Psychological and medico-legal indicators of child sexual abuse
M. Strano, V. Gotti, P. Germani
To ascertain a case of sexual abuse on the minor means to carry out a delicate and complex intervention which requires a high degree of competence and professionalism in each of the operators who, although different tasks and modalities, take part in it. It also requires a good level of coordination and collaboration between the various areas of relevance and the ability to operate with a broader perspective that takes physical and psychological aspects into consideration simultaneously; individual and relational aspects and together evaluate the potential victim and his abusive potential.
It would be desirable, in this sense, that the individual professional who deals with an abused minor case has general knowledge of the problem from different perspectives (physical, legal, psychological, etc.) while contributing specifically. Furthermore, it is necessary that the objectives that guide the ascertainment of abuse are clear. Firstly, to verify whether there has been sexual abuse of the child, by collecting “objective evidence”  on the basis of which it will be possible to undertake the process of protection of the child, as well as the criminal prosecution of the abuser. At the same time, the experience of listening and acceptance must be guaranteed to the minor throughout the revelation phase; it is therefore necessary, alongside the exploration of the facts, investigate and support the feelings and emotions related to the story of the abuse; only in this way will the assessment constitute an experience for the child in which to receive understanding and help and not only the occasion for a painful re-enactment of the facts. In this sense, faced with a suspicion of abuse, investigating the real nature of the events means making a first intervention in terms not only of protection but also of psychological support of the minor.
Explicit information, indirect information of abuse.
Generally a professional who works in the health, social, psychological, educational, judicial sector, etc. comes into contact with an abuse case mainly in two ways:
– Explicit disclosure by the victim or direct information of the abuse;
– Indirect or masked information of the abuse.
In the first case, the minor himself will reveal the abuse to family members, the teacher, or a trusted adult; or it will be an adult to request an investigation for suspected abuse or report the incident.
In the second case, the suspicion of abuse arises following the intervention of an operator (from the social, educational, health, etc. sector) who, in his ordinary activity, comes across a situation with characteristics compatible with an abuse case; for example, a teacher who observes suspicious behavior and signs in her own pupil, such as frequent absences from school; stories with explicit sexual references, difficulty playing with one’s peers, etc.
Or the operator is asked for another type of intervention, from which however information of suspected abuse emerges; for example, the request for a pregnancy test by a young teenager with vague indications of paternity; or the request for a medical examination following physical ailments extended to the genital area, etc.
Only apparently cases of explicit information of abuse are presented as less problematic in terms of ascertaining the facts. 
If in the case of masked abuse, in fact, the main problem is that of the detection and therefore of the operators’ ability to know how to recognize and grasp the signs of unease expressed more or less consciously by the minor, in the case of explicit disclosure of the abuse, the problem that arises poses is that of the credibility of the complainant. In this case legitimate suspicions arise about the veracity of his statements, both in the case of the victim (suggestion, confusion about the real meaning of the events, etc.), and in the case of the complainant adult, who could have instrumental interests to “create” a case of incest (for example, accusing a spouse with whom you are in conflict).
Several professional figures are required to report cases of suspected abuse.
In the first place, on the basis of articles 365 of the criminal code and 334 of the criminal code, there is an obligation to report by health professionals who, in the exercise of their profession, have provided their work or assistance in cases that may present the characters of an ex officio crime.
It is also obliged to report a crime, the “public officer” or “the person in charge of a public service” who, in the exercise or because of the functions or service, learns of an offense that can be prosecuted ex officio
It is important to remember that the obligation to report to the Authorities exists even only on the basis of a suspicion (the code speaks of cases that “may” present the characteristics of a crime that can be prosecuted ex officio) as it is only for the judicial function to establish the truthfulness of the fact and the malicious or accidental nature of the case.
The law therefore punishes the omission of a report or denunciation, unless forced by the need to save himself or a close relative from a serious and inevitable damage to freedom and honor (art. 384 of the Italian penal code); or when, through the report, the patient would be exposed to criminal proceedings (art.365 of the criminal code). In this case, however, it is necessary to specify that the patient whose health must be protected and the possible crime ignored, is exclusively the minor (victim) and not the potential offender who accompanies him. In these cases, the parent cannot even claim the right to professional secrecy (Article 622 of the Italian Criminal Code) since there is a serious conflict of interest between the true owner (the minor patient) and who would like to or should represent him (the parent). 
