From: rdsmith@magnus.acs.ohio-state.edu (R David Smith)
Subject: ****SPOILER ALERT**** Stories of abuse seen in clinics
Organization: The Ohio State University
Date: Mon, 5 Oct 1992 03:42:41 GMT



I got some positive responses on e-mail about posting some of my experiences 
this summer at the Adolescent Clinic at Children's Hospital.  I would estimate 
we had 2-3 known abuse cases to deal with each week, and I wanted to post some 
of the stories and observations I made about how both the survivor and the 
medical establishment dealt with what was happening.  This will contain some
details of abuse, so, if you don't feel up to reading such things, stop here.

I first want to say that I was impressed with the way the people at the clinic 
handled the survivors we saw.  They demonstrated a sensitivity towards their 
situations that I didn't know if I would see.  There was one particular social 
worker I always hated to see in the clinic because her presence always meant 
some kind of sexual abuse case was being worked up in the clinic. The social 
worker was a great person, but I came to dread her because of what her presence
sigified.

A thread was going through this group about whether or not survivors make up 
their stories or whether some survivors are lying.  I asked this social worker 
about what made her not believe a teen who was telling her she had been abused.
It is a tough question, because you certainly don't want to seem to be not
believing someone who has and is going through the pain of a sexual 
assault/abuse, but in the clinic, we have to make some kind of "truth" 
determination because
1.  Some teens do have vendettas
2. Once the social worker gets a hold of the case, that gets the law involved
and opens the clinicians up for potential lawsuit and liability if the
accusations prove unsubstantiated.

That second reason for being skeptical about a survivor's story is not a very
good one in terms of being sensitive to the needs of that person if they are
telling the truth, but it is a "real world" concern and a legitimate one.  When
Children's Hospital gets involved, Franklin County Children's Services gets
involved and the law gets involved and that puts a greater emphasis on
determining believability than if we were just trying to get the survivor into
counselling.

Anyway, the basic criteria his social worker used was consitency.  If the
teen's story of the abuse/assault was consistent over time and did not
contradict itself, then the social worker would feel fairly confident that the
teen was telling the truth.  Most of the time, there is no reason to believe
that the teen is just trying to get back at someone, and I really doubt that
happens very often.  There are other ways at getting revenge for something that
come to a teen's mind much faster than fabricating an abuse story.

How do we detect a survivor in the clinic?  With younger adolescents, we 
usually ask a direct question during the history.  Has anyone ever touched you
whenyou didn't want to be touched?  Has anyone ever touched your "privates" (or
whatever word they seem to understand as meaning genitals) when you didn't want
them to? Obviously, the shame factor may keep them from answering truthfully, 
and certainly, there is little we can do when the patient is in denial or is 
repressing memories.  We do sort of get around the shame factor a little by 
using a "Worry Form."  The teen fills it out prior to coming into the exam room
(they fill it out in a private room away from mom or dad or whoeever brought 
them in) and the questions are worded in such a way that the teen is never
asked directly "Are you worried about Dad abusing you sexually?" but the teen
is aked if she/he worries about rape or if she is worried about mom or dad
being bad or something like that.  The answers to those worry forms give us
some idea that there may be something going on and we need to probe a bit when
we see the patient.

Normally, we ask that whoever brought them in remain in the waiting area while 
the teen is in the exam room so there is less of a chance of the teen being
intimidated into silence.  If the guardian refuses to wait in the waiting room,
we usually find some means of distracting her/him.  We often will ask to talk 
with the parent privately before the teen goes to the exam room and then take 
the teen aside once the parent is occupied with another staff member.

We had a case early in the summer where it was very obvious that a 13 year old 
girl was in an abusive home.  She was being pretty severely physically abused 
and we had enough evidence from what she told us and from exam to call the 
police and FCCS (Children's Services) immediately.  The problem was that Mom
figured out that something was up and was insisting to take her daughter home
immediately.  We managed to stall her long enough to get the police there and
they got her out of the way without too much of a scene.  There were some
extremely tense moments in the clinic though as we weren't sure what the woan
was going to do.

Do the teens actually tell us about the abuse when asked?  That is hard to say.
 I feel fairly confident that when we get the perp away from them and if they 
aren't repressing or denying the memories, they seem pretty willing to tell 
despite the shame or self-hate factor.  Of the ones whom we saw this summer 
(granted, it is hard to draw conclusions from them because they are fairly 
self-selected), it seemed that they were very happy to finally have someone to 
tell.  Somehow, they felt we would protect them despite any threats made by the
perp.  (I don't know how valid their trust in us as protectors is, but it did 
help in getting them to talk.)

