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Abstract
Objective This study examines the forensic medical examination (FME) service provided to children in a regional centre in Dublin, Ireland, over 5 years. It reports on patient characteristics, alleged perpetrators and service provision. The goal is to inform future service provision and prevention strategies.
Design The retrospective cohort study included all children and adolescents who underwent FME from January 2018 to December 2022. Data was collected from encrypted child protection reports and analysed with descriptive statistics
Setting The study was undertaken in the Laurels Clinic, one of the three regional Irish centres for FME.
Results Of 448 patients, 79% were female, with 37.3% aged 5–11 years. Vaginal penetration occurred in 46% of cases, with digital penetration (vaginal or anal) being the most common method. Anal penetration was reported in 26%, and 6.3% had anogenital findings suggestive of child sexual abuse (CSA). CSA was most often perpetrated in the home, with nearly half of patients showing behavioural changes. About 18% had developmental concerns, and 30% lived in blended families. Alleged perpetrators were mainly male (90.1%), with over 20% being teenagers and 12.8% under 13. Over half of cases involved repeated abuse. Disclosure rates were higher with age, with 69% of disclosures made to a parent.
Conclusion This study highlights CSA risk factors, including blended families and developmental concerns. A worrying finding was that many perpetrators were adolescents or children. Prevention programmes must address risks related to smartphone use and exposure to pornography. These findings can guide clinicians, policymakers and institutions in strengthening CSA prevention and response efforts.
- Forensic Medicine
- Paediatrics
- Paediatric Emergency Medicine
- Child Abuse
- Child Protective Services
Data availability statement
Data are available upon reasonable request. Data reuse is possible following consideration by the Research committee at Children’s Health Ireland @ Crumlin, Ireland. De-identified attendance data is available from Dr Naomi Bergin, at naomi.bergin@childrenshealthireland.ie.
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WHAT IS ALREADY KNOWN ON THIS TOPIC
A paediatric forensic medical examination (FME) is an important part of the holistic assessment and care for victims of child sexual abuse (CSA).
Risk factors for CSA include being female, having developmental concerns, with other risk factors relating to family dynamics and stressors.
The majority of children and adolescents seen for FME have normal or non-specific clinical examinations.
WHAT THIS STUDY ADDS
The findings of this study show a higher incidence of anal abuse among children than indicated in earlier research studies.
30% of victims lived in blended households, revealing this as a potential emerging risk factor for CSA amid changing societal demographics.
A notable number of perpetrators were children or teenagers themselves, which is a societal concern.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
The study highlights the importance of FME, as a national Barnahus multiagency model of care for CSA is being rolled out in Ireland.
Prospective national research is warranted to monitor emerging risk factors for abuse, to guide clinicians and policymakers.
This study underscores the urgency for policies regarding online exposure and appropriate youth education, given the prevalence of young perpetrators seen here.
Introduction
Child sexual abuse (CSA) occurs internationally, across all nations, cultures and demographics and can occur within a child’s home, school and care settings.1 2 CSA is defined 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 violates the laws or social taboos of society’.3 The WHO has a reported lifetime prevalence of CSA of up to 18% for females and 8% for males.4
Two Irish studies 20 years apart have demonstrated an increased prevalence within the Irish population.5 6 The more recent Irish Central Statistics Office 2022 survey identified that 36% of women and 22% of men reported experiencing sexual violence as a child.5 6 The true prevalence may be higher due to the lack of a clear consensus definition for CSA. The abuse is often carried out covertly and is often unnoticed by adults and not recognised by victims. Victims frequently under-report, and disclosures may be significantly delayed.7 8 Although there have been studies on children attending for assessment and therapy services in Ireland, there have been few previous studies on children and adolescents attending for a forensic medical examination (FME).9 This study aims to gather information on referrals, patients, their alleged perpetrators and the service provided. This will inform clinicians regarding risk factors for CSA, the role of this important service and inform future service provision.
