ChddAbused Ne&cr, Vol. 15. pp. 523-529. Printed in the U.S.A. All rights reserved.
014s2134/9l $3.00 + .a, Copyright 0 1991 Pergamon Press plc
1991
CHILD SEXUAL
ABUSE IN SHELBY COUNTY,
TENNESSEE:
A NEW EPIDEMIC?
DAVIDMURAMANDBRIDGETDORKO Section
of Pediatric
and Adolescent Gynecology, Department of Obstetrics University of Tennessee, Memphis
and Gynecology,
JUDY G. BROWN Regional
Social Services, The Tennessee
Department
of Human
Services
ELIZABETHA.TOLLEY The Department
of Biostatistics
and Epidemiology,
University
of Tennessee,
Memphis
Abstract-Following the introduction ofa comprehensive child sexual abuse program in 1985, there was a significant increase in the number of validated incidents of abuse involving minors. However, following the initial increase, the number of validated incidents of abuse remained relatively stable at about 30-35 per month. While the overall validation rate was 57%. it fluctuated widely from as low as 2 I% to as high as 92%. The validation rate rose from 1984 through 1987, declining in the latter part of 1989. The validation rate appeared to reflect the number of validated cases and not be dependent upon the number of reported cases. The number of cases validated was not significantly correlated with time, but was moderately correlated with the number of cases reported (estimated Spearman correlation coefficient was .45 with p i .05). However, after adjusting for time, the partial correlation between the number of validated and the number of reported cases was no longer significant. The percent of validated cases (the validation rate) was correlated with number of cases validated (estimated Spearmen correlation coefficient was .84 with p < .OOOI), but not with the number of cases reported. Validation rates were higher for girls than for boys, 7 1.1% and 3 1.8%respectively. The majority of the perpetrators (78%) were known to the children and had access to the victims. In over half the incidents, family members were implicated as the perpetrators. Key Words-Child
sexual abuse, Perpetrator,
Child protection
agencies,
Detection,
Prevention,
Legislation.
INTRODUCTION IN 1985,the Tennessee Legislature introduced House Bill 495, which passed into law, Public Chapter 145, a comprehensive child sexual abuse program. Among its provisions, the law requires that “any person, physicians included, who knows or has reasonable cause to suspect, that a child has been sexually abused shall report such knowledge or suspicion to the department.” At the same time, the Tennessee Department of Human Services (TDHS) initiated a central child sexual abuse registry, which identified victims and perpetrators of child sexual abuse. The registry was designed to enable TDHS to identify and locate prior reports or cases of child sexual abuse, and to evaluate the effectiveness of the department’s Received
for publication
January
22, 1990; final revision
Requests for reprints should be sent to David Muram, Tennessee, 853 Jefferson Ave., Memphis, TN 38 103.
received Department 523
September
25, 1990; accepted
of Obstetrics
October
and Gynecology,
I, 1990.
University
of
524
D. Muram.
B. Dorko.
J. G. Brown,
and E. A. Tolley
program for sexually abused children. During the first two years of the registry, the number of validated incidents of abuse involving minors rose, from an average of 15 reports per month in 1984, to 60 validated incidents per month in 1986 (Muram & Weatherford, 1988). We assumed that this increase in the number of validated incidents reflected only increased awareness and action by the individuals notifying TDHS (Muram & Weatherford, 1988). However, with time we became concerned that this increase might reflect a true increase in the number of sexually abused children. To further assess this issue, the central registry was evaluated over an additional three-year period. The following paper summarizes our observation during this extended period.
MATERIALS
AND
METHODS
The demographics of Shelby County, Tennessee, have been previously described (Census Tracts, 1986; Muram & Weatherford, 1988). Briefly, Shelby County is the most populated county in Tennessee, with a population of about 800,000. It includes the city of Memphis, the largest city in the state. While almost 50% of the Memphis population is black, the percentage of Caucasians is higher in the surrounding areas, so that countywide the black population represents about 43%. Of the total population, 27 1,000 are individuals under age 19. TDHS of Shelby County is located in Memphis. Its registry receives all reports of incidents in which children, age 18 and under, are suspected to be victims of sexual abuse. An investigative team is then assigned to the case, and all validated cases are entered into the registry. Nonvalidated incidents were listed as reported but were not entered into the registry. The registry entries were analyzed and compared with the findings observed between 1984-1986.