The legal obligation to report abuse or suspected abuse does not concern the ordinary citizen, who is required to do it on a moral level.
The indicators of abuse
According to Sgroi (1982), the recognition of sexual abuse on children totally depends on the inner willingness of people to take into consideration their existence . Indeed, the child victim of abuse is often the only witness to the incident and if, after overcoming fears and reticence, he talks about it to the adult, he must be available to “listen” to what the minor tells him. In some cases, it is only the child’s words to “tell” the violence suffered, given that, unlike physical abuse, sexual abuse can leave less evident signs; in others the victims are so small that the discomfort is hardly expressed through verbal communication. It is the behavior then that sends signals of suffering and help, visible only to those who make themselves available and able to understand them. A diagnosis of sexual abuse of a minor can therefore only be implemented through the careful analysis of the child at 360 °, which includes an assessment of the psychological, physical and behavioral aspects of his experience. While taking into account that in a good percentage of cases it can manifest itself as asymptomatic , the child victim of abuse usually exhibits certain behaviors or symptoms that can be considered as indicators of possible sexual violence.
We propose an analysis grid for the location of the indicators.
PHYSICAL INDICATORS: 
– Skin signs (bruises, scratches, bites, grasping signs) if the abuse was carried out with the help of physical violence
– Physical symptoms or itching in the genital area
– Difficulty walking
– Difficulty in maintaining the sitting position
– Stained, torn underwear
– Traces of blood or seminal fluid on clothing or on the skin
– Pregnancy in the early adolescence in the absence of a known partner
– Early puberty
Identifiable with clinical examination:
– Presence of traces of semen in the vagina or in the rectum
– Presence of urethral, vaginal and / or rectal foreign bodies;
– Genital and / or anorectal lesions
– Unjustified vaginal or urethral dilatation
– Inflammations, bleeding without obvious organic causes
– Manifestation of sexually transmitted infectious diseases (gonorrhea, chlamydia, sharp conditomas, syphilis, HIV, etc.) 
BEHAVIORAL INDICATORS: [ 8]
– Passivity, fear, distrust of adults
– Age-appropriate knowledge and sexual behavior
– Difficulty in being in relationship with peers (aggressive attitudes, disinterest in playful activities)
– Seductive attitudes towards adults
– Decline in school performance
– Language and attention
difficulties ASPECIFIC SYMPTOMATOLOGY
– Sleep disturbances (insomnia, nightmares also with a sexual background; pavor nocturnus)
– Eating disorders
– Sphincter control disorders (enuresis, encopresis)
– Symptoms hypochondriacs
– Obsessive rituals (mainly related to personal cleansing)
– Psychosomatic disorders of the gastrointestinal tract
– PTSD 
PREVALENT ADOLESCENT INDICATORS
– Deviant behaviors
– Abuse of substances
– Self-harm, suicide attempts
– Early and promiscuous sexuality
– Sexual inhibition
– Sexual rejection
A diagnosis can be correctly made only after a careful and accurate anamnestic collection, an appropriate evaluation of the story of the alleged victim or of the complainant, the careful examination of the behavior and a psychological evaluation of the child, a medical examination and the execution, if necessary , of laboratory tests. The physical examination of the minor is essentially based on the general clinical examination and on the local objective examination of the genital, perigenital and anal regions. These assessments allow, where possible, to acquire objective elements to confirm or not the hypothesis of abuse. However, it must be remembered that many children do not exhibit physical signs of violence since, often, sexual abuse of children, especially if very young, it does not consist in penetration but in a series of sexual practices (kisses, manipulations, caresses, oral intercourse, etc.) which do not give the opportunity to be demonstrated a posteriori. Even when violence includes penetration, for example in the case of adolescent victims, or in cases where the manipulation still leaves its marks, it happens that minors are visited when a long time has passed since the abuse and the signs themselves are no longer recognizable. For this reason it is important that the medical examination is conducted as soon as possible, especially if it is assumed that the violence was perpetrated within the previous 72 hours; or when the victim has symptoms such as genital discharge, pain, bleeding. If instead the violence dates back to weeks or months before, the medical assessment loses its urgency value, while it is a priority to give greater attention to the deepening of the story and to the psychological evaluation of the victim.  According to Del Vecchio (1997) there are greater identification problems in cases of sexual abuse than physical abuse. In fact, recognizing fractures, burns, bruises, bruising and assessing the reliability of the testimonies of minors and adults on the incident is a complex task but that allows you to provide, with greater security, differential diagnoses between violence and accidental injury. Sexual abuse, on the other hand, would present greater problems in terms of health assessment, such as : deepening of the story and the psychological evaluation of the victim.  