Sometimes, it is a matter of asking the right questions.  We have asked some
teens if they have ever had sex, and they say, "No."  We then later find out
that they had intercourse with a perp.  They did not consider this as having
sex.  You have to ask two questions (at least).  Have you ever had sex?  Has
anyone ever had sex with you? In one case, we got a "no" to the first question 
and a "Well, my uncle used to take showers with me and then have sex with me
afterwards."

There are a lot of frustrations in dealing with this on a level of the clinic.
In the clinics, we are so closely tied to medicolegal issues that addressing 
the problem of abuse gets tied up in politics and legal technicalities and it 
seems the survivor gets lost in the shuffle sometimes.  The laws still seem 
geared to protect the "family" at the expense of the child.  Even when FCCS 
takes a child away, the parent still has guardianship and must be consulted for
all procedures needing consent of a guardian.  The child was taken away because
of the parent's inability to act in the child's best interest and yet we still
have to go to the parent for these decisions.  It seems fairly illogical to me.

Then there are the cases where you just know there is something horribly wrong 
but you can't do anything about it.  The most bizzare case we had was a 14 year
girl (for anyone wondering why I have not mentioned male survivors, our clinic 
patient population is about 80% female, and they seem more willing to talk 
about there abuse, so that is most of what we see) whose mother had brought her
in for an exam, pelvic exam STD tests, and an HIV test after finding love 
letters written to a 46 year old man.  The girl claimed to be in love with the 
man and the man claimed to be in love with the girl and said he wanted to marry
her.  They both denied having had interourse any other sexual contact.  The 
kicker was that the 46 year old man had been dating the girls mother until
November of last year.  Not healthy.  But, with both denying sexual contact,
with the mother not having seen anything, and with a pelvic exam being pretty
useless for getting any evidence because the girl claimed previous sexual
activity with other teens (thus making the fact that her hymen was broken a
finding that proved nothing), we could do nothing about the situation. STD/HIV
tests turned up nothing, and that was the end of it.

I do not wish to open up the discussion again on whether or not it is possible
for a 14 year old and a 46 year old to have a productive, loving relationship.
In theory, it could work, but I don't think many such couples could execute the
relationship so that it was not pathological for the younger member.  I have
never seen it work, but we do have to consider the possibility that this
relationship was what both partcipants claimed it was.  I really don't believe 
either one of them though.  What do I think was happening?  A 46 year old man 
was taking advantage of a teen from a dysfunctional home who needed love, 
intimacy, and a father figure.  Unfortunately, he was providing all of that in
one and I feel it was damaging to the girl. However, if she was claiming not to
be harmed by him and we had no evidence to the contrary, there was nothing we 
could do.  That was frustrating.

What can you take away from this to feel good about?  First, know that 2-3 
times a week, a concerted effort is being made to break the cycle of abuse in a
teen's life.  Very often I think, it is a successful effort.  That is something
to feel very good about, to know that it is being recognized and we are trying 
to get them out of the hands of the perps.  Second, people in the white coats 
care.  There is more and more awareness training going on in medical schools so
that survivors can be more easily identified and steos be taken to get them out
of the abusive situation or to get them into therapy to help deal with their
pain. Third, these kids are being BELIEVED.  We are no longer trying to dismiss
these things or sweep them under the rug.  We are believing them and we are
trying to help them and help them get the message that they did not deserve
what happened to them.

Certainly, there is more to be done.  I know that there are more than 2-3
survivors a week going through the clinic doors.  Hopefully, we can find ways
to identify them too.  As there is more and more awareness, as groups like asar
continue to grow, more and more people will come to realize that this is a very
real problem and more will be done to make sure that health care professionals 
display the kind of sensitivity and interest necessary to be an effective part 
of the soltuion.  Because you are here posting to or reading this group, you 
increase awareness and even have a direct effect through me or others like me.
Because  of this group, I think I will better be able to recognize survivors in
clinic and help them.  What can you feel good about from this post then?  If 
nothing else know that because of what this group has done for me, more people 
will have this cycle of abuse recognized, and hopefully broken, than would have
been without asar.

That's something to feel really good about.

Hugs to all who want them.

Dave Smith (MD2B)