RESULTS Between October 1, 1986 and September 30, 1989, 3,46 1 incidents of child sexual abuse were reported to TDHS (1,211 males and 2,250 females); and of these, 1,985 (57.4%) were validated by the ensuing investigation and entered into the registry. During the study period, the number of validated incidents of abuse remained relatively stable at about 30-35 per month (Figure 1). While the overall validation rate was 57%, it fluctuated widely from as low as 2 1% to as high as 92%. The validation rate rose from 1984 through 1987, declining in the latter part of 1989 (Figure 2). The validation rate appeared to reflect the number of validated cases and not be dependent upon the number of reported cases (Figure 3). To qualify and quantify our impressions, we estimated Spearman correlation coefficients. Looking at validation rates over the study period, the number of reported cases appeared to increase over time. The estimates of Pearson product moment and the Spearman correlation coefficients were .57 (a < .O 1) and .48 (a < .04), respectively. The number of cases validated was not significantly correlated with time, but was moderately correlated with the number of cases reported (estimated Spearman correlation coefficient was .45 with p < .05). However, after adjusting for time, the partial correlation between the number of validated and the number of reported cases was no longer significant. The percent of validated cases (the validation rate) was correlated with number of cases validated (estimated Spearman correlation coefficient was .84 with p < .OOOl), but not with the number of cases reported. Some authors have suggested that an increase in the number of reported cases may overwhelm the system, and thereby lead to a decrease in the validation rate. When we eliminated the first four time periods, based on the assumption that learning was taking place and these data were not representative of later periods, we found that validation rate was moderately
525
Child sexual abuse
EI
Reported
l
Validated
Figure 1. Child sexual abuse: Number of reported and validated cases, Shelby County, Tennessee
(1984-1989).
correlated in a negative fashion with number of cases reported (estimated Spear-man correlation coefficient was -.62 with p < .02), but strongly correlated in a positive fashion with number of cases validated (estimated Spearman correlation coefficient was .73 with p < .002). Furthermore, we looked at the relationship among the variables within the groups. In the group with caseloads of 300 or less, the only estimated correlation coefficient that was significant was between number of cases validated and the validation rate. In the group with caseloads of 300 or more, the number of cases reported was strongly related in a negative manner
Figure 2. Validation
rate, Shelby County, Tennessee
(1984-1989).
526
D. Muram, B. Dorko, J. G. Brown, and E. A. Tolley 100
20
1
,a 200
0 I
I
I
300
400
500
No.
Reported
Figure 3. Child sexual abuse: Validation rate as a percent of reported cases, Shelby County, Tennessee
(1984-1989).
to validation rate and positively to time. Overall, it appears that the number of validated cases had remained relatively constant, but the number of reported cases has generally increased. Abuse rates remained much higher for girls than for boys. During the study period, 3,46 1 separate incidents were reported (2,250 involving girls and 1,211 involving boys); 2,332 (67.4%) were black, 1,121 (32.38%) were Caucasians, and 8 (0.2%) were of other ethnic origins. Of these, 1,985 incidents were validated (1,600 involving girls and 385 involving boys); 1,108 (55.8%) were black, 874 (44%) were Caucasians, and 3 (0.2%) were of other ethnic origins. Validation rates were higher for girls than for boys, 7 1.1% and 3 1.8% respectively. Compared with the previous study group (Muram & Weatherford, 1988), more incidents involving girls were validated. In 1986- 1989 the female to male ratio increased to 4 to 1, compared with a ratio of 3.2 to 1 for the years 1984-1986. The mean age of the child victims was 8.6 years, (range 0- 18), and children of all ages were affected (Figure 4). Young children, age 11 and under, accounted for 1,235 (62%) of the victims; while children age 11 and older accounted for the remaining 750 (38%) alleged victims. Male victims accounted for 29% of the younger patients; 29% were males, compared with 16% of the older group (a < .OO1). The sex and race distribution are detailed in Table 1. Table 2 summarizes the relationship between the perpetrator and the child-victim. Immediate family members were most frequently the identified perpetrators. Family members and acquaintances were reported to be the perpetrators in the majority of incidents. The alleged perpetrator was a member of the victim’s family in 1,O12 of the 1,985 validated incidents, and family friend or a neighbor in 542 instances. When the child was able to provide information about the perpetrator, only on rare occasions ( 10 cases) was the perpetrator totally unknown to the victim. The relationship between the victim and the perpetrator was not determined by the victim’s age. However, it appeared that stepparents and mother’s beaus were more likely to assault girls age 11 or older, and the assailant was likely to remain unidentified when the victim was age 6 or younger. DISCUSSION The new Child Sexual Abuse Law in Tennessee has resulted in a significant increase in the number of reported cases of suspected child sexual abuse in Shelby County, TN. The increase
521
Child sexual abuse
1
2
3
4
5
6
7
8
9
10
AGE
Figure
4.