According to Del Vecchio (1997) there are greater identification problems in cases of sexual abuse than physical abuse. In fact, recognizing fractures, burns, bruises, bruising and assessing the reliability of the testimonies of minors and adults on the incident is a complex task but that allows you to provide, with greater security, differential diagnoses between violence and accidental injury. Sexual abuse, on the other hand, would present greater problems in terms of health assessment, such as : deepening of the story and the psychological evaluation of the victim.  According to Del Vecchio (1997) there are greater identification problems in cases of sexual abuse than physical abuse. In fact, recognizing fractures, burns, bruises, bruising and assessing the reliability of the testimonies of minors and adults on the incident is a complex task but that allows you to provide, with greater security, differential diagnoses between violence and accidental injury. Sexual abuse, on the other hand, would present greater problems in terms of health assessment, such as : recognizing fractures, burns, bruises, bruising and assessing the reliability of the testimonies of minors and adults on the incident is a complex task but that allows you to provide, with greater security, differential diagnoses between violence and accidental injury. Sexual abuse, on the other hand, would present greater problems in terms of health assessment, such as : recognizing fractures, burns, bruises, bruising and assessing the reliability of the testimonies of minors and adults on the incident is a complex task but that allows you to provide, with greater security, differential diagnoses between violence and accidental injury. Sexual abuse, on the other hand, would present greater problems in terms of health assessment, such as :
– The story of the minor risks being overlooked if it is not proven by physical evidence of what happened.
– In the absence of obvious physical signs, it does not mean that the minor has not suffered violence, just as the presence of various symptoms does not prove the abuse since they are non-specific.
– Doctors would consider it very rare to encounter cases of sexual abuse of minors in daily practice and university education would not train sufficiently for such occurrences;
– There would be little specialization of healthcare professionals on prepubertal anal and genital anatomy.
Equally complex and problematic is the process of ascertaining abuse in the context of psychological evaluation. Also in this case it is necessary to refer to indicators, such as those mentioned  and to some criteria that would increase the degree of reliability achieved by the verification. This last point appears significant especially if we consider that, in asking questions to the child, an adult would inadvertently provide a considerable amount of suggestive information on what happened, on what the child saw, on his / her impressions, etc. . In this sense, it is crucial to be able to verify or falsify, in the evaluation, the hypotheses of erroneous or false denunciation.
To this end, the following possibilities must be excluded :
– that it is a psychotic child with invasive persecutory fantasies;
– that the story is a fantasy fruit of an emphasis on the child’s Oedipal experiences;
– suggestibility: it should be excluded that the child has collected and made his own fantasies or sexual concerns of a particularly significant adult;
– misunderstanding: it must be excluded that for example a mother may have erroneously attributed sexual meaning to the normal behavior of another adult
– persuasion: it must be excluded that an adult deliberately fabricated a false report and that the child was persuaded to report being abused sexually.
Other psychological areas of the child can also be investigated, such as verifying the existence of the following emotional experiences, indicated  as typical of Child Sexual Abuse:
– Impotence (the child no longer feels master of his own body since he cannot escape the external violence, a sense of inability to ask for help, distrust in being able to change the situation or be believed)
– Treason (the child feels violated the sense of trust that he has towards an adult who should protect him, but who, on the contrary, uses him violence; may appear disheartened, suspicious, passive or angry.)
– Stigmatization (negative connotation of the role of victim and presence of guilt and shame)
– Traumatic sexualization (presence in the child of abnormal sexual behaviors and attitudes due to forced involvement in improper sexual experiences compared to his age)
P Fuligni (1997) , regarding the psychological expertise on minors in the processes for pedophiles, claims are possible different sources of error in this type of assessment, related to:
– Equivocality of the indicators
– Suggestibility of the children
– Level of linguistic competence of the victim
– Any handicap problems
– Context of re-enactment conditioned by adult figures.