Case 2: A 16-year-old girl with a history of sexual assault and post-traumatic stress

A 16-year-old girl presented to a community clinic with a history of sexual assault by a 24-year-old man six months earlier. She reported accepting a ‘Facebook’ friend request from this previously unknown man, chatting with him online for several weeks and confiding in him about problems she was experiencing with her peers at school. After engaging in increasingly intimate online conversations and exchanging a number of sexually explicit photos, she agreed to meet him in person for the first time at his home. When she refused his sexual advances, he forcefully sexually assaulted her. They have since had no contact. She presented as anxious and reluctant to report the assault to the police. Her mother, who accompanied her to the clinic, appeared distraught yet very supportive of her daughter. No current physical symptoms, such as vaginal bleeding, discharge or pain, were noted. The physical examination, including close inspection of her genital area, demonstrated normal findings. Specimens were collected to test for pregnancy and sexually transmitted infections, including gonorrhea, chlamydia, HIV, hepatitis B and C, and syphilis. A sexual assault evidence kit was not indicated due to the historical timeframe of the incident. A HEADSS (Home, Education, Activities, Drug use and abuse, Sexual behaviour, Suicidality and depression) assessment highlighted feelings of sadness, anxiety, social isolation and bullying at school. She reported experiencing intrusive thoughts of the assault, particularly at night, as well as intense feelings of self-blame and shame. The option of involving the police was discussed; however, she declined despite ongoing fears for her safety. Although a significant underestimation of true prevalence, there were more than 3800 incidents of sexual violations against children in 2011 according to Canadian police-reported crime statistics, 3% more than the previous year (1). Unlike the declining trend of most other crime rates, there was a 10% increase in the relatively new offence of luring a child via computer (1). With most adolescents having unlimited access to the Internet, unsupervised and injudicious online activity may pose serious health and safety concerns. The Internet offers adolescents a vehicle to accessing a new and exciting social environment, one that provides endless opportunities to connect with individuals they may not have otherwise met in person. While many adolescents develop healthy online relationships with peers, some will engage in potentially dangerous online interactions. Sometimes lacking mature judgement, emotional control and experience with intimate relationships, adolescents may find themselves in rapidly advancing, high-risk online encounters leading to sexual exploitation and victimization. Adolescents who experience difficulties offline, such as previous abuse, delinquency, depression and social interaction problems, are particularly susceptible to online victimization (2). Sexual offenders often seek vulnerable children and adolescents, quickly identifying their weaknesses and desire for attention, and gaining their trust and loyalty through manipulative grooming tactics. They may be openly or subtly enticed by intimate chats and sexual material to lower inhibitions with the intent to solicit online or offline sexual encounters. Such interactions constitute a form of Internet-initiated child sexual abuse. In addition to a thorough medical evaluation that is nonjudgmental, culturally and developmentally appropriate, and sensitive to possible trauma triggers and legal proceedings, it is important for health care providers to address the risks associated with online sexual behaviour, assess for symptoms of post-traumatic stress disorder (PTSD) and refer to appropriate mental health services when indicated. Inquiry into adolescent online behaviour can be easily integrated within the paediatric HEADSS assessment with questions specific to Internet usage, online gaming, cyber-bullying, pornography and online sexual victimization (eg, “Do you ever chat with people online that you have not met in person about sex?”) (3). With emphasis on careful social networking and healthy sexual development, Internet safety strategies should be based on the best available research evidence, developmentally sensitive, and focused on practical skills aimed at reducing the risks associated with online sexual interactions with unknown individuals. At-risk adolescents, including those with a history of abuse, those questioning their sexual orientation, and those engaging in a pattern of risky offline and online behaviours, must be carefully assessed and may require targeted approaches to prevention and intervention that address their presenting vulnerabilities (2). While some adolescents who have been sexually assaulted demonstrate highly resilient responses, many develop a range of adverse effects on psychological, emotional, behavioural, physical and interpersonal functioning. Adolescents who have experienced a potentially traumatic event may initially appear asymptomatic; however, a significant proportion will meet full or partial criteria for PTSD. Paediatricians and other health care clinicians are in a unique position to identify, monitor and, in some cases, treat trauma symptoms in adolescents. The UCLA PTSD Reaction Index is a brief and reliable screening tool that can be administered to detect post-traumatic stress reactions in children and adolescents (4). Screening results can then guide the health care provider’s intervention, which may include psychoeducation regarding common trauma responses, self-care and coping strategies, and referral to evidence-based mental health treatment such as trauma-focused cognitive-behavioural therapy with special consideration of the dynamics associated with online victimization. The Internet offers adolescents opportunities to engage in healthy online social relationships; however, it can also be a vehicle for online sexual exploitation. While often overlooked, paediatricians and other health care professionals play a vital role in the prevention, assessment and management of high-risk online activity and sexual victimization of children and youth. Inquiry into adolescent online behaviour should be routinely incorporated within the paediatric HEADSS assessment. Internet safety strategies should be developmentally appropriate, skill-based and evidence-informed. Adolescents who present with Internet-facilitated sexual assault should receive a thorough medical examination, be screened for post-traumatic stress reactions and be referred for trauma-focused treatment if necessary. Law enforcement and child welfare service involvement must be considered in accordance with jurisdictional legislation and reporting protocols. The authors thank Dr Michelle Shouldice for her helpful review of the manuscript.

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