Child
sexual
abuse:
Age
of
11
12
13
14
15
16
17
(Years)
Child Victims of Sexual (Oct. 1986~Sept. 1989).
Abuse,
Shelby
County,
Tennessee,
in the number of reports resulted in a comparable increase in the number of validated cases. However, following this initial rise, the number of validated cases has remained relatively constant, although the number of cases reported has generally increased. However, as in the previous study, we believe that not all child victims of abuse are being reported to TDHS. In this study population the ratio of female to male victims of sexual abuse was 4 to 1. Previous retrospective studies have shown the ratio to be about 2 to 1 (Gelinas, 1983; Kempe, 1978, 1980). Although this higher ratio might represent a true difference which is unique for the population of Shelby County, our impression is that it represents misdiagnosis and under-reporting of male victims. The increased female to male ratio over the past five years reflects better recognition by professionals of signs and symptoms of abuse in female victims. Studies have shown that many physicians have difficulties in identifying, managing, and reporting these children to child protective services (James, Womack, & Strauss, 1978; Ladson, Johnson, & Doty, 1987; Or-r, 1978). These difficulties have undoubtedly contributed to discrepancies between the number of reported incidents of child sexual abuse, and the estimated number of victims calculated from retrospective studies (National Center on Child Abuse and Neglect, 1978). Validation rate fluctuated widely during the study period. It has been suggested that the validation rate declines when the number of reported incidents increases. In the current study the validation rate rose from 1984 through 1987, but declined in the latter part of 1989. This pattern may reflect the experience gained by the on-the-job training of the TDHS investigators, resulting in an increase in the validation rates. With time, some of the more seasoned
Table 1. Sex and Race Distribution
of Population Studied, Shelby County, TN, 1986-1989
All Patients
Patients Age c 11
Patients Age > 11
Race
White
Other
White
Black
Other
Male
205
178
2
156
125
2
49
53
0
Female Total
669 874
930 1108
:
376 532
575 700
1 3
293 342
355 408
0 0
Black
White
Black
Other
528
D. Muram, B. Dorko, J. G. Brown, and E. A. Tolley Table 2. The RelationshiD Between the Peroetrator and the Child-Victim
__
No. of Incidents All Ages N = 1985
Perpetrator Parent Stepparent Sibling Grandparent Other relative
362 186 115
Age>11 N = 750
AgeO-II N = 1235
18.2% 9.4% 5.8% 1.5% 16.1%
194 61 72 19 218
15.7% 4.9% 5.8% 1.5% 17.7%
168 125 43 11 101
22.4% 16.7% 5.7%
1.5% 13.5%
Immediate Family
1012
51.0%
564
45.7%
448
59.7%
Acquaintance Teacher/Child care
504 40
25.4% 2.0%
314 16
25.4% 1.3%
190 24
25.3% 1.9%
Known to child
544
27.4%
330
26.7%
214
28.5%
Stranger” Unknowr? Other”
10 361 58
0.5% 18.0% 2.9%
5 294 42
0.4% 23.8% 3.4%
5 67 16
0.7% 8.9% 2.1%
All others
429
21.6%
341
21.6%
88
11.8%
’ The child was able to identify the perpetrator, who had no previous contact with the victim. ’ The child was unable or unwilling to identify the perpetrator whose identity remains unknown. c Refers to many small subgroups of perpetrators with only casual previous contact with the chiId.
investigators are being transferred and replaced by less experienced workers who may muster a lower validation rate. But as the number of reports increases, some authors have found that the validation rate declines, presumably because the investigators have less time to devote for each individual case. Furthermore, as the caseload increases, more new workers are being hired and their lack of experience may account for an overall decline in validation rate. When we eliminate the first four time periods, based on the assumption that learning has been taking place and these data are not representative of later periods, we find that validation rate is moderately correlated in a negative fashion with number of cases reported. Possibly, some trend is developing that merits additional monitoring. The study also demonstrates that the majority of the perpetrators (78%) were known to the children and had access to the victims. In over half the incidents, family members were implicated as the perpetrators, These data highlight the need for immediate protective services to be provided for these young victims. Prompt reporting to protective services of sexual abuse of children provides for early intervention and thereby better protection to the victims. In Shelby County, any incidence in which intrafamilial abuse is reported is considered an emergency, and a TDHS worker is immediately dispatched to the scene.
