification tests may be needed for diagnosis). Marked, immediate anal dilation to an anterior-posterior diameter of 2 cm or more, in the absence of other predisposing factors Lesions with etiology confirmed: Indeterminate specificity for sexual transmission (Report to protective services recommended by AAP Guidelines unless perinatal or horizontal transmission is considered likely) 31. Genital or anal Condyloma accuminata in child, in the absence of other indicators of abuse. 32. Herpes Type 1 or 2 in the genital or anal area in a child with no other indicators of sexual abuse. Findings Diagnostic of Trauma and/or Sexual contact (The following findings support a disclosure of sexual abuse, if one is given, and are highly suggestive of abuse even in the absence of a disclosure, unless the child and/or caretaker provide a clear, timely, plausible description of accidental injury. (It is recommended that diagnostic quality photodocumentation of the examination findings be obtained and reviewed by an experienced medical provider, before concluding that they represent acute or healed trauma. Follow-up examinations are also recommended.) Acute trauma to external genital/anal tissues 33. Acute lacerations or extensive bruising of labia, penis, scrotum, perianal tissues, or perineum (May be from unwitnessed accidental trauma, or from physical or sexual abuse) 34. Fresh laceration of the posterior fourchette, not involving the hymen (Must be
52
differentiated from dehisced labial adhesion or failure of midline fusion. May also be caused by accidental injury or consensual sexual intercourse in adolescents) Residual (healing) injuries (These findings are difficult to assess unless an acute injury was previously documented at the same location) 35. Perianal scar (Rare, may be due to other medical conditions such as Crohn's Disease, accidental injuries, or previous medical procedures) 36. Scar of posterior fourchette or fossa. (Pale areas in the midline may also be due to linea vestibularis or labial adhesions) Injuries indicative of blunt force penetrating trauma (or from abdominal/pelvic compression injury if such history is given) 37. Laceration (tear, partial or complete) of the hymen, acute. 38. Ecchymosis (bruising) on the hymen (in the absence of a known infectious process or coagulopathy). 39. Perianal lacerations extending deep to the external anal sphincter (not to be confused with partial failure of midline fusion) 40. Hymenal transection (healed). An area between 4 and 8 o'clock on the rim of the hymen where it appears to have been torn through, to or nearly to the base, so there appears to be virtually no hymenal tissue remaining at that location. This must be confirmed using additional examination techniques such as a swab, prone kneechest position or Foley catheter balloon (in adolescents), or prone-knee chest position or water to float the edge of the hymen (in prepubertal girls). This finding has also been referred to as a complete cleft in sexually active adolescents and young adult women. 41. Missing segment of hymenal tissue. Area in the posterior (inferior) half of the hymen, wider than a transection, with an absence of hymenal tissue extending to the base of the hymen, which is confirmed using additional positions/methods as described above. Presence of infection confirms mucosal contact with infected and infective bodily secretions, contact most likely to have been sexual in nature: 42. Positive confirmed culture for gonorrhea, from genital area, anus, throat, in a child outside the neonatal period. 43. Confirmed diagnosis of syphilis, if perinatal transmission is ruled out. 44. Trichomonas vaginalis infection in a child older than 1 year of age, with organisms identified by culture or in vaginal secretions by wet mounts examination by an experienced technician or clinician) 45. Positive culture from genital or anal tissues for Chlamydia, if child is older than 3 years at time of diagnosis, and specimen was tested using cell culture or comparable method approved by the Centers for Disease Control. 46. Positive serology for HIV, if perinatal transmission, transmission from blood products, and needle contamination has been ruled out. Diagnostic of sexual contact 47. Pregnancy. Sperm identified in specimens taken directly from a child's body. * Follow-up examination is necessary before attributing these findings to trauma.
(modified from Adams and colleagues [16]).
A Challenging Diagnosis: Its Normal to Be Normal! Table 2. Adams assessment of the likelihood of abuse
Class I No indication of abuse 1. normal examination findings, no history, no behavioural changes, no witnessed abuse 2. category-2 findings with another known or likely explanation and no history, no behavioural changes 3. child at risk of CSA but no history and non-specific behavioural changes 4. physical findings consistent with injury history Class II Possible abuse 1. category-1 or category-2 findings with abnormal behaviour, no history herpes type 1; otherwise normal examination findings, no history Condyloma acuminatum (genital wart); otherwise normal examination findings, no history statement from child, but not sufficiently detailed or consistent Class III Probable abuse 1. consistent history with or without abnormal physical findings positive Chlamidia trachomatosis culture in prepubertal child (not via rapid antigen test) positive herpes simplex virus 2 culture trichomoniasis Class IV Definite abuse 1. category-4 findings, no accident history sperm or seminal fluid found pregnancy positive Neisseria gonorrhoea culture postnatal syphilis photographs or videotapes showing abuse HIV infection, not perinatal acquired, via needle or blood
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2.
2.
2.
3. 4.
5. 6.
3.
3.
7.
4.
4.
(modified from Adams and colleagues [16]).
THE CHILDS EVALUATION

A medical evaluation should be offered to all the suspected victims of sexual abuse. The aims of this evaluation are to obtain the history (child and/or guardian), take into consideration other possible explanations for the observed injuries and signs and for the referred symptoms, document evidence of infection, diagnose and treat medical conditions resulting or not from abuse, assess carefully the child for any developmental, emotional, or behavioral problems, evaluate the child's safety and make a report to child protective services and law enforcement
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agency if needed (see Box 7, The crime of Sexual Abuse and Child Sexual Abuse: The Italian law). Crucial steps of the medical examination include: 1 2 3 the medical history collection the documentation collection proper examination techniques
1. The Medical History

This is usually the most important part of the whole evaluation. To obtain the history, specific principles and competencies are required. First of all, information needs to be gathered from the parent or other caretakers as well as from the child (past medical history, signs, symptoms relevant to the medical assessment). For example, ask questions regarding past history of injury or surgery involving the genital or anal areas, past episodes of physical or sexual abuse, recent or current symptoms of anogenital pain, bleeding, itching or discharge, symptoms of dysuria, painful urination, pain with bowel movements, constipation, and any recent medical treatment of anogenital conditions. Secondly the type of contact described by the child has to be understood and, if possible, estimate how recently this may have occurred. The medical record should fully contain all the gathered information, and if possible, the child's interview should be video or audio recorded, or at least, documentation of the specific wording should be taken. To obtain a more detailed history of the abuse allegations, several models are available (see box 5, Sexual abuse examination do's and don'ts), bearing in mind the general rule that the number of times the child must recount the details of what he/she has experienced should be minimized. In particular, leading questions should be avoided and techniques specific for the child's cultural background and level of language development should be used.
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BOX 5. SEXUAL ABUSE EXAMINATION DO'S AND DON'TS*

Do
Educate caretakers and patients that most sexually abused children have normal examination results. Perform a complete physical examination, including the skin and oropharynx. Place patient in a frog-leg position in the caretaker's lap or on the examination table. Use gentle labial traction to visualize the genital anatomy. Gently apply preservative-free saline if hymenal visualization is inadequate. Consider examination in the knee-chest position to confirm suspected abnormalities. Consult a specialist if the examination is inadequate or if abnormalities are present. Document thoroughly, using quotations where possible, detailed examination findings, descriptions, drawings, and, if feasible, photographs.
Don't
Force examinations on uncooperative children. Use a speculum in the prepubertal child. Touch the hymen with swabs or other objects. Perform a digital rectal examination.
*(modified from Bernard and collegues [38]).
Taking into consideration that a skilled evaluation is required and not every provider is usually competent in performing and documenting a comprehensive examination for a suspect or an allegation of sexual abuse, a medically based screening process can determine the need for an emergency evaluation and where or when non-emergency examinations should be conducted. This will help to decide for the timing, the location, and the provider of the medical examination. Reasons for emergency examinations include, but are not limited to, the child complains of pain in the genital or anal area, the evidence or complaint of anogenital bleeding or injury, the alleged assault occurred within the previous 72 hours (or other state mandated time interval) and the possible transfer of biological material, the need for a medical intervention emergently to assure the health and safety of the child, the risk of possible suicidal ideation/plan.
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2. Documentation
As already underlined, the medical history and the physical examination findings must be fully documented in the medical record. Photographic still and/or video documentation of examination findings is strongly encouraged for different purposes, not only forensic (peer review, obtaining an expert opinion, not to repeat examination of the child) [39].
3. Examination Techniques
Examination techniques should be appropriate and minimally invasive, utilizing the conscious sedation rarely only when the medical benefits clearly prevail over the potential risks. Such techniques are often necessary to determine the reliability of an examination finding; for example, different techniques may be used to ensure that an apparent defect or cleft in the posterior hymen is not a normal hymeneal fold or congenital variation. In addition, instruments that magnify and illuminate the genital and rectal areas should be used. Speculum or digital examinations should not be performed on the pre-pubertal child unless under anesthesia, and digital examinations of the rectum are not necessary [16,39].
Differential Diagnosis Some medical conditions, normal variants, or trauma may be confused with findings seen in sexual abuse (Box 6). The possibility of these diagnoses should be considered in any patient with suspected sexual abuse, particularly in patients with physical findings, but with no specific concern of sexual abuse and no patient disclosure. It is important to remember, however, that the presence of any of these does not exclude the possibility of sexual abuse. Patients with specific concern of sexual abuse based on caretaker history, or disclosure by the patient should have Child Protection Services involvement, even if a nonabusive medical condition is suspected.
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BOX 6. FINDINGS CONFUSED WITH SEXUAL ABUSE

