The mishandling of sexual abuse in the Catholic church continues to unfold as more information has become available through the years. Six weeks after Archbishop Carlo Maria Viganò, the former Vatican ambassador in the United States, accused Pope Francis of covering up sexual abuse, the Vatican broke its public silence this past weekend with a response from a powerful prefect for the Congregation for Bishops.

This comes on the heel of a grand jury report that found bishops and other leaders of the Roman Catholic Church in Pennsylvania covered up child sexual abuse committed by more than 300 priests during a period of 70 years, persuading victims to not report the abuse and law enforcement to not investigate it. Following these findings, the attorneys general of New York and New Jersey launched investigations into sexual abuse by Catholic clergy in their states, and the attorney general of Illinois announced that she was launching an investigation in her state.

These investigations address problems that involved the church, but sexual violence involving children and teenagers can involve anyone, anywhere at any time. In 2016, almost 300,000 children in the U.S. were alleged victims of sexual abuse, according to the Children's Bureau of the Department of Health and Human Services. Only 12 percent of child sexual abuse is reported to the authorities. The silence needs to be broken.

As a doctor, I know that a victim's pain and suffering does not end when the abuse stops.  Whether individuals disclose that they have been victimized or keep silent about it, consequences are inevitable. Physical ailments may surface including chronic pain and headaches. Immediate psychological reactions include shock, confusion, denial, fear, withdrawal and shame or guilt.  Long-lasting emotional problems include depression, anxiety and post-traumatic stress disorder. PTSD includes emotional detachment, sleep disturbances and flashbacks. Victims of abuse may even resort to suicide.

The burden is heavy, as reflected in one study that found about 80 percent of 21-year-olds who were abused as children met criteria for at least one psychological disorder. Teenagers who have been abused are more likely to engage in sexual risk-taking, according to the Center for Disease Control and Prevention. They are also three times more likely to develop a substance abuse problem. As a doctor of teenagers, I see the drug abuse, sexually transmitted diseases and teen pregnancies.

You probably have questions, like I do, about these sexual abuse cover-ups. Why did these crimes happen? Why were they covered up? And, equally worrisome, why didn't the children and teenagers speak up when the crimes occurred?

There are many reasons why victims of sexual harassment and abuse don't come forward. These include shame, denial and minimization, fear of the consequences, low self-esteem, and feelings of hopelessness and helplessness, according to psychotherapist Beverly Engel, L.M.F.T.  If it sounds complicated, well, that's because it is.

How can we encourage children and teens to speak up? Parents and teachers could routinely let them know how important it is to speak up in front of peers and to adults in authority — including questioning and disagreeing — according to