Design
This is a retrospective cohort study of children and adolescents who attended an FME at the Laurels Clinic over a 5-year period. Data was gathered from the child protection reports of attendees. The research findings are presented in accordance with the guidelines outlined in the Strengthening the Reporting of Observational Studies in Epidemiology statement.10
Service
A paediatric FME describes the medical assessment that occurs when there is a concern that a child or adolescent may have been sexually abused. The terminology is used regardless of whether forensic samples are indicated. Forensic samples, when taken, are used to detect DNA, detect saliva or seminal fluid and may include urine toxicology and blood. Best practice recommends that FME assessments are conducted by trained specialists, in a timely and efficient manner.11
The clinic (‘Laurels Clinic’) located at Children’s Health Ireland (CHI) hospital group is one of three centres providing paediatric FME assessments in Ireland. It serves Dublin city and county and 14 surrounding counties, which account for approximately 50% of the population. Children over 14 years of age requiring forensic samples are seen in the local adult Sexual Assault Treatment Unit. All other acute cases (for those children under 14 years of age) are seen at the Laurels Clinic, as well as non-acute cases for all ages up to 18 years of age. This results in approximately 100 new assessments each year. Patients are assessed using a standardised proforma which informs the child protection report.12 The child protection report is a typed medico-legal report for Criminal Justice purposes or to inform Social Work assessment. It is derived from the contemporaneous medical notes within the standardised proforma.
Patients
All patients who attended for an FME at CHI from January 2018 to December 2022 (5 years) were included. There were no exclusion criteria. Patient ages ranged up to 18 years of age.
Patient and public involvement
Patients were not included in the design of this research study due to the retrospective nature of the study and the sensitive nature of the presentations.
Data
Patient’s contemporaneous child protection reports were stored in an encrypted, password-protected file accessible only to the investigators on site. Data was collected from these and entered into an encrypted data collection form. A data validation process was conducted to ensure consistency across the data prior to analyses. Data included a range of variables regarding patient demographics including patient disclosure, presentation, examination findings, as well as family and social structure. Alleged perpetrator characteristics, details of the assault and details on service provision were also recorded. Descriptive statistics were calculated using Microsoft Excel.
Results
448 patients attended for FME during the study period, 355 (79%) were female. Age ranged from 5 weeks to 18 years. Most of the patients fell within the age group of 5–11 years (n=167) (table 1). The median age was 7 years and 4 months, mode was 3 years.
Patient demographics and reason for referral
Over two-thirds of the patients referred had made a disclosure (table 1). Over 12% disclosed on the same day as the incident occurred and 22.6% within 7 days of the incident. Older children were more likely to make a disclosure; 88% of children aged 11–18 years compared with 56% in children<5 years. Female patients aged 14–18 years were more likely to disclose than males (93% vs 67%), with similar disclosure rates for gender in all the other age groups. Most disclosures (69.2%) were made to a parent (table 1). Touching/fondling (of anogenital area) was disclosed in 52% of cases, vaginal penetration in 46% and anal penetration in 26%. Digital penetration (either vaginal or anal) was the most common method of penetration (53.7%), while penile penetration was reported in 37.7% of cases. (table 1) Objects were used in 3.3%. Penetration was disclosed in over 50% of children>12 years compared with 45% of those<5 years and 50.9% of those in middle childhood. A small number of children (2.3%) were shown pornography.
Behavioural change was reported in almost half of patients, with sexualised behaviour in 17% (table 1). Sexualised behaviour occurred more commonly in younger children, 24%<5 years old compared with 6% of patients>12 years old. Developmental concerns including speech delay, autistic spectrum disorder, and attention deficit hyperactivity disorder were reported in 18.1%.
CSA occurred most frequently in the home where the child lives (35%) or in the other parent’s home (18.6%). 58 patients were assaulted outdoors, 69% of those were over 11 years of age. Almost one-third of patients (30.6%) lived in a ‘blended family’, another 21% lived with only one parent (table 1). The percentage of attendees living in a blended family increased from 19.7% in 2018 to 35.3% over the 5-year period. There was a family history of CSA in 18% of cases.