REFERENCES Census Tracts: 1985, (1986). Shelby County, TN: Data from the Office of Planning and Development. Gelinas, D. J. (1983). The persisting negative effects of incest. Psychiatry, 46, 3 12-332. James, J., Womack, W. M., & Strauss, F. (1978). Physician reporting of sexual abuse of children. Journal of& American Medical Association, 240.
1I45- 1146.
Jason, J. Andereck, N. D., Marks, J., &Tyler, C. W. (1982).Child abuse in Georgia: A method to evaluate risk factors and reporting bias. American Journal of Public HeaBh, 72, 1353-l 358. Kempe, C. H. (1978). Sexual abuse. another hidden pediatric problem. Pediatrics, 62, 382-389.
Child sexual abuse
529
Kempe, C. H. (1980). Incest and other forms of sexual abuse. In C. H. Kempe & R. E. Helfer (Eds.), The battered child. Chicago: University of Chicago Press. Ladson, S., Johnson, C. F., & Doty, R. E. (1987). Do physicians recognize sexual abuse? American Journal ofDiseases of Children, 141,41 I-415. Muram, D., & Weatherford, T. (1988). Child sexual abuse in Shelby County Tennessee: Two years of experience. Adolescent Pediatric Gynecology. 2, 114-l 18. National Center on Child Abuse and Neglect (NCCAN). (1987, August). Child sexual abuse: Incest. assault and exploitation (Special Report). Washington, DC: HEW Children’s Bureau. Orr, D. P. (1978). Limitations of emergency room evaluations of sexually abused children. American Journal of Diseases of Children, 132, 873-875.
Resume-Suite a l’introduction d’un programme dttaille et complet portant sur les abus sexuels a l’egard des enfants en 1985, le nombre d’abus confunks impliquant des mineurs a augment6 significativement. Cependant apres une augmentation initiale, le nombre d’incidents confirmts est rest& relativement stable aux environs de 30 a 35 cas par mois. Si le taux de confirmation globale etait de 57 pour-cent, il fluctuait largement de 21 pour-cent a 92 pour-cent. Le taux de confirmation a augment6 de 1984 a 1987 et a diminue dans la dernitre partie de 1989. Le taux de validation refletait apparament le nombre de cas confirmts et ne paraissait pas dependant du nombre de cas signales. Le nombre de cas confinn& n’etait pas correle avec le temps, mais t&s moderement avec le nombre de cas rapportts (coefficient de correlation estime de Spearman etait de 0.45 pour p < 0.005). Cependant apt& ajustement pour le temps, la correlation entre le nombre de cas valid&s et rapport& perdait sa signification. Le pourcentage de cas confirm&s (le taux de confirmation) etait correle avec le nombre de cas confirn-ks (coefficient de correlation estime de Spearman ttait de 0.84 pour p < 0.000 1) et non avec le nombre de cas signal&s. Les taux de confirmation Ctaient plus eleves pour les filles que pour les garcons, respectivement de 7 1.1 pour-cent et de 3 1.8 pour-cent. La majorite des abuseurs (78 pour-cent) ttaient connus des enfants et leur victime etait facilement accessible. Dans plus de la moitie des incidents les abuseurs faisaient partie de la famille. Resumen-Desputs de introducir un programa comprensivo de abuso sexual al menor en 1985, se determino un aumento significativo en el numero de incidentes validados de abuso relacionados con menores. Sin embargo, desputs de1 aumento initial, el numero de incidentes validados de abuso permanecio relativamente estable en alrededor de 30 a 35 por mes. A pew de que la tasa de validaci6n total era 57%, fluctuaba ampliamente desde tan baja coma 2 1% hasta tan alta coma 92%. La tasa de validacibn aumento de 1984 hasta 1987, declinando en la ultima parte de1 1989. La tasa de validation parecera reflejar el numero de cases validados y no depender de el nimero de cases reportados. El nimero de cases validados no correlacionaban signiticativamente con el tiempo, pero si correlacionaba moderadamente con el ntimero de cases reportados (Coeficiente de Correlacidn Spearman era 0.45 con p < 0.05). Sin embargo, despues de ajustar el tiempo, la correlation partial entre el numero de cases validados y el numero reportados no era significativo. El porciento de cases validados (tasa de validacibn) se correlacionb con el nimero de cases validados (Coeficiente de Correlation Spearman estimado era 0.84 con p < 0.000 I), pero no con el numero de cases reportados. Las tasas de validation eran m&s altas en las muchachas que en 10s muchachos, 7 1.1% y 3 I .8%, respectivamente. La mayoria de 10sperpetradores (78%) eran conocidos para 10snifios, y tenian acceso a sus victimas. En m&s de la mitad de 10s incidentes, estaban implicados coma perpetradores miembros de la familia.
