Female perpetrators of child abuse – a case for being alert

We present a case of a child, who was subjected to life threatening physical injury, where the perpetrator was her foster mother. Usually men, rather than women, are implicated in serious physical abuse of young children 1,2 . It is also known that children, who are fostered or in residential care, are 7 to 8 times more likely to be abused by their carers, compared to the general population 3 . In many such cases the abuse can be severe enough to cause death 3 . Most literature on female perpetrators and their attributes are available on Munchausen syndrome by proxy where a child is physically abused through intentional subjection to medical procedures 4,5 . In case of abusive parents, recognized risk factors are unemployment, drug abuse, violent spouse relationship and poor mental health 6,7 . A gender preference in physical abuse is also recognised in families, where men are more likely to abuse boys and women more likely to abuse girls 6 .


Introduction
We present a case of a child, who was subjected to life threatening physical injury, where the perpetrator was her foster mother.Usually men, rather than women, are implicated in serious physical abuse of young children 1,2 .It is also known that children, who are fostered or in residential care, are 7 to 8 times more likely to be abused by their carers, compared to the general population 3 .In many such cases the abuse can be severe enough to cause death 3 .Most literature on female perpetrators and their attributes are available on Munchausen syndrome by proxy where a child is physically abused through intentional subjection to medical procedures 4,5 .In case of abusive parents, recognized risk factors are unemployment, drug abuse, violent spouse relationship and poor mental health 6,7 .A gender preference in physical abuse is also recognised in families, where men are more likely to abuse boys and women more likely to abuse girls 6 .

Case report
A 4 year old girl was admitted to Lady Ridgeway Hospital with suspected peritonitis.A laparotomy confirmed the diagnosis and a perforation was found at the recto-sigmoid junction.This perforation was obviously caused by direct trauma to the site but the method was unclear.This little girl was fostered three months before by a middleclass couple who already had two other sons, 15 and 7 years old, respectively.The history was obtained from the foster mother who stayed with the child in hospital.The child was given away for fostering by an aunt who could not financially support her.Both biological parents were unavailable to this child.
According to the foster mother, at the time this child ___________________________________________ 1 Senior Lecturer, Department of Psychological Medicine, 2 Senior Lecturer, Department of Surgery, Faculty of Medicine, Colombo.

(Received on 3 July 2003)
was brought to her for fostering, she was in a high state of neglect, had no intelligible speech and was faecally incontinent.Despite all these disabilities, the foster mother accepted the child, as she had long desired a replacement for a daughter who died in a road traffic accident.She could not satisfactorily explain how the child sustained the abdominal injury.The 15 year old boy was obviously the first suspected perpetrator but this could not be substantiated.Information could not be directly obtained from the child as she did not talk and looked withdrawn and scared.Her emotional state was attributed at the time to pain and debility of the post-surgical state.
When the foster mother left the hospital, claiming to have urgent matters to attend at home, there was an immediate transformation in the behaviour of the child.She became active, lively and talkative.It was obvious that she had normal intelligence and a welldeveloped speech and language ability.The child confided, with some reluctance, that the foster mother pinned her down on a bed and forced a stick into the anus.This was the punishment meted out to the child for peeping into the room when the foster mother was in bed with her lover while the husband was at work.The child gave a vivid description of the incident, the profuse bleeding afterwards and the severe pain she experienced.Subsequently, the foster mother had persistently threatened the child with death if she confided in anyone about the incident.

Discussion
Physical abuse is a major public health issue, due to its well-recognized long-term adverse effect on the psychological and physical well being of the child victim 8 .Thus, prevention of further exposure to abuse is crucially important.In this case, the child may have been sent home to further physical and emotional abuse but for the unexpected opportunity she got to directly confide in the doctors and nurses.There are some important lessons to learn here.Firstly, doctors can become the gullible victims of clever perpetrators who will feed them with false information.Secondly, physical abuse by a parent may evade recognition if none of the traditional family risk factors are particularly relevant, as in this case.Thirdly, it is important to maintain a high degree of suspicion and not be too distracted by the presence of men on the scenario, to the point of ignoring the female perpetrators.