The general physical examination was normal in 92.2% of the cases. Acute genital injury was reported by 5% (23) of patients. Anogenital examination data are summarised in table 2. Anogenital findings attributed to CSA by examiners were present in 6.3% (7% in females and 2.2% in males) and these included bleeding, complete hymenal transection, deep hymenal notches, vaginal lacerations and dynamic anal dilatation.
Anogenital examination findings
Alleged perpetrator characteristics are outlined in table 3. 90% of alleged perpetrators, when identified, were male. Of 19 alleged female perpetrators, one abused a boy, and the remainder abused females. Of those with a female perpetrator, 14 girls were only abused by females and four girls by both male and female perpetrators. Multiple alleged perpetrators were reported in 31 cases (8.2%). Of those patients with multiple alleged perpetrators, 45% were teenagers. First and second-degree relatives were reported in 48.3% of cases. Over 35% of alleged perpetrators were less than 19 years of age, and 12.8% were children. The number of alleged perpetrators aged<13 years increased from 12.2% in 2018 to 16.7% in 2022. Over half (53%) of victims reported abuse on more than one occasion.
Alleged perpetrator demographics and relationship to the victim
Table 4 relates to the service provided to the attendees. Over 43% of referrals were from healthcare professionals while An Garda Síochána (national police service of Ireland) referred 37.9%. Almost a quarter of cases (22.5%) underwent forensic sampling. Overall, 35.5% of referrals were seen at an unscheduled visit.
Service provision
Discussion
While some published Irish data is available on children presenting for FME, this is the first comprehensive Irish cohort study of patients attending for an FME comprised of 448 children and adolescents, attending over a 5year period from January 2018 to December 2022.
Patient characteristics
Many of the findings in our cohort were in line with those from international studies, with most patients (355/448, 79%) being female and the most common age of attendance for assessment being middle childhood (see table 1).13–15
In keeping with international evidence, only a small number of patients (27/448, 6%) had definitive anogenital findings suggestive of CSA (see table 2).16–19 While not a surprising finding, it is essential that up-to-date statistics such as this are available to families, clinicians and the legal system to ensure ongoing understanding that a normal genital examination does not exclude CSA. Findings were interpreted using best practice guidance including the ‘Adams’ criteria and Royal College of Paediatrics and Child Health guidance for interpretation of findings in CSA.19 20
Although this review confirmed that children delay disclosing CSA, the type of sexual abuse disclosed was different from prior studies.21 In 2014, Hobbs and Wright reported that in a cohort of disclosures of CSA from 1997 to 2004, only 5%22 reported anal abuse in comparison to this study, which recorded that 26% of disclosures included anal abuse. Further research exploring whether this finding is replicated in other centres would be of interest.
Other reasons for referral were as expected (see table 1) and included (42/448, 9.4%) concerns of sexualised behaviour, which was mainly reported in younger children. However, almost 50% of patients had reported general changes in their behaviour at presentation. This highlights the importance of considering CSA in the differential for unexplained behavioural change in children and adolescents. At present, many paediatric programmes teach trainees not to directly ask children if they have been abused to avoid contaminating evidence or ‘leading’ a suggestible child. While this is a valid approach, undertaken for important reasons, we are possibly doing a disservice to those children with unexplained behavioural changes (and no disclosures) by not being receptive to facilitating an open-ended conversation about possible abuse or Adverse Childhood Experiences23 24
Alleged perpetrator characteristics
A concerning finding was that over 20% (23.2%) of alleged perpetrators were teenagers with a further 12.8% aged less than 13 years old. Early access to smartphones is growing, with exposure to pornography, sexting and online exploitation now common in younger age groups. This emphasises the need for policymakers, educators and parents to address these specific issues in relationship and sexual education programmes in this age group.25 26 Of note, our pro forma does not specifically prompt the user to document pornography exposure, and this was recorded in free text when disclosed. This explains the lower rates of pornography exposure documented in our study (2.6%) in comparison to 13.9% and 9.8% of patients in other reports27 28 and is likely not an accurate representation of pornography exposure in Irish children.