014s2134/9l $3.00 + .a, Copyright 0 1991 Pergamon Press plc
1991
CHILD SEXUAL
ABUSE IN SHELBY COUNTY,
TENNESSEE:
A NEW EPIDEMIC?
DAVIDMURAMANDBRIDGETDORKO Section
of Pediatric
and Adolescent Gynecology, Department of Obstetrics University of Tennessee, Memphis
and Gynecology,
JUDY G. BROWN Regional
Social Services, The Tennessee
Department
of Human
Services
ELIZABETHA.TOLLEY The Department
of Biostatistics
and Epidemiology,
University
of Tennessee,
Memphis
Abstract-Following the introduction ofa comprehensive child sexual abuse program in 1985, there was a significant increase in the number of validated incidents of abuse involving minors. However, following the initial increase, the number of validated incidents of abuse remained relatively stable at about 30-35 per month. While the overall validation rate was 57%. it fluctuated widely from as low as 2 I% to as high as 92%. The validation rate rose from 1984 through 1987, declining in the latter part of 1989. The validation rate appeared to reflect the number of validated cases and not be dependent upon the number of reported cases. The number of cases validated was not significantly correlated with time, but was moderately correlated with the number of cases reported (estimated Spearman correlation coefficient was .45 with p i .05). However, after adjusting for time, the partial correlation between the number of validated and the number of reported cases was no longer significant. The percent of validated cases (the validation rate) was correlated with number of cases validated (estimated Spearmen correlation coefficient was .84 with p < .OOOI), but not with the number of cases reported. Validation rates were higher for girls than for boys, 7 1.1% and 3 1.8%respectively. The majority of the perpetrators (78%) were known to the children and had access to the victims. In over half the incidents, family members were implicated as the perpetrators. Key Words-Child
sexual abuse, Perpetrator,
Child protection
agencies,
Detection,
Prevention,
Legislation.
INTRODUCTION IN 1985,the Tennessee Legislature introduced House Bill 495, which passed into law, Public Chapter 145, a comprehensive child sexual abuse program. Among its provisions, the law requires that “any person, physicians included, who knows or has reasonable cause to suspect, that a child has been sexually abused shall report such knowledge or suspicion to the department.” At the same time, the Tennessee Department of Human Services (TDHS) initiated a central child sexual abuse registry, which identified victims and perpetrators of child sexual abuse. The registry was designed to enable TDHS to identify and locate prior reports or cases of child sexual abuse, and to evaluate the effectiveness of the department’s Received
for publication
January
22, 1990; final revision
Requests for reprints should be sent to David Muram, Tennessee, 853 Jefferson Ave., Memphis, TN 38 103.
received Department 523
September
25, 1990; accepted
of Obstetrics
October
and Gynecology,
I, 1990.
University
of
524
D. Muram.
B. Dorko.
J. G. Brown,
and E. A. Tolley
program for sexually abused children. During the first two years of the registry, the number of validated incidents of abuse involving minors rose, from an average of 15 reports per month in 1984, to 60 validated incidents per month in 1986 (Muram & Weatherford, 1988). We assumed that this increase in the number of validated incidents reflected only increased awareness and action by the individuals notifying TDHS (Muram & Weatherford, 1988). However, with time we became concerned that this increase might reflect a true increase in the number of sexually abused children. To further assess this issue, the central registry was evaluated over an additional three-year period. The following paper summarizes our observation during this extended period.
MATERIALS
AND
METHODS
The demographics of Shelby County, Tennessee, have been previously described (Census Tracts, 1986; Muram & Weatherford, 1988). Briefly, Shelby County is the most populated county in Tennessee, with a population of about 800,000. It includes the city of Memphis, the largest city in the state. While almost 50% of the Memphis population is black, the percentage of Caucasians is higher in the surrounding areas, so that countywide the black population represents about 43%. Of the total population, 27 1,000 are individuals under age 19. TDHS of Shelby County is located in Memphis. Its registry receives all reports of incidents in which children, age 18 and under, are suspected to be victims of sexual abuse. An investigative team is then assigned to the case, and all validated cases are entered into the registry. Nonvalidated incidents were listed as reported but were not entered into the registry. The registry entries were analyzed and compared with the findings observed between 1984-1986.