Hemangioma [45] Lymphangiomatosis [40] Failure of midline fusion (anal in both sexes or female genital) [45] Prominent linea vestibularis [45] Epispadius [45] Midline anal skin tags [43] Myotonic dystrophy [41,42] Increased pigmentation around the anus [43,44] Excoriation owing to self scratching [6] Irritation owing to bubble-bath and other irritants (urine, stool, perfumes, soaps, bleach, scented toilet paper, clothing dyes) [45] Poor hygiene [45] Phytodermatitis [46] Atopic dermatitis [47] Contact dermatitis [48,49,50] Vulvar pemphigoid [51] Psoriasis [52] Lichen planus [52] Lichen sclerosus [53,54,55] Nonspecific vaginitis [56] Genital candidiasis [43] Varicella zooster infections [57,58] Herpes zooster infections [59] Streptococcal cellulitis [60] Genital warts [61] Chronic chlamydia trachomatis infection [62] Hemolytic uremic syndrome [63] Crohns disease [64] Foreign bodies [65,66] Nonabusive trauma (dynamics consistent with observed injury) [67,68] Straddle injuries [45] Self-inflicted injuries [66] Masturbatory injuries [69] Anal fissure [70]
Congenital disorders
Dermatological disorders
Infectious diseases
Inflammatory diseases
Trauma
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Toilet-lid injuries (penis) [71] Seat-belt injuries [72,73] Urethral prolapse [74,75] Urethral caruncle [74] Urethral polyps [75] Urinary tract infection [76] Urinary tract mimics [76] Urine crystals in infancy [76] Hemorrhagic cystitis [77] Periurethral or perihymenal bands [74] Henoch-Schnlein purpura [78,79] Hematochezia [80] Other causes of hematuria [76] Rhabdomyosarcoma [81] Sarcoma botryoides [45] Tumors [81] Bleeding disorders [82] Chronic severe constipation [43] Postmortem anal dilatation [83,84]
Urethral conditions
Other conditions
CONCERNS
Although the body of knowledge on CSA has reached a considerable dimension (see Box 1, 2 ,3), as some Authors have indicated, research in this area remains in an early phase of development [85] and the field is still complex. Although research efforts have been made in some of the involved areas, a clear answer is still missing. For example, it is urgent to understand if the prevalence of CSA is changing in recent years, or if the validity of classifications of genital and anal findings is sufficiently demonstrated (particularly for the anal findings, expecially in girls), and how sensitive and specific are physical and behavioral indicators of CSA, for example, it would be interesting to know how indicative of sexual contact are genital warts, and to what extent is wart typing helpful, or for how long the vertically transmitted HPV persist. Another source of concern regards the maximal length of time that forensic medical evidence may be collected after reported sexual assault, to be able to still find an indicative injury.
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BOX 7. THE CRIME OF SEXUAL ABUSE AND CHILD SEXUAL ABUSE: THE ITALIAN LAW
The Italian Legal System punishes the sexual assault. The legal definition of criminal sexual assault is any genital, oral, or anal penetration by a part of the accused's body or by an object, using force or without the victim's consent (penal code Art. 609 bis). When the victim is under the age of 18, the punishments laid down by law worsens. According to the Italian Legal System, there is another crime, sexual intercourse with a minor, punishing those who have a sexual intercourse with a child under the age of 14 (or under the age of 16 if the abuser is family member) without threats or physical violence or using force. This definition of crime arises from the principle that under a certain age the child is not enough mature to give consent to sexual intercourse, and therefore the consent is legally irrelevant because the child is defined as being incapable of consenting. For this reason, the accused is considered guilty despite the consent of the child the same as those who sexually abuse a child using force or without the victim's consent (in this last case, the punishment is higher.
Health Professionals Duties

The Italian law provides that a health professional being acquainted or aiding a victim of a sexual assault has the duty to keep the secret. If the victim decides to report the assault, the judicial authority can ask the doctor a report of the examination performed. When the victim is a child, any physician or any health professional has the duty to mandatory report to the Authority an alleged case of child sexual abuse. The reporting is mandatory also when the professional suspects a CSA and not only when the diagnosis is stated. The law does not specify if the suspect should be based on clinical findings, on behavioral disturbances or on the basis of the childs disclosure. For this reason the reported cases are various. The higher the professionals sensitivity to detect signs of likelihood of abuse, the better will be the ability in signs &symtpoms interpretation.
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Judicial Investigation
When the law enforcement authority get to know a suspect of a sexually abused child, an investigation starts in order to ascertain if a crime has been committed. Depending on the case, the investigation is carried out utilizing covert surveillance and/or collecting the child testimony helped by an expert of child psychiatry and/or with the medical examination. If the suspect lays within the family, the leading problem is to protect the child until the truth is ascertained. In such cases, the judicial authority often decides for a temporary foster care of the child in a protected condition, under the guardianship of the Social Services. In Italy, such as in the United States and in most European countries, physicians are required by law to report known or suspected cases of sexual child abuse to the judicial authorities, regardless of their obligation to professional secrecy. There is also a Juvenile Court which is legally involved in cases of sexual child abuse and which provides frequent contacts with social, educational and assistance services. In some other European countries, e.g., Germany, there is no obligation on the part of doctors to report cases of suspected child sexual abuse.
Chapter 4
PUBLISHED CASE REPORTS REVIEW

This chapter explores and quantifies the idea the researchers may have of the issue of false allegations in the international literature. This information could be gathered either from editorials and commentaries or reviews, case series reviews or directly form case reports. The review was made on case reports. By definition, a case report is a way of communicating information to the medical world about a rare or unreported feature, condition, complication, or intervention by publishing it in a medical journal [86]. Historically, case reports have proven to be extremely valuable to clinicians faced with diseases they knew little about [87]. Grouping them together, in fact, helps doctors establishing timelines or patterns of pathologies even rare. It is a first-line instrument to extract relevant evidence when the literature is almost exclusively limited to case reports, and gives an indirect indicator of how cases are handled in daily clinical practice. Case reports do not necessarily introduce new disorders or new understanding of a known disorder, but may help in changing the clinicians attitude in general, and specifically for a particular disease [88]. Moreover, reported cases are particularly useful for comparison and contribute in enlarging the list of other differential diagnoses. For all these reasons, all case reports of child sexual abuse available in the international e-databanks have been searched and reviewed. The search was performed in PubMed utilizing the quoted phrase child sexual abuse without limiting the search to manuscripts classified as case reports. All original cases (i.e., those not cited from another publication) mentioned in the articles were included in the data presented here. The inclusion criteria were to consider reports involving children (age tag <18 years) with specific language of publication (English, French and Italian), or
62
whose on-line full-text was available. Exclusion criteria were: all case reports described as teaching reports, and cases of adults recollecting their experiences of sexual abuse in childhood. Each manuscript was examined and information was recorded on authors, year of publication, classification, final diagnosis, victims sex, victims age, abusers role, abusers age, abusers sex, legal procedure, clinical picture, clinical work-up, abuse typology, story referred by the child (table 3). Furthermore, published reported cases were classified according to 4 main categories, as suggested by Oates and collegues [24].
Substantiated sexual abuse. Sexual abuse was confirmed as being occurred on the basis of information obtained from the child and family, medical evidence, court findings or perpetrators confession. Not sexual abuse. A case in which sexual abuse could be confidently excluded. Inconclusive cases. A case where sexual abuse may have occurred but where there was insufficient evidence for the case to classified in the first category. Erroneous concerns by the child. A case where the allegation was made in collusion with a parent, or where the child thought that sexual abuse had occurred (but the professional did not) or a case where the child had knowingly fabricated a story of sexual abuse.
Table 3 sums up the cases revision. Starting from retrieval of 456 manuscripts, the use of inclusion and exclusion criteria lead to a manuscripts amount of 45 papers describing 70 cases. The reviewed papers included single cases or case series, each published case, although published in the same article, was considered and reviewed separately. A first-sight analysis of the table demonstrates a wide presence of missing information. Authors do not describe the cases in the same way paying particular attention to some details and neglecting other data. Some case reports for example largely described the child disclosure and others not, or the clinical picture including the specific signs observed, a detailed description of the clinical workup or the reasons why CSA was substantiated or excluded and so on. In particular, the clinical aspects of the case are very often briefly described and sometimes do not help in understanding the process of substantiation. Despite these differences, many considerations on published data can be drawn.
Table 3. Case reports review for the interval period 1995-2007
Abbreviations
CBDC CSA CT GU HIV HPV PCR PTSD SA US Chronic Bullous Disease of Childhood Child Sexual Abuse Computed Tomography GenitoUrinary Human Immunodeficiency Virus Human Papilloma Virus Polymerase Chain Reaction Post Traumatic Stress Disorder Sexual Abuse UltraSound
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Findings Case classification. More than 45% of reported cases are those were CSA was excluded and another diagnosis was confirmed, while a 24% of cases were confirmed cases of CSA. The remaining 30% of cases regards patients whose diagnosis could not be confirmed (table 4).
Table 4. Classification of final diagnosis in reported cases
Classification Not SA Inconclusive case Substantiated CSA Erroneous Concern Total N 29 20 17 4 70 % 41.4 28.6 24.3 5.7 100.0
Victims Gender. Of the 68 cases whose gender was indicated, 59 (86.8%) were females and 9 (13.2%) were males, suggesting a strong overall female gender preponderance, with a female-male ratio of 6.5:1, distributed as follows according to classification (table 5). Furthermore, there are fewer studies[5, 135] of CSA in boys in comparison to girls leading to a general acknowledgement for wich the sexual abuse of boys is common, under reported, under recognized and under treated. Table 5. Female/Male ratio per case classification
Classification Erroneous Concern Substantiated CSA Not sexual abuse Inconclusive cases F/M Sex Ratio 0.5:1 7.5:1 27:1 4:1
Victims Age. The average age of the children was 7 years and 8 months (N = 17 cases; range: 4m-17y; SD: 4y 8m; median: 7 y; mode: 3 y) in substantiated cases of CSA, and the average age in not CSA was 7 years and 1 month (N = 29 cases; range: 1y 6m-17y; SD: 4y; median: 6y 6m; mode: 3 y) (figure 1). Perpetrators Relationship with the Victim. This information is missing in 63% of cases, for the remaining 37%, the perpetrators are mostly males. The
Published Case Reports Review
71
perpetrators age is nearly never indicated (only 3 cases). The abuse occurs within the family or in the relatives group. Perpetration Typology. The figure is missing for all the cases classified as Erroneous Concerns, Inconclusive Case and Not SA. In substantiated cases the abuse typology is indicate in 10 cases out of 17: they consist of penetration in 7 cases (3 anal, 1 anal & vaginal, 2 vaginal, 1 vaginal with foreign body), the 3 remaining cases are touching practices.
12 preverbal (0-2) preschool (3-5) elementary school (6-10) high school (10-17)
10
0 Erroneous Concern Inconclusive case Not SA Substantiated CSA
Figure 1. Distribution of cases per age class.
Victims Disclosure. Despite the predominance of missing data on child disclosure (the details were missing in 9 substantiated case, in 14 inconclusive cases in 23 cases classified as not SA and in 3 cases defined as erroneous concerns), in substantiated cases, child disclosure results fundamental in the decision-making process. Clinical workup and differential diagnosis. This datum results coherent with the clinical picture described in the report, even if authors use different approaches. CSA differential diagnoses subsequently confirmed are mainly infectious diseases (15 cases), dermatological diseases (7 cases), malformations or anatomical variants (6 cases), or inflammatory diseases (5 cases) as shown in table 6. Moreover the group of infectious diseases comprehends all STD.
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In the substantiated case of child sexual abuse, the diagnosis has been made thanks to the finding of a sexually transmitted infectious disease (5 cases). The remaining cases are acute injuries with a class IV likelihood of abuse. Table 6. Not SA: final diagnosis
Group Congenital diseases Disease Imperforate hymen congenital Myotonic dystrophy Infantile Perianal Pyramidal Protrusion Delta-storage pool disease CBDC Lichen sclerosus et atrophicus Pemphigoid confined to the vulva Vulvitis circumscripta plasmacellularis Chlamydia trachomatis Condyloma acuminata Herpes zoster Neisseria gonorrhoeae Crohns disease Accidental injury Ectopic urethers Ovulation, ovarian cyst, appendicitis N 1 1 1 1 2 6 1 1 1 2 1 1 1 3 1 1
Dermatological diseases
Infectious diseases
Inflammatory diseases Trauma Urethral conditions Other conditions
Chapter 5
CASE REPORT
In this chapter we report a case of supected CSA not substantiated that came to our attention at the Emergency Room (ER) of the Pediatrics Department of Padua University. 2 years ago, late in the evening, Paula (5 years old, Caucasian) was brought to the ER by her mum. The reason of entering the ER was described by Anna, Paulas mum, with extreme anguish. Paula she told the doctors came home after spending all the afternoon with her father, Mark. An hour later, while changing her for bed, Ive noticed that her knickers were stained with blood. She told the doctors she was afraid that her father could have sexually abused the child. She told she was separated from Mark since 2 years ago. Anna said to have good grounds for suspecting this and asked for a prompt medical examination to verify her fears and doubts. She gave us also the spotted knickers. At first sight, the knickers show large traces of blood. Paula, questioned by the mother about the spots, told her she didnt noticed the blood, but urged by Anna, she reported a fall happened during the afternoon. Before going to the ER, Anna carefully washed and changed Paula. Paula is not in the ambulatory while this information is collected. Paulas medical physical examination reveals good general conditions. She interacts with the interlocutor, showing to be able to get along with others, even if she looks constantly for her mum. Her attitude is basically shy, but in general she is calm and collaborative. A careful examination of the skin surface does not reveal any past or recent traumatic injury . External genitalia appear to be normally conformed and with no apparent lesions or bleeding.
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The doctors decide for the admission to the hospital. For the morning after, we plan for a gynecological examination, an interview for both parents with the Child Psychiatrists and an observation for Paula. All the evidence makes it clear that the family has few problems. Paulas mum, Anna, is the second-born child of two sisters. She is on good terms with her family of origin, particularly with her sister. She got married with Mark when she was 30, after a short engagement. She separated 2 years ago and she was granted of the custody of Paula. She works in a nursery school. The pregnancy had a regular course, but after delivery Anna underwent a period of severe depression requiring a prise en charge by the local psychiatric services. The reason for the involvement of the psychiatric services was due to a psychotic episode, requiring an admission to the hospital with a compulsory treatment order for a delirium in which she was convinced to be a child being abused. After that period, the psychosis never relapsed with a complete restitutio ad integrum to the pre-morbid period. Annas social functioning is adequate; in her looking after to Paula she is solicitous, careful and, all in all, able to meet Paulas affective and material needs. Mark, Paulas father, is the first-born out of 4. He had broken off all the relationships with his family of origin. He works in a factory, but feels very frustrated with his job, considering it too disqualifying for his cultural level (high school degree). He shares a house with two colleagues younger than him. He refers to be very attached to his daughter and not to stand the doubts risen by his wife, ascribing them to her madness. Analyzing thoroughly, we find out that he is currently in charge to the local psychiatric services due to a borderline personality disorder, showing rapid changes in mood, intense unstable interpersonal relationships, marked impulsively, instability in affect, in self image and sexual identity. The gynecologic exam performed the morning after showed normal external genitalia with no apparent injuries. The anatomical structures of the vestibulum were occupied by a red mucous membrane prolapsed form the urethra. The urethral prolapse made difficult the inspection of the hymen. Vulvar tampons were collected.
Case Report
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DISCUSSION
The urethral prolapse found during the gynaecological exam called for further diagnostic investigation by the urological staff the day after. Nearly complete spontaneous remission of the prolapsed mucous membrane was noticed and, compared to the picture of the previous day, the mucosa was little protruding right out the urethral ostium. The cystoscopy excluded the presence of other malformations of the urinary tract, frequently associated with these pictures according to the literature. The hymenal membrane examination showed an hymen integral and annular-shaped. The clinical characteristics did not require a surgical excision. Few days rest should have been enough for a complete remission of the prolapse. Paula stayed in the hospital for 5 days. She underwent daily interviews with a child psychiatrist. The global assessment indicated an IQ over the average, a reactive depressive background due to the parents conflicts and separation. Telling about the afternoon spent with her father before being brought to the ER, Paula told she stayed at home with him and played. She remembers she fell on the buttocks while running in the corridor, just before going back to her mothers house.
Urethral prolapse Urethral prolapse is a circular protrusion of the distal urethra through the external meatus. It is a rarely diagnosed condition that occurs most commonly in prepubertal black females and postmenopausal white women. Even less common is strangulated urethral prolapse. Vaginal bleeding is the most common presenting symptom. Upon examination, round doughnut-shaped mucosa is observed protruding from the urethral opening. Because the condition is so rare, the rate of misdiagnosis is high. The differential diagnosis of a urethral mass is broad, ranging from a simple urethral caruncle to rhabdomyosarcoma. Increased physician awareness and early recognition of urethral prolapse avoids unnecessary examinations and patient anxiety. Management of urethral prolapse ranges from medical therapy that consists of topical estrogen use to conservative surgical excision in whom medical therapies fail.
Chapter 6
THANK GOD IT WASNT THAT!

The world of abusive relationships is generally very complex and has several components that concur in its genesis, typically societal, economic, psychological, familial and cultural factors. The clinicians attempt to cast light upon the medical aspects of abuse without expertise and without being at the same time cautious and firm, is likely to end in failure for clinicians, and most of all, for patients. The decision to substantiate a suspect of child abuse is a very difficult task for the physician since it is a complex multidimensional decision-making process, influenced by a considerable list of factors related to child and family characteristics such as the type of maltreatment, the severity of harm, the characteristics of the reporter, but also to professionals characteristics, clinical data and institutional factors [136]. The great number of variables to be taken into consideration renders the substantiation process very complicated, and this results particularly true for the cases of suspected CSA, in which normal physical examination does not rule sexual abuse, nor is an abnormal examination pathognomonic. Over the past 15 years, the number of reports to be considered by the Child Protection Units for CSA has increased dramatically, leading to a considerable discussion regarding how professionals evaluate allegations of abuse and how many cases referred, result in a diagnosis of sexual abuse. According to the results of the Canadian Incidence Study (CIS 2003), the rates of substantiation result in 20.3% of reported cases for child sexual abuse, increasing to a 37% for physical abuse, and a 40% and 44% for neglect and emotional maltreatment respectively; the substantiation rate results significantly higher in cases involving multiple forms of maltreatment (59%). A recent study by Kelly and colleagues [137] has conducted an audit for the work of a regional specialist child abuse assessment
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unit and retrospectively reviewed 2 134 medical reports for allegations of child sexual abuse. The revision stated an overall conclusion as to the likelihood of sexual abuse in 2 119 of the 2 134 cases, distributed as follows: 6.1% where diagnosis of sexual abuse was stated and 10.2% concluded that there had been no sexual abuse, 78.9% with normal/non specific medical findings neither confirming nor refuting the allegation, referring the question back to the statutory authorities, and a remaining 4.8% where medical findings were suspicious but not diagnostic. In the great majority of cases, the elements collected were not sufficient to confirm or exclude and do not help to reach a final decision. The complete absence of objective elements and/or the detection of highly unspecific sings combined usually with the absence of witnesses avoids the possibility of deciding whether CSA has occurred or not, leaving the diagnosis to the statutory authority. In the international literature it is well-documented that not among all the victims of CSA there is a specific identifiable clinical picture and, on the contrary, many non-abused children show behaviors and/or signs that are considered to be indicative of abuse, making difficult to identify the real victims: for this reason experts universally recommend to rely on a comprehensive assessment, rather than on aspecific single indicators of abuse. A debate is still ongoing on what is comprehensive, in other words which indicators should be used and if there is a minimum number of indicators to assure adequate comprehensiveness, and how to make sense of all the information gathered. A lack of guidance on these issue is daily observed and it probably explains the vast differences that exist among clinicians in how they assess allegation of abuse. If no a priori method to integrate all the findings exists, clinicians might risk to take into account multiple indicators and obtain mixed results, then selectively choose indicators consistent with personal biases [138,139]. For example, a recent study examining whether clinicians investigating CSA rely more on scientific knowledge or on clinical experience when evaluating their own expertise, demonstrated that most professionals relied more on their clinical experience when evaluating their expertise as investigators of CSA [140]. Moreover, other research evidence suggests that clinicians involved in CSA examinations do not use skills consistent with good decision making in their work, and sometimes may be influenced by other factors not related with the case itself, such as, for example, a heavy caseload, that might lead the professional to substantiate fewer cases because it requires less work to unfound than to substantiate [141]. In the end, grounding the substantiation decision on heuristic rules, rather than on statistical probabilities may lead to systematic errors and jeopardize clinical work.
Thank God It Wasnt that!
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Not understanding the role of uncertainty in CSA investigations could cause professionals to increase the number of children erroneously classified as either abused or not abused when interpreting available information. Very often, allegations of child maltreatment, particularly the sexually abused cases are contested [23,15]. Investigators, researchers, and the public opinion have all expressed doubts about errors in classification because of the worry of a wrong categorization resulting in a false allegation of child sexual abuse. The worry lies in the serious consequences such as separation, imprisonment, loss of job and reputation, and major psychological stress, both for the child and the involved carers/parents following substantiation of a case when no sexual abuse had occurred. Some Authors have also suggested that the consequences of the label of sexually abused have an additional adverse impact itself that should be taken into consideration, while investigating [142]. Misclassifying a case of CSA usually terrifies professionals approaching the problem. Although relatively rare, it captures the medias attention shifting away the focus from childs health and well-being, and increasing the opposite phenomenon of false negative cases, leading to an underestimation of the burden of CSA. In fact, despite the acknowledgement of the epidemics of violence against children, the rate of detection of violence and its consequences and sequelae on childs health by clinicians remains extremely low. The problem of lack of detection and the consequent missed opportunity for the healthcare community to assess, exclude, confirm or prevent any kind of violence is probably higher than expected. In a recent study Theodore and colleagues [143] conducted 1 435 computerassisted, anonymous, cross-sectional, telephone surveys with mothers of children 0 to 17 years of age in North and South Carolina, asking about potentially abusive behaviors (themselves or their husbands or partners) in the context of other disciplinary practices, and about their knowledge of any sexual victimization their children might have experienced. For child sexual abuse the results demonstrated that official state level figures of estimation of sexual abuse, were more than 15 times lower than mothers referrals (whose figure was 10.5 cases per 1 000 children). Even worse differences were registered for other types of maltreatment (for example, more than 40 times for physical abuse) [143]. From referral to diagnosis many steps are needed to be taken and result in a potential source of mistake, including the investigation of the concern, the medical examination, a broad differential diagnosis, specific criteria for such diagnosis, objective assessment of the signs and symptoms, focused laboratory data, an understanding of the patterns and mechanisms of injury (mechanics and dynamics of the abuse), the interview, the covert surveillance, a decision thanks to
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the collected elements to whether or not the reported concern comprises a case of sexual abuse or constitutes an error and the needed child protection action [144]. From the very beginning, starting from the agencies in place for reporting possible incidents crucial decisions need to be taken: the professional receiving the report or getting to know that something might have occurred has an element of discretion in deciding whether what has happened is a reportable incident or not, and different professionals may categorize the same behavior differently (discretionary reporting). Nevertheless, the phenomenon of false positive cases is undoubtedly a matter of fact. A recent study by Oates and colleagues [24] aimed at distinguishing the types of referred concerns, in order to better understand the number and characteristics of cases that were unsubstantiated at case conclusion in 1 year series of 551 consecutive concerns at the Denver Department of Social Services. The Authors find that 42.5% of cases were substantiated in the end, 21% were inconclusive, 34% where sexual abuse was excluded and 2.5% where an erroneous account by the child was demonstrated. The erroneous concerns regarded cases where a parent/caregiver overreacted or fabricated allegation, a community member notified a sexual abuse found to be groundless, a professional suspect was excluded. Although relatively uncommon, erroneous concerns of sexual abuse from children do occur, requiring therefore the Child protection teams to identify these cases so that an erroneous concern is not automatically classified as a substantiated case of CSA [145]. In conclusion, decision making process in CSA results in a land mine field, and a systematic review of possible sources of mistakes is needed. There are 3 main components that can be extremely variable and might become a source of misclassification and mistake: factors related to the case itself, factors related to the professional/s involved in the investigation process, and factors related to the context.
1. THE CASE
Physical Signs
Objective scientific validation of evidence that reliably distinguishes between traumatic findings and normal findings has been hard to establish. A huge void in epidemiological data existed in the early days of paediatric forensic anogenital examinations. Medical theories, once held as fact, collapsed when objective scientific research sought to establish the range of anogenital findings in non-
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abused children. Except from selected cases, in most suspected CSA, research, largely from the US, has progressively clarified that examination findings do not justify any conclusion concerning causation, to a reasonable medical probability, and also normal findings do not exclude abuse and the majority of cases of proven sexual abuse in prepubertal children show normal or non-specific findings [36, 146]. With the introduction of standard terminology and photograph documentation, research became more reliable and rates of anatomic variations reported as abnormal dropped from more than 80% to less than 5% in 2000 [147]. The explanation of this lays on the fact that not all forms of sexual abuse determine a traumatic injury in the anogenital area (for example exposure to pornography or witnessing of sexual intercourses) and most of all, even if the injury exists, the healing process is often very rapid and complete, with no scar [147, 148]. At this stage, some questions needed to be answered and some issues are still unclear [146]. For example, up to the present time there is a lack of clear differentiation between prepubertal children and adolescents [146]. Studies assessing the hymen size included only children with no evidence of breast development (Tanner stage 1), or to stratify by breast development. This choice was based upon the fact that the breasts and the hymen characteristics are estrogen-dependent and change during puberty. While the stages of breast development are well documented, the hymen changes have not. The hymen is a dynamic structure that changes in appearance and size according to estrogen status, as well as being influenced by penetration. It is unfortunate that the time scale and range of findings through from a delicate avascular and translucent membrane of mid childhood to the thick, elastic, fimbriated structure found in most adolescent girls is unknown. This has not assisted doctors interpreting findings in those in whom sexual assault is alleged. Another example is represented by the study of the anal injuries. Very little evidence is currently available on this specific topic and mostly case reports are at stake. Very few papers have tackled the problem in the general pediatric population (pre and post puberal)I and very little is know for example on the degrees of anal dilation and which is the normality range, leaving to single professional experience the duty to decide, case by case. According to the bibliometric analysis, it seems that specific and dedicated scientific research has stopped at a gross level, not further investigating the finest aspects and spectrum of injuries due to violence and the specific healing profiles. Current international guidelines in fact give indication to search for gross injuries mostly to be seen just with the naked-eye examination, and, for instance,
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no systematic studies on endoscopic imaging and microscopic analysis of mucosal structure -mostly prepuberal- are currently available. The international literature on CSA is characterized by few specific and typical orientations, with a clear kick off and predominance of the psychological literature, as the figures shown in PsychInfo box demonstrate. Moreover, most published case reports (29 out of 70) report a clinical history where unclear signs were observed, but the clinical work-up has demonstrated the presence of a different disease included in the spectrum of differential diagnosis or a consistent traumatic event. The substantiated cases are 17, in 8 a class IV sign was observed and in the remaining cases victims or perpetrator disclosure was diagnostic. Further studies exploring the fine patterns of all possible injuries are urgently needed.
Disclosure
As previously outlined, most crimes of child sexual molestation have no witnesses, leave no physical signs, and are concealed by the perpetrators. These characteristics make the detection of child sexual molestation very difficult and debatable and make the victims disclosure results in the end crucial for diagnostic and investigative as well as for treatment purposes. Although usually where it is established that the childs testimony is entirely spontaneous and free from contamination, then it is reasonably be regarded as highly reliable, some studies have shown that inaccurate memories and suggestibility are observed, as well as children consciously making false accusations of maltreatment, or vindictive and prevaricating adults as well as parents involved in divorce [28]. Usually, the children who produced erroneous concerns were significantly older than the remaining children. In any case, by far, the phenomenon of children not revealing their sexual abuse spontaneously is much higher than the number of cases where the child presents with an erroneous concern and the even smaller number of cases where the child makes a deliberately false allegation.
2. THE PROFESSIONAL
Since identifying workers biases is essential to child protection, professional should be aware about the potential for subjectivity in the decision making process, as well as being able to identify cases where personal biases affect
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decision-making. In the literature, a well documented phenomenon is represented by the influence of cultural, training, experiences values in reporting and substantiating tendencies and in the differences in the degree of adherence to certain variables some professionals demonstrate. For example, it is well demonstrated that belonging to particular ethnic groups may influence the acceptability of corporal punishment or of culturally based practices [149]. Issues such as the lack of dedicated training, the lack of a shared gold standard, the high emotional impact these cases generate, implicit and explicit beliefs and values, clinicians own personal experience and so on can be some of the elements related to the professionals that may hamper the diagnosis.
Knowledge: The Training

Relevant training and clinical experience should be provided to the child sexual abuse medical professional who is responsible for the interpretation of findings, diagnosis and treatment of alleged sexual abuse. For this specific topic the sources of self-learning are probably not lacking but are not so easily reachable and widespread. Images atlases and manuals in fact are not commonly found in the lists of public and hospital libraries and are usually owned by specialized groups or professionals. Another important source of training should be represented by journal papers, and in particular case reports, but the amount of cases published in the medical literature is surprisingly small. The revision of case reports currently published demonstrates that these papers give a partial description of the examination and of the lesions and injuries observed, and the medical work-up and usually, contrary to the classical medical decision making process, does not help the professional to clarify the inconclusive cases in daily practice. Moreover, the reason why the suspect was confirmed is not always clearly described and motivated. The predominance of false positive cases supports the hypothesis that the exclusion of sexual abuse is more accepted than the confirmation of a case. These cases clearly constitute a non-random sample that reflects the interests of authors and editors. Probably due to editing purposes and authors orientation, reports tend to highlight different aspects of the problem, lacking in describing childs disclosure, familial characteristics, diagnostic workup and/or results of the physical examination (more often lacking in the cases where abuse was confirmed, since it is treated as a secondary information). Inconclusive cases do not report a follow up and the statutory authorities decision
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whether a CSA has occurred or not is not reported, this makes the information on the clinical case report less fruitful.
Know How to Do: The Skills

Any opportunity to simplify, strengthen, or streamline the assessment process would be desirable, but there are some difficulties in operationalizing the available indicators due to the large numbers of potential procedures and the variety of the background of assessors, the multiple ways of utilizing and interpreting such procedures, and the importance given to the results. The crucial moments of the substantiation process are generally considered the medical examination and the childs disclosure and each of them has specific tools to be carried out. In some cases, the allegation of CSA can be validated just on the basis of the results of the medical examination: the physical evidence is so incontrovertible, that is sufficient to state a diagnosis. Unfortunately, these represent the minority of cases. In most of the cases of allegations of CSA, there is no reliable gold standard and universally accepted criterion to which clinicians judgments can be compared and its accuracy be evaluated [150]. Since substantiation decisions lack a firm scientific foundation, clinical research should work to provide additional sources of evidence, including for example ultrastructural tissue damage, and also provide shared guidelines on clinical work-up and global assessment of the child utilizing also all the current fine diagnostic procedures available. Looking at childs disclosure, the difficulty of distinguishing between true and false allegations creats a serious dilemma for investigative interviewers and most of the research is dedicated to uncover the best interview method avoiding the problem of false allegations. During the past decade, several professional experts have organized conferences and published books, articles and handbooks describing how interviews of alleged child abuse victims should be conducted. Many researchers have warned against the risk of evoking inaccurate information and thus eliciting false allegation from children. This phenomenon has been widely studied and the suggestive process and its consequences have been described in many studies [151]. The failure of interviewers to follow best practice guidelines has fostered intense discussion among researchers and practitioners, but still most training programs have little demonstrable impact on interviewers behavior [152]. In current literature, several interview approaches are listed to identify false reports. First of all, there is a shared agreement that interviewers should establish
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relationship with children before questioning them about the facts. Children should be allowed to practice narrative elaboration techniques and initially openended questions should be asked, concluding with focused but not suggestive questions [153]. One of the most utilized instruments is the Criterion Based Content Analysis (see reference [154]), a method designed to discriminate between truthful and false statements [155]. A current trend in the core literature is exploring the different styles of interviewing practices and the best one to be used to reduce the risk of false positive cases [151]. Many assumptions mislead the professionals attitude: for example the stereotype that abuse victims are highly embarrassed and reluctant to disclose the abuse, or assuming that nondisclosure always stem from emotional issues. Hershkowitz and colleagues [154] pointed out that children who participate in investigative interviews are a varied group including different categories of children: abuse victims willing to disclose the abuse; victims who do not want to disclose it; victims who fail to disclose because they do not define their experiences the way interviewers are describing them (or not currently remembering target events); non-abused children falsely reporting; non-abused children who do not disclose.
Because the percentage of children who fall into each of these categories is unknown, current research counting disclosure has to be carefully considered. Moreover, researchers and clinicians agree that some children deny incidents of abuse they have actually experienced and that suggestive interviewing can elicit false disclosures, making it important to ensure that children are not repeatedly interviewed in a coercive manner that may elicit false allegations. In the end, the authors wish is that their research will promote a system of categorization assisting children and parents in the long term, encouraging the maintenance of objectivity and lowering the likelihood of the tragedy of false positives, whilst at the same time enabling definite cases of abuse to be successfully evaluated and identified [24]. Since most previous studies have relied upon workers opinion to select case of false allegations, researchers would be challenged to select a set of criteria consensually developed for determining intentionally false reports than professionals opinion [28].
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Know How to Be: The Emotions

Violence disclosure in a medical setting is not only difficult for the clinical peculiar aspects of the maltreatment syndromes, but is also hampered by the emotional barriers perceived to routinely screening for violence. CSA is an emotionally charged diagnosis and to reach decisions in the best interest for the child, there is considerable pressure on clinicians. In dealing with victims of sexual abuse unaware clinicians may run the risk of behaving as police officers, judges, social workers or onlookers, neglecting their specific role of searching for sings and symptoms, or contaminating the clinical investigation with mistakes and incorrect actions. Some studies have outlined several barriers to questions asking for matters pertaining violence, such as for example not enough trained to do it, not to be considered as a medical problem, not a clinicians business and other specialists duty, not characteristic of their usually examined population. In general the clinicians assessment requires an impartial mind, open to the possibility the allegations may or may not be true, but in many cases, the clinicians attitude results in trying to exclude rather than confirm, as Everson has stated, A false allegation is in the eye of the beholder [155]. This could explain the fact that the publishing a report describing a story of false positive case is much more attractive than a false negative one. False negative cases require also a long term follow-up to be uncovered and are usually reported in retrospective studies involving adults. On the other hand, being given a history of abuse increases also experienced clinicians willingness to interpret non-specific genital findings as diagnostic of abuse.
3. THE CONTEXT
The Media
In the least years, a key role on CSA issue was played by the media being involved in CSA cases. Although, media reporting about CSA may be a powerful tool in reinforcing or changing perceptions of people on the issue, promoting community safety campaigns, in many cases that have reached the lay public, the media have succeeded in pushing anxiety to a level that has provoked an inappropriate reluctance by pediatricians to be involved in child protection work. Sometimes an isolated false allegation hamper all the subsequent child protection processes and influences the attitude of professional.
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Another problem in influencing decision can be the common use of prejudicial terminology strongly implying something untoward did happen, and this may subtly influence opinion Lay people reporting sexual assault, professionals, bureaucrats, Police and courts, use different terms to often describe the same thing: for example, disclosure in place of allegations, and complainants called victims while the accused are called offenders. This attitude may be pejorative if not used in the appropriate context.
Statutory Authority
According to the legal system, in criminal trials, in order to reduce the likelihood of convicting an innocent person, the rigorous standard of beyond e reasonable doubt is preferred, but when important interests are at stake, for example termination of parental rights, a less rigorous standard is used (clear and convincing standard), and finally, in most civil litigation a still less rigorous standard is preferred (preponderance of the evidence). When the decision regards a child protection matter, the law makers have decided that it is more important to try to protect a child by risking a false positive error than to avoid the erroneous determination that someone has maltreated a child. For this reason, a report is made when a mandated reporter develops a reasonable suspicion that a maltreatment has occurred [141]. During the subsequent investigation process, the cases resulting in unfounded or unsubstantiated determination do not mean that no CSA has occurred, but mean only that the level of evidence necessary to support a determination was not present. According to the Blacks Law Dictionary, evidence is defined as ...the case which a reasoning mind would accept as sufficient to support a particular conclusion and consists of more than a mere scintilla of evidence, but may be somewhat less than a preponderance. Each country legal context may use different approaches and standards of proof. Legislature that use the lower standard of some credible evidence (or similar) are less concerned about reducing false positive errors, believing that the risk of a false positive determinations less important than the risk of missing a case of CSA. On the contrary, legislatures using the preponderance standard are more concerned by avoiding a false accusation, which may result in stigmatization or liberty limitation [141].
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Child Protection Agencies

A large number of agencies is usually involved in information sharing about circumstances involving sexual assault, particularly in CSA. In some cases, the efficiency and effectiveness of communication between agencies can have a significant impact on the decision-making process and consequently on children well-being. Inappropriate or not timely interagency communication may impact on evidence gathering and jeopardize the possibility to be able to substantiate.
A PROPOSED CLASSIFICATION MODEL

This model is provided to include all possibilities to be taken into consideration while a child is brought to a professionals attention. The gray areas need a long term follow-up to be clarified.
*Missed case: reported retrospectively (questionnaires) and cases presenting in their case history the neglect of important signs that could lead to a diagnosis.
Chapter 7
CONCLUSION
Given this level of uncertainty and the high levels of emotion and prejudice attaching to allegations of child sexual abuse, the current analysis calls urgently for a global rethinking of research and policy on the procedures of decision making upon the substantiations of CSA, in terms of refinement, cross validation, dissemination, and mandated adoption. Up until now in fact, current international guidelines that categorize findings have not yet undergone vigorous scientific evaluation in order to consider them as a gold standards. The main goal to be pursued is to guarantee the decreasing of errors (false positive and false negative) and reducing the secondary trauma inflicted on children and families resulting from poorly conducted examinations. Professionals duty is to try to adhere as close as possible to current empirical research indications and existing published recommendation, utilizing standardized instruments to prospect greater justice for children and adults. As Geddes and Plunkett [156] pointed out if the issues are much less certain than we have taught to believe, then to admit uncertainty sometimes would be appropriate for experts, this will lead to a good quality science at the service of child protection, through a process of amelioration of professionals training standards, enhancement of multidisciplinary team working, integration of allsectors available knowledge, improving in the end the consistency, the quality and the accuracy of the decisions.
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INDEX
A
AAP, 51, 92 abnormalities, 55, 94 abusive, 2, 77, 79 accidental, 51, 52, 95, 100 accidental injury, 51 accidents, 95, 97 accuracy, 84, 89 achievement, 49 acid, 51 acute, 51, 52, 72 Adams, 50, 52, 53, 92, 93, 99 adhesion, 51 adhesions, 50, 52 adolescents, 1, 46, 51, 52, 81, 92 adult, 1, 16, 26, 47, 52, 91 adulthood, vii, 1, 47 adults, 3, 62, 82, 86, 89 advocacy, 16, 92 Africa, 13, 21, 24, 30, 32, 33, 39, 41 African-American, 50 afternoon, 73, 75 age, 1, 6, 39, 44, 45, 52, 59, 61, 62, 70, 71, 79 aggression, 2 aiding, 59 allergy, 94 amelioration, 89 American Academy of Pediatrics, 2, 92, 96 amputation, 98 anatomy, 46, 55, 94 anger, 2 antigen, 53 anus, 52, 57 anxiety, 2, 75, 86, 91 anxiety disorder, 91 appendicitis, 72 application, 50, 101 Argentina, 32, 33 Asia, 21, 30 assault, 15, 25, 34, 42, 55, 58, 59, 81, 87, 88, 95, 97, 98 assessment, 2, 16, 26, 43, 44, 49, 53, 54, 75, 77, 78, 79, 84, 86, 101 assumptions, 85 attitudes, 46, 100 attribution, 16 Australia, 13, 14, 21, 24, 31, 33, 39, 44, 45 Austria, 21 authority, 59, 60, 78 awareness, 49, 75
B
bacterial, 51 banks, 93 barriers, 86 bed-wetting, 94 behavior, 2, 26, 80, 84 behavioral problems, 2, 53
104
Belgium, 21 beliefs, 83, 100 benefits, 56 bias, 45 bleeding, 50, 54, 55, 73, 75, 96 blood, 50, 52, 53, 73, 96 blood vessels, 50 borderline, 74 borderline personality disorder, 74 Botswana, 32, 33 bowel, 54 boys, 1, 70, 91, 99 Brazil, 20, 21 breakdown, 48 bubble, 57
Index
chlamydia, 57 Chlamydia trachomatis, 72, 95, 97 classes, 11, 50 classical, 83 classification, 3, 5, 6, 62, 70, 79, 93 clinical trial, 18, 19, 30, 31, 37 clinician, 52, 77, 83, 86 coagulopathy, 52 coercion, 1 collaboration, 13 collusion, 62 commissure, 50 communication, 88 community, 26, 79, 80, 86 complete remission, 75 components, 77, 80 concordance, 91 confession, 2, 62 confusion, 94, 95 Congress, 93 consent, 1, 59 constipation, 50, 54, 58 consulting, 22, 39 contamination, 52, 82 corporal punishment, 83, 100 couples, 27, 47 courts, 50, 87 covering, 35 CPS, 46 credibility, 44, 46, 101 crime, 54, 59, 60 crimes, 82 cross-sectional, 79 crystals, 58 cultural factors, 77 culture, 52, 53 cyst, 72 cystitis, 58 cystoscopy, 75 Czech Republic, 21, 31, 33
C
campaigns, 86 Canada, 13, 21, 24, 31, 33, 39, 41, 43, 44 candidiasis, 57 caregiver, 80 caretaker, 51, 55, 56 case study, 100 cast, 77 categorization, 79, 85 Caucasian, 73 causation, 81 cell, 52 cell culture, 52 cellulitis, 57 CHILD, 6, 7, 17, 18 child abuse, 3, 5, 12, 15, 23, 25, 34, 40, 42, 45, 60, 77, 84, 92, 94, 95, 96, 97, 100 child maltreatment, 47, 49, 79, 91, 92, 93, 100 child protection, 2, 15, 25, 34, 41, 42, 47, 80, 82, 86, 87, 89, 100 child protective services, 2, 51, 53 childhood, 28, 62, 81, 91, 94, 97, 99 childhood sexual abuse, 91, 99 children, 1, 2, 3, 5, 28, 41, 43, 45, 46, 50, 55, 61, 70, 78, 79, 80, 81, 82, 84, 85, 88, 89, 91, 92, 93, 94, 95, 96, 99, 100 Chile, 20, 21 China, 13, 21, 24, 32, 33
D
database, 6, 9, 17, 27, 32, 35, 39, 47 decision making, vii, 78, 80, 82, 83, 89, 100
Index
decision-making process, vii, 3, 71, 77, 88 decisions, 80, 84, 86, 89 definition, 6, 59, 61, 99 delinquency, 2, 92 delirium, 74 delivery, 74 Denmark, 21, 33 depression, 2, 74, 91, 92 dermatitis, 57, 95 detection, 78, 79, 82, 97 diagnostic criteria, 46 diarrhea, 99 differential diagnosis, 49, 71, 75, 79, 82, 94 differentiation, 81 diffusion, 46 dilation, 51, 81 disaster, 93 discipline, 5, 49 disclosure, 50, 51, 56, 59, 62, 71, 82, 83, 84, 85, 86, 87 discounts, 50 discretionary, 80 diseases, 28, 61, 71 disorder, 2, 61 displacement, 32 disputes, 3 distribution, 6, 7, 8, 9, 10, 17, 18, 19, 20, 22, 30, 35, 36, 37, 38 divorce, 46, 82 doctors, 60, 61, 73, 74, 81 dyes, 57 dysuria, 54 equilibrium, 40 estrogen, 50, 75, 81 ethnic groups, 83 etiology, 51 Europe, 20, 21, 30, 31, 32, 39, 45 evening, 73 examinations, 51, 55, 56, 75, 78, 80, 89 excision, 75 exclusion, 62, 83 expertise, 77, 78, 100 exposure, 81
105
F
failure, 46, 50, 51, 52, 77, 84 false negative, 46, 47, 79, 86, 89 false positive, 46, 80, 83, 85, 86, 87, 89 false statement, 85 familial, 77, 83 family, 16, 28, 29, 59, 60, 62, 71, 74, 77, 91 family physician, 29 FBI, 14, 25, 32, 41 fear, 2 fears, 73 feelings, 2 females, 70, 75 financial aid, 3 Finland, 21, 33, 100 float, 51, 52 flow, 92 fluid, 53 focusing, 47 Foley catheter, 52 forensic, 29, 56, 58, 80, 96, 97 France, 21, 31, 43, 44 frog, 55 fusion, 50, 51, 52, 57
E
eczema, 50 Egypt, 21 elaboration, 85 emotion, 89 emotional, 53, 77, 83, 85, 86 encopresis, 50 engagement, 74 England, 21, 31, 32, 43, 45 enlargement, 40 epidemics, 79
G
gender, 6, 70 Geneva, 91, 93 genital herpes, 95 genital warts, 58, 93
106
Germany, 13, 20, 21, 31, 39, 60 girls, 1, 50, 51, 52, 58, 70, 81, 93, 95, 96, 97 God, 77 gold, 83, 84, 89 gold standard, 83, 84, 89 gonorrhea, 52 Greece, 33 grounding, 78 groups, 14, 25, 32, 41, 83 guardian, 53 guidance, 78 guidelines, 2, 49, 81, 84, 89 guilt, 92 guilty, 59 Guinea, 21
Index
Hungary, 21 hygiene, 57 hypothesis, 83
I
identity, 74 imaging, 82 imprisonment, 3, 79 inclusion, 61, 62 indexing, 11 India, 21 indication, 53, 81 indicators, 1, 51, 58, 78, 84 industry, 46 infancy, 58 infection, 50, 52, 53, 57, 58, 98 infections, 50, 57, 95 infectious, 50, 52, 71, 72 infectious disease, 71, 72 inflammatory, 71 inflammatory disease, 71 information sharing, 88 informed consent, 1 injuries, 52, 53, 57, 72, 74, 81, 82, 83, 91, 93, 95, 97, 100 injury, 49, 52, 53, 54, 55, 57, 58, 72, 73, 79, 81, 95, 97, 99 inspection, 74 instability, 74 institutions, 14, 24, 25, 32, 34, 41, 42, 45 instruments, 56, 85, 89 integration, 89 interpersonal relations, 74 interpersonal relationships, 74 interval, 55, 63 intervention, 6, 55, 61 interview, 2, 54, 74, 79, 84, 97, 101 interviews, 46, 47, 75, 84, 85, 93 intraperitoneal, 97 invasive, 56 investigative, 3, 82, 84, 85, 101 Ireland, 13, 14, 21, 24, 33, 43, 44 irritation, 50 isolation, 2