An unexpected result from this study was the high number of patients in this cohort who were living in a ‘blended family’, the term used to denote the union of individuals with children from previous relationships. Studies have shown that children whose parent has a live-in partner are at the highest risk of all forms of maltreatment, including sexual abuse.29–31 30% of patients in our study lived in ‘a blended family’. We estimate that this is much higher than the proportion of children in Ireland living in a blended family currently. Census data from 2006 estimated that only 2.5% of children lived in this family structure.32 Unfortunately, more recent national census data on blended families was not available.
Regarding other alleged perpetrator data, some results were comparable with international data, with the majority being male and mostly known to the patient (see table 3). However, regarding female perpetrators, previous studies have noted that victims were more likely to be males, or males and females.5 33 In contrast to this, the victims of alleged female perpetrators in our study were almost all female. This study has prompted our team to review the importance of accurate recording of perpetrator data in cases of suspected CSA.
Service provision characteristics
A surprisingly low number of cases, only 15%, were referred by Tusla—the Child and Family Agency (child protective/social services). Further education of potential referrers as to the non-invasive nature of the assessment and the therapeutic benefit of the FME for victims about their physical well-being may be needed. In addition, the Irish government has committed to implementing the Barnahus model of care in response to CSA in line with the Promise Barnahus network standards34 and other European countries. Once this is established, improved interagency collaboration will likely change this referral pattern that may be more in keeping with other international centres.
Of the cases that were assessed in our clinic, 22.5% of children (<14 years old) underwent forensic sampling. While it was challenging to find data from other centres on their rates of forensic sampling in this age group, anecdotally, based on our collective experience, this figure is relatively high. As specialist forensic interviewing of children in Ireland by police and social services is not immediately available this may lead to a higher than expected number of cases with DNA collection in Ireland.
Limitations
This was a retrospective study with the collection of data from child protection reports. Future studies with a prospective study design could yield more robust evidence. It is possible that the contemporaneous medical assessment records captured more data that was not always completely reflected in the child protection medico-legal reports particularly relating to perpetrator or family characteristics or dynamics.
Conclusion
This is the largest cohort study of patients presenting for FME from an Irish CSA centre to be reported, and to our knowledge the first study looking at all aspects of children and adolescents attending for an FME. It is important that up-to-date evidence is available to clinicians, families and those working in the criminal justice system. Unexpected findings from our study that reflect a changing society was the notable high percentageof ‘blended’ families in our cohort highlighting this as a particular risk factor for CSA and a higher rate of disclosure of anal abuse.
A key finding for general paediatricians and other non-specialists is the low rate of physical findings in CSA. Worryingly, there has been an increase in the proportion of adolescent and prepubertal perpetrators. This is thought to be attributable to access to smartphones and pornography. It is essential that public policymakers, parents and educators are cognisant of this trend so that appropriate educational materials are developed.
Data availability statement
Data are available upon reasonable request. Data reuse is possible following consideration by the Research committee at Children’s Health Ireland @ Crumlin, Ireland. De-identified attendance data is available from Dr Naomi Bergin, at naomi.bergin@childrenshealthireland.ie.
Ethics statements
Patient consent for publication
Ethics approval
Ethical approval was obtained from the research committee of Children’s Health Ireland (CHI) at Crumlin (REC-095–22)
Acknowledgments
We would like to acknowledge the contribution of many other people. In particular, we would like to thank Doctors Claire Power, Una Murtagh and Emma Curtis who were involved in the care of these patients.
References
Footnotes
X @aidowalshie
Contributors NB and AA contributed equally to this paper. NB was involved the data interpretation, drafting the first manuscript and its revisions. AA was involved in design of the work, data collection and some data analysis as well as revising the written manuscript. MB was involved in the design of the study, and in revision of the manuscript. SR was involved in data collection and revision of the manuscript. AW was involved in data collection and revision of the manuscript. ARG was involved in data collection and in drafting and revising the manuscript. SH was involved in study conception, design, drafting and revision of the manuscript, and is responsible for its overall content (as guarantor).
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Disclaimer The views expressed in the submitted article are those of the above authors and not an official position for Children’s Health Ireland.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.