RESULTS Between October 1, 1986 and September 30, 1989, 3,46 1 incidents of child sexual abuse were reported to TDHS (1,211 males and 2,250 females); and of these, 1,985 (57.4%) were validated by the ensuing investigation and entered into the registry. During the study period, the number of validated incidents of abuse remained relatively stable at about 30-35 per month (Figure 1). While the overall validation rate was 57%, it fluctuated widely from as low as 2 1% to as high as 92%. The validation rate rose from 1984 through 1987, declining in the latter part of 1989 (Figure 2). The validation rate appeared to reflect the number of validated cases and not be dependent upon the number of reported cases (Figure 3). To qualify and quantify our impressions, we estimated Spearman correlation coefficients. Looking at validation rates over the study period, the number of reported cases appeared to increase over time. The estimates of Pearson product moment and the Spearman correlation coefficients were .57 (a < .O 1) and .48 (a < .04), respectively. The number of cases validated was not significantly correlated with time, but was moderately correlated with the number of cases reported (estimated Spearman correlation coefficient was .45 with p < .05). However, after adjusting for time, the partial correlation between the number of validated and the number of reported cases was no longer significant. The percent of validated cases (the validation rate) was correlated with number of cases validated (estimated Spearman correlation coefficient was .84 with p < .OOOl), but not with the number of cases reported. Some authors have suggested that an increase in the number of reported cases may overwhelm the system, and thereby lead to a decrease in the validation rate. When we eliminated the first four time periods, based on the assumption that learning was taking place and these data were not representative of later periods, we found that validation rate was moderately
525
Child sexual abuse
EI
Reported
l
Validated
Figure 1. Child sexual abuse: Number of reported and validated cases, Shelby County, Tennessee
(1984-1989).
correlated in a negative fashion with number of cases reported (estimated Spear-man correlation coefficient was -.62 with p < .02), but strongly correlated in a positive fashion with number of cases validated (estimated Spearman correlation coefficient was .73 with p < .002). Furthermore, we looked at the relationship among the variables within the groups. In the group with caseloads of 300 or less, the only estimated correlation coefficient that was significant was between number of cases validated and the validation rate. In the group with caseloads of 300 or more, the number of cases reported was strongly related in a negative manner
Figure 2. Validation
rate, Shelby County, Tennessee
(1984-1989).
526
D. Muram, B. Dorko, J. G. Brown, and E. A. Tolley 100
20
1
,a 200
0 I
I
I
300
400
500
No.
Reported
Figure 3. Child sexual abuse: Validation rate as a percent of reported cases, Shelby County, Tennessee
(1984-1989).
to validation rate and positively to time. Overall, it appears that the number of validated cases had remained relatively constant, but the number of reported cases has generally increased. Abuse rates remained much higher for girls than for boys. During the study period, 3,46 1 separate incidents were reported (2,250 involving girls and 1,211 involving boys); 2,332 (67.4%) were black, 1,121 (32.38%) were Caucasians, and 8 (0.2%) were of other ethnic origins. Of these, 1,985 incidents were validated (1,600 involving girls and 385 involving boys); 1,108 (55.8%) were black, 874 (44%) were Caucasians, and 3 (0.2%) were of other ethnic origins. Validation rates were higher for girls than for boys, 7 1.1% and 3 1.8% respectively. Compared with the previous study group (Muram & Weatherford, 1988), more incidents involving girls were validated. In 1986- 1989 the female to male ratio increased to 4 to 1, compared with a ratio of 3.2 to 1 for the years 1984-1986. The mean age of the child victims was 8.6 years, (range 0- 18), and children of all ages were affected (Figure 4). Young children, age 11 and under, accounted for 1,235 (62%) of the victims; while children age 11 and older accounted for the remaining 750 (38%) alleged victims. Male victims accounted for 29% of the younger patients; 29% were males, compared with 16% of the older group (a < .OO1). The sex and race distribution are detailed in Table 1. Table 2 summarizes the relationship between the perpetrator and the child-victim. Immediate family members were most frequently the identified perpetrators. Family members and acquaintances were reported to be the perpetrators in the majority of incidents. The alleged perpetrator was a member of the victim’s family in 1,O12 of the 1,985 validated incidents, and family friend or a neighbor in 542 instances. When the child was able to provide information about the perpetrator, only on rare occasions ( 10 cases) was the perpetrator totally unknown to the victim. The relationship between the victim and the perpetrator was not determined by the victim’s age. However, it appeared that stepparents and mother’s beaus were more likely to assault girls age 11 or older, and the assailant was likely to remain unidentified when the victim was age 6 or younger. DISCUSSION The new Child Sexual Abuse Law in Tennessee has resulted in a significant increase in the number of reported cases of suspected child sexual abuse in Shelby County, TN. The increase
521
Child sexual abuse
1
2
3
4
5
6
7
8
9
10
AGE
Figure
4.
Child
sexual
abuse:
Age
of
11
12
13
14
15
16
17
(Years)
Child Victims of Sexual (Oct. 1986~Sept. 1989).
Abuse,
Shelby
County,
Tennessee,
in the number of reports resulted in a comparable increase in the number of validated cases. However, following this initial rise, the number of validated cases has remained relatively constant, although the number of cases reported has generally increased. However, as in the previous study, we believe that not all child victims of abuse are being reported to TDHS. In this study population the ratio of female to male victims of sexual abuse was 4 to 1. Previous retrospective studies have shown the ratio to be about 2 to 1 (Gelinas, 1983; Kempe, 1978, 1980). Although this higher ratio might represent a true difference which is unique for the population of Shelby County, our impression is that it represents misdiagnosis and under-reporting of male victims. The increased female to male ratio over the past five years reflects better recognition by professionals of signs and symptoms of abuse in female victims. Studies have shown that many physicians have difficulties in identifying, managing, and reporting these children to child protective services (James, Womack, & Strauss, 1978; Ladson, Johnson, & Doty, 1987; Or-r, 1978). These difficulties have undoubtedly contributed to discrepancies between the number of reported incidents of child sexual abuse, and the estimated number of victims calculated from retrospective studies (National Center on Child Abuse and Neglect, 1978). Validation rate fluctuated widely during the study period. It has been suggested that the validation rate declines when the number of reported incidents increases. In the current study the validation rate rose from 1984 through 1987, but declined in the latter part of 1989. This pattern may reflect the experience gained by the on-the-job training of the TDHS investigators, resulting in an increase in the validation rates. With time, some of the more seasoned
Table 1. Sex and Race Distribution
of Population Studied, Shelby County, TN, 1986-1989
All Patients
Patients Age c 11
Patients Age > 11
Race
White
Other
White
Black
Other
Male
205
178
2
156
125
2
49
53
0
Female Total
669 874
930 1108
:
376 532
575 700
1 3
293 342
355 408
0 0
Black
White
Black
Other
528
D. Muram, B. Dorko, J. G. Brown, and E. A. Tolley Table 2. The RelationshiD Between the Peroetrator and the Child-Victim
__
No. of Incidents All Ages N = 1985
Perpetrator Parent Stepparent Sibling Grandparent Other relative
362 186 115
Age>11 N = 750
AgeO-II N = 1235
18.2% 9.4% 5.8% 1.5% 16.1%
194 61 72 19 218
15.7% 4.9% 5.8% 1.5% 17.7%
168 125 43 11 101
22.4% 16.7% 5.7%
1.5% 13.5%
Immediate Family
1012
51.0%
564
45.7%
448
59.7%
Acquaintance Teacher/Child care
504 40
25.4% 2.0%
314 16
25.4% 1.3%
190 24
25.3% 1.9%
Known to child
544
27.4%
330
26.7%
214
28.5%
Stranger” Unknowr? Other”
10 361 58
0.5% 18.0% 2.9%
5 294 42
0.4% 23.8% 3.4%
5 67 16
0.7% 8.9% 2.1%
All others
429
21.6%
341
21.6%
88
11.8%
’ The child was able to identify the perpetrator, who had no previous contact with the victim. ’ The child was unable or unwilling to identify the perpetrator whose identity remains unknown. c Refers to many small subgroups of perpetrators with only casual previous contact with the chiId.
investigators are being transferred and replaced by less experienced workers who may muster a lower validation rate. But as the number of reports increases, some authors have found that the validation rate declines, presumably because the investigators have less time to devote for each individual case. Furthermore, as the caseload increases, more new workers are being hired and their lack of experience may account for an overall decline in validation rate. When we eliminate the first four time periods, based on the assumption that learning has been taking place and these data are not representative of later periods, we find that validation rate is moderately correlated in a negative fashion with number of cases reported. Possibly, some trend is developing that merits additional monitoring. The study also demonstrates that the majority of the perpetrators (78%) were known to the children and had access to the victims. In over half the incidents, family members were implicated as the perpetrators, These data highlight the need for immediate protective services to be provided for these young victims. Prompt reporting to protective services of sexual abuse of children provides for early intervention and thereby better protection to the victims. In Shelby County, any incidence in which intrafamilial abuse is reported is considered an emergency, and a TDHS worker is immediately dispatched to the scene.
REFERENCES Census Tracts: 1985, (1986). Shelby County, TN: Data from the Office of Planning and Development. Gelinas, D. J. (1983). The persisting negative effects of incest. Psychiatry, 46, 3 12-332. James, J., Womack, W. M., & Strauss, F. (1978). Physician reporting of sexual abuse of children. Journal of& American Medical Association, 240.
1I45- 1146.
Jason, J. Andereck, N. D., Marks, J., &Tyler, C. W. (1982).Child abuse in Georgia: A method to evaluate risk factors and reporting bias. American Journal of Public HeaBh, 72, 1353-l 358. Kempe, C. H. (1978). Sexual abuse. another hidden pediatric problem. Pediatrics, 62, 382-389.
Child sexual abuse
529
Kempe, C. H. (1980). Incest and other forms of sexual abuse. In C. H. Kempe & R. E. Helfer (Eds.), The battered child. Chicago: University of Chicago Press. Ladson, S., Johnson, C. F., & Doty, R. E. (1987). Do physicians recognize sexual abuse? American Journal ofDiseases of Children, 141,41 I-415. Muram, D., & Weatherford, T. (1988). Child sexual abuse in Shelby County Tennessee: Two years of experience. Adolescent Pediatric Gynecology. 2, 114-l 18. National Center on Child Abuse and Neglect (NCCAN). (1987, August). Child sexual abuse: Incest. assault and exploitation (Special Report). Washington, DC: HEW Children’s Bureau. Orr, D. P. (1978). Limitations of emergency room evaluations of sexually abused children. American Journal of Diseases of Children, 132, 873-875.
Resume-Suite a l’introduction d’un programme dttaille et complet portant sur les abus sexuels a l’egard des enfants en 1985, le nombre d’abus confunks impliquant des mineurs a augment6 significativement. Cependant apres une augmentation initiale, le nombre d’incidents confirmts est rest& relativement stable aux environs de 30 a 35 cas par mois. Si le taux de confirmation globale etait de 57 pour-cent, il fluctuait largement de 21 pour-cent a 92 pour-cent. Le taux de confirmation a augment6 de 1984 a 1987 et a diminue dans la dernitre partie de 1989. Le taux de validation refletait apparament le nombre de cas confirmts et ne paraissait pas dependant du nombre de cas signales. Le nombre de cas confinn& n’etait pas correle avec le temps, mais t&s moderement avec le nombre de cas rapportts (coefficient de correlation estime de Spearman etait de 0.45 pour p < 0.005). Cependant apt& ajustement pour le temps, la correlation entre le nombre de cas valid&s et rapport& perdait sa signification. Le pourcentage de cas confirm&s (le taux de confirmation) etait correle avec le nombre de cas confirn-ks (coefficient de correlation estime de Spearman ttait de 0.84 pour p < 0.000 1) et non avec le nombre de cas signal&s. Les taux de confirmation Ctaient plus eleves pour les filles que pour les garcons, respectivement de 7 1.1 pour-cent et de 3 1.8 pour-cent. La majorite des abuseurs (78 pour-cent) ttaient connus des enfants et leur victime etait facilement accessible. Dans plus de la moitie des incidents les abuseurs faisaient partie de la famille. Resumen-Desputs de introducir un programa comprensivo de abuso sexual al menor en 1985, se determino un aumento significativo en el numero de incidentes validados de abuso relacionados con menores. Sin embargo, desputs de1 aumento initial, el numero de incidentes validados de abuso permanecio relativamente estable en alrededor de 30 a 35 por mes. A pew de que la tasa de validaci6n total era 57%, fluctuaba ampliamente desde tan baja coma 2 1% hasta tan alta coma 92%. La tasa de validacibn aumento de 1984 hasta 1987, declinando en la ultima parte de1 1989. La tasa de validation parecera reflejar el numero de cases validados y no depender de el nimero de cases reportados. El nimero de cases validados no correlacionaban signiticativamente con el tiempo, pero si correlacionaba moderadamente con el ntimero de cases reportados (Coeficiente de Correlacidn Spearman era 0.45 con p < 0.05). Sin embargo, despues de ajustar el tiempo, la correlation partial entre el numero de cases validados y el numero reportados no era significativo. El porciento de cases validados (tasa de validacibn) se correlacionb con el nimero de cases validados (Coeficiente de Correlation Spearman estimado era 0.84 con p < 0.000 I), pero no con el numero de cases reportados. Las tasas de validation eran m&s altas en las muchachas que en 10s muchachos, 7 1.1% y 3 I .8%, respectivamente. La mayoria de 10sperpetradores (78%) eran conocidos para 10snifios, y tenian acceso a sus victimas. En m&s de la mitad de 10s incidentes, estaban implicados coma perpetradores miembros de la familia.