H
harassment, 43 harm, 77 healing, 46, 52, 81 health, vii, 1, 6, 14, 25, 26, 29, 32, 35, 41, 55, 59, 79, 93, 96, 97 health care, 29, 93 health care professionals, 93 health services, 29 healthcare, 79 hematuria, 58 herpes, 53, 94, 97 herpes genitalis, 94 herpes simplex, 53 herpes zoster, 97 heuristic, 78 high school degree, 74 HIV, 26, 52, 53, 69 HIV infection, 53 hospital, 14, 25, 32, 41, 44, 45, 74, 75, 83 hospitals, 24, 32, 44, 45 hostility, 2 households, 1 HPV, 58, 69 HSC, 91 human, 98, 100 human immunodeficiency virus, 98 Hungarian, 38
Index
Israel, 13, 21, 24, 32, 33, 44, 45 Italy, 13, 21, 60 lymphangioma, 93
107
M J
JAMA, 39, 94, 96, 99 Japan, 21 Japanese, 9, 38 Jordan, 95 judges, 86 judgment, 92 justice, 89, 92 juvenile victims, 92 maintenance, 85 Malaysia, 32, 33 males, 70 maltreatment, 77, 79, 82, 86, 87, 100 management, 99 mapping, 93 mass media, 46 media, 46, 79, 86 median, 43, 44, 45, 70 medical care, 92 medicine, 5, 12, 15, 23, 25, 27, 28, 29, 34, 42, 43, 44, 45, 97 MEDLINE, 17 memory, 46, 47 meningitis, 98 mental health, 2, 29 meta-analysis, 18, 19, 31, 37 metatarsal, 98 Mexican, 50 mimicking, 96, 97 mining, 47 minority, 84 minors, 12, 22, 39 models, 54 mood, 74 Moon, 98 morning, 74 morphology, 93 mothers, 79 movement, 101 mucosa, 75 mucous membrane, 74, 75 multidimensional, 77 multidisciplinary, 46, 50, 89 myotonic dystrophy, 57, 72, 94, 99
K
Kenya, 21 King, 99 Korea, 32, 33 Korean, 9, 38
L
laceration, 51 land, 80 language, 5, 9, 13, 20, 24, 32, 37, 54, 61 language development, 54 law, 2, 5, 15, 34, 42, 43, 44, 45, 46, 53, 59, 60, 87 law enforcement, 2, 53, 60 laws, 1 learning, 83 legal issues, 2, 46 lesions, 50, 51, 73, 83, 94, 97, 98 liberty, 87 lichen, 50, 99 Lichen sclerosus, 57, 72, 94, 97 likelihood, 50, 53, 59, 72, 78, 85, 87 limitation, 87 links, 14 litigation, 87 location, 52, 55 longitudinal study, 95, 100 lying, 3
N
National Institutes of Health, 17 ND, 92, 93, 94
108
neglect, 5, 15, 25, 34, 42, 45, 77, 88 neonatal, 52 neonates, 95 Netherlands, 13, 21, 31, 32, 33, 39, 41 neuromodulation, 99 New Zealand, 13, 14, 21, 24, 28, 33, 45 Newton, 91 NGO, 14, 25, 32, 41 Nielsen, 98 Nigeria, 13, 41 NIH, 17, 22, 39 NIS, 99 nondisclosure, 85 non-emergency, 55 non-infectious, 50 non-random, 83 normal, 50, 53, 55, 56, 74, 77, 78, 80, 93 Norway, 13, 21, 31, 33 nucleic acid, 51 nursery school, 74 nursing, 12, 23, 29
Index
pediatric, 29, 81, 94, 95, 96, 99 peer, 56 peer review, 56 pelvic, 52 penis, 50, 51, 57 perception, 100 perceptions, 86 perinatal, 51, 52, 53 perineum, 51 Philippines, 21 photographs, 53, 55 physical abuse, 5, 77, 79, 92, 100 physicians, 2, 60 Poland, 21, 31, 33 police, 2, 14, 25, 32, 41, 86 polyps, 58 poor, 2, 47 population, 81, 86 pornography, 81 Post Traumatic Stress Disorder, 69 postmenopausal, 75 posttraumatic stress, 2 posttraumatic stress disorder, 2 power, 1 predisposing factors, 51 pregnancy, 53, 74, 98 prejudice, 89 preschool, 94 preschool children, 94 preservative, 55 pressure, 86 prevention, 15, 25, 26, 34, 35, 42 primary care, 98 probability, 81 prolapse, 50, 58, 74, 75 prolapsed, 74, 75 prostitution, 1 protection, 2, 15, 25, 34, 41, 42, 47, 80, 82, 86, 87, 89, 100 protocol, 101 proxy, 46, 48, 96, 99 Psoriasis, 57 psychiatrist, 75 psychological stress, 3, 79
O
objectivity, 85 obligation, 60 Oceania, 21, 31 offenders, 87 on-line, 62 oral, 59 orientation, 83 oropharynx, 55 ostium, 75 outpatients, 91
P
pain, 54, 55, 99 Papua New Guinea, 21 parents, 2, 3, 17, 27, 35, 43, 45, 74, 75, 79, 82, 85, 92 patients, 55, 56, 70, 77 PCR, 69 pedestrians, 95
Index
psychology, 5, 8, 15, 27, 28, 29, 34, 42, 43, 44, 45, 46 psychosis, 74 psychotic, 74 PsycInfo, 43 PsycINFO, 5, 6, 9, 27, 28, 30, 32, 35, 39, 47 PTSD, 26, 69, 92 puberty, 81 public, 3, 12, 23, 41, 46, 79, 83, 86 public health, 12, 23, 41 public opinion, 46, 79 punishment, 59, 83, 100 purpura, 58, 96
109
S
safety, 53, 55, 86 saline, 55 sample, 1, 46, 83 SAS, 6 schistosomiasis, 98 school, 74 scientific knowledge, 78, 100 scrotum, 50, 51 search, 5, 6, 7, 15, 17, 18, 19, 26, 27, 35, 39, 40, 42, 44, 46, 47, 49, 61, 81 searches, 6, 27, 40, 47 searching, 7, 18, 44, 86 secret, 59 sedation, 50, 56 selecting, 5 Self, 57 self image, 74 self-destructive behavior, 2 self-esteem, 2 sensitivity, 59 separation, 3, 75, 79 sequelae, 79, 91, 99 series, 6, 61, 62, 80 serology, 52 services, 2, 14, 15, 24, 25, 32, 34, 41, 42, 43, 44, 45, 51, 53, 60, 74, 92 severity, 77 sex, 62 sexual abuse, vii, 1, 2, 3, 5, 7, 8, 15, 17, 18, 19, 25, 26, 27, 34, 35, 37, 42, 45, 46, 49, 50, 51, 53, 54, 55, 56, 59, 60, 61, 62, 70, 72, 77, 79, 80, 81, 82, 83, 86, 89, 91, 92, 93, 94, 95, 96, 97, 98, 99, 100, 101 sexual activity, 1 sexual assault, 15, 25, 34, 42, 58, 59, 81, 87, 88, 95, 97, 98 sexual contact, 52, 58 sexual identity, 74 sexual intercourse, 51, 59, 81 sexual violence, 93 sexually abused, vii, 2, 3, 50, 55, 60, 73, 79, 91, 92, 93, 98, 100 sexually transmitted disease, 2, 99
Q
questioning, 85 questionnaires, 88
R
range, vii, 2, 6, 17, 18, 30, 35, 40, 46, 70, 80, 81 rape, 43 reasoning, 87 recognition, 75 recollection, 47 recovery, 47, 92 rectal examination, 55 rectum, 56 redness, 50 regional, 77, 95 regular, 74 relationship, 1, 85, 100 relationships, 74, 77 relatives, 71 relaxation, 50 reliability, 56 remission, 75 reputation, 3, 79 retention, 99 risk, 53, 55, 78, 84, 85, 86, 87, 91 risk factors, 91 risks, 56
110
shame, 92 shares, 74 sharing, 14, 88 shy, 73 sign, 49, 82 signs, vii, 1, 2, 49, 53, 54, 59, 62, 78, 79, 82, 88, 94, 95 skills, 2, 78 skin, 50, 55, 57, 73 skin tags, 57 social sciences, 34, 45, 46 Social Services, 60, 80 social work, 86 social workers, 86 software, 6 somatization, 2 South Africa, 13, 21, 24, 32, 33, 39, 41 South Carolina, 79 Spain, 21 specificity, 51 spectrum, 49, 81, 82 speed, 95 sperm, 2, 53, 98 sphincter, 50, 52 stages, 81 standards, 46, 87, 89, 100 statutory, 78, 83 STD, 71 stereotype, 85 stigma, 2 stigmatization, 87 storage, 72 storage pool disease, 72 strategies, 93, 101 stress, 3, 79 subjectivity, 82 suicidal, 2, 55, 92 suicidal ideation, 2, 55 suicide, 16 surgery, 54, 95, 100 surgical, 75 surveillance, 60, 79 suspects, 59, 98 Sweden, 13, 21, 24, 33, 45 swelling, 50
Index
Switzerland, 21, 33 symptom, 16, 49, 75, 99 symptoms, 49, 53, 54, 79, 86, 94, 97, 100 syndrome, 46, 48, 57, 95, 101 synthesis, vii, 3 syphilis, 52, 53 systems, 5
T
Tanzania, 13, 14 teaching, 62 technician, 52 telephone, 1, 79 temperament, 46 testimony, 8, 46, 60, 82 text mining, 47 therapy, 12, 16, 75 threats, 59 throat, 52 time, 52, 55, 58, 77, 81, 85 timing, 55 tissue, 52, 84 title, 5, 27, 47 traction, 50, 55 tradition, 47 training, 83, 84, 89, 101 training programs, 84 transection, 52 transfer, 55 transmission, 51, 52, 98 trauma, 16, 46, 47, 49, 50, 51, 52, 56, 57, 89, 94, 97 trial, 18, 19, 31, 37 trust, 1 typology, 6, 7, 8, 11, 14, 17, 18, 19, 20, 25, 30, 31, 32, 33, 35, 37, 41, 43, 45, 62, 71
U
UK, 13, 14, 20, 24, 32, 33, 39, 41, 44, 45, 100 uncertainty, 79, 89 United States, 1, 21, 31, 39, 60 universities, 39, 43, 44, 45
Index
updating, 47 ureters, 98 urethra, 74, 75, 95 urinary, 75, 99 urinary retention, 99 urinary tract, 75 urine, 57 visible, 47, 50 visualization, 55 voids, 75, 78 vulva, 72, 97 vulvar, 94, 95
111
W V
warts, 57 water, 51, 52 well-being, 79, 88 white women, 75 witnesses, 78, 82, 101 women, 26, 35, 43, 47, 52, 75 workers, 2, 82, 85 World Health Organization (WHO), 1, 91, 93 worry, 3, 79
vaginitis, 57 validation, 45, 80, 89 validity, 58 values, 83 variability, vii, 2 variables, vii, 77, 83 variation, 56 vehicles, 95 victimization, 1, 79, 91 victims, 8, 53, 78, 82, 84, 85, 86, 87, 92, 93, 97, 100 violence, 5, 12, 15, 23, 25, 26, 34, 40, 42, 45, 59, 79, 81, 86 virus, 53, 98
Z
Zimbabwe, 13, 41

Child Sexual Abuse - Pitfalls in The Substantiation Process (2009) - Anna Aprile Et Al

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Children's Issues, Laws and Programs Series

CHILD SEXUAL ABUSE: PITFALLS IN THE SUBSTANTIATION PROCESS

CHILDREN'S ISSUES, LAWS AND PROGRAMS SERIES

Children's Issues, Laws and Programs Series

CHILD SEXUAL ABUSE: PITFALLS IN THE SUBSTANTIATION PROCESS

ANNA APRILE, CRISTINA RANZATO, MELISSA ROSA RIZZOTTO

Nova Science Publishers, Inc.

Copyright 2009 by Nova Science Publishers, Inc.

NOTICE TO THE READER

Published by Nova Science Publishers, Inc.  New York

ABOUT THE AUTHORS

Anna Aprile, Cristina Ranzato, Melissa Rosa Rizzotto et al.

SEXUAL ABUSE: A BIBLIOMETRIC ANALYSIS

Anna Aprile, Cristina Ranzato, Melissa Rosa Rizzotto et al.

BOX 1. PSYCINFO AND CHILD SEXUAL ABUSE

Sexual Abuse: A Bibliometric Analysis

Table B1.1. Publication typology

Anna Aprile, Cristina Ranzato, Melissa Rosa Rizzotto et al.

Book 20% ElectronicCollection 2% DissertationAbstract 13%

Figure B1.3. child sexual abuse publication typology.

Sexual Abuse: A Bibliometric Analysis

Anna Aprile, Cristina Ranzato, Melissa Rosa Rizzotto et al.

Figure B1.4. Language distribution (written pages).

Sexual Abuse: A Bibliometric Analysis

Figure B1.6. Publication typologies: rating pages per authors.

Anna Aprile, Cristina Ranzato, Melissa Rosa Rizzotto et al.

adolescent 0.5% women 0.7% family 2.2%

child 26.5% child+adolescent 1.6% child+women 0.2% child+family 0.3%

Figure B1.7. Journals tags.

psychiatry 9% pediatrics law social science 1% 9% miscellaneous 1% 4%

Figure B1.8. Journals main areas of interest.

Sexual Abuse: A Bibliometric Analysis

Table B1.4. Countries collaboration

Anna Aprile, Cristina Ranzato, Melissa Rosa Rizzotto et al.

Sexual Abuse: A Bibliometric Analysis

N 1 299 899 433 399 360 201 147 139 3 878

% 33.5 23.2 11.2 10.3 9.3 5.2 3.8 3.6 100.0

social science 15%

law 6% pediatrics 5% medicine 14% psychiatry 17%

Figure B1.9. Authors affiliation main area.

Sexual Abuse: A Bibliometric Analysis

BOX 2. PUBMED AND CHILD SEXUAL ABUSE

Anna Aprile, Cristina Ranzato, Melissa Rosa Rizzotto et al.

Table B2.1. Publication typology

Sexual Abuse: A Bibliometric Analysis

Anna Aprile, Cristina Ranzato, Melissa Rosa Rizzotto et al.

Figure B2.3. Language distribution.

Sexual Abuse: A Bibliometric Analysis Table B2.3. Journals countries of publication

Anna Aprile, Cristina Ranzato, Melissa Rosa Rizzotto et al.

Africa 0 50 100 150 200

Figure B2.4. Journal distribution per continent.

Figure B2.5. Authorship.

Sexual Abuse: A Bibliometric Analysis

child+adolescent 4% family child+adolescent+all 1% 1%

Figure B2.6. Journals tags.

pediatrics 11% law social science 1% psychology 13%

Figure B2.7. Journals main areas of interest.

Anna Aprile, Cristina Ranzato, Melissa Rosa Rizzotto et al.

Table B2.5. 10 mostly represented countries of affiliation

Sexual Abuse: A Bibliometric Analysis

not indicated 23%

social science 15%

Published by Nova Science Publishers, Inc. New York