Child Abuse: What Ob/Gyns Can Do About It

Like most of us in medicine, I have been reading articles showing that as of 2010, reports of child abuse have been going down. I have been so encouraged. I spent almost 10 years working in the South Bronx in the 1990s, at which time the degree and frequency of child abuse I saw was deeply disturbing. That we, as a society, had begun to effect a decrease in child abuse was so encouraging (Figure).

Note:

A child was counted as a victim each time he or she was found to be a victim of maltreatment (duplicate count).
(

From the Department of Justice, Office of Juvenile Justice and Delinquency Prevention, Child Victimization Rates, 2010.

)

According to data from the Department of Justice, Office of Juvenile Justice and Delinquency Prevention:
- The child maltreatment victimization rate of 10.0 per 1000 children in 2010 was 25% below the rate of 13.4 per 1000 in 1990.
- An estimated 754,000 children were the victims of maltreatment in 2010, down 12% from the number of victims in 1990 (860,000).

Amazing. All the social programs and supports that have been instituted seem to be bearing fruit. We are beginning to find ways to protect our children consistently and effectively.

Then, this summer, I came across a blog about child abuse in The Incidental Economist that I found very troubling.¹ It commented on an article from the New York Times from July of this year by economist Seth Stephens-Davidowitz, in which he discussed his novel use of Google searches to tease out trends in child abuse during the Great Recession.² He points out that the official statistics focus on child fatalities, which do not represent most child abuse, and presents compelling data in his scholarly article that child abuse is in fact on the rise. Furthermore, he posits that the recent financial downturn of the US economy has fostered more child abuse than in previous years.

As a physician, I was not only disturbed by the suggestion that child abuse rates have significantly risen since the economic tailspin of 2008, but that the agencies whose job it is to track these things are not aware of it. Stephens-Davidowitz writes³:

“If the Great Recession increased suspicion of child maltreatment, why were fewer cases reported? Keep in mind first that many, probably most, suspected cases are never reported. Even primary care doctors, who are legally mandated to report suspected child abuse, admit in surveys that they do not report 27 percent of suspicious incidents.… Overworked teachers, doctors and nurses may be that much less likely to go through with the reporting process.”

So what is our role as ob/gyns? In my office, I see adolescent as well as adult patients. With the adolescents, I use an approach that I’ve adapted from the domestic abuse literature.⁴ First and foremost, I see my teenage patients alone and, in our time together, I try to create an atmosphere of safety and confidentiality. We will have already reviewed her right to privacy with the parent present, so we begin from a point of trust.
I have had many teens reveal to me that they are or have been in physically or sexually abusive situations at home or at school. Depending on the degree of fear and perceived danger, we discuss options for therapy or reporting and we make a plan for escape should it be needed. We also make a follow-up appointment, sometimes under pretense of an infection or birth control check. I do my best to find a trained counselor or advocate for the teen as well. Finally, I reach out to the pediatrician whenever possible, with the permission of the teen.

For those of you who only see adult patients, remember that they may have been victims of child abuse and, as such, are at risk for being in abusive relationships and for abusing their own children. We need to find the time and willingness to open the door to these discussions with our patients. We need to check in with them about life at home, social supports, perception of parenting skills, depression, anxiety, and past histories of personal victimization.

Certainly this will not happen in one, inevitably too-short, visit. However, by asking the questions, we are letting patients know that we are concerned about them as a whole person functioning in society; we are concerned about more than their last menstrual period and whether they are due for a pap smear.

Laying the foundations for a deeper level of communication with our patients will make them feel safe enough to reveal troubling or dangerous situations in their lives when they arise. Specifically, with regard to child abuse, asking targeted questions over the course of our relationship with a patient will allow us to identify troubled patients and their children, to offer resources and support and, hopefully, to help nudge the trend in child abuse in the downward direction.

References:

1. Gardner B. Child maltreatment, reported child maltreatment, and the recession. July 14, 2013. Available here. Accessed October 1, 2013.
2. Stephens-Davidowitz S. How Googling unmasks child abuse. July 13, 2013. Available here. Accessed October 10, 2013.
3. Stephens-Davidowitz S. Unreported victims of an economic downturn. July 13, 2013. Available here. Accessed October 10, 2013.
4. Gerbert B, Moe J, Caspers N, et al. Simplifying physicians’ response to domestic violence. West J Med. 2000;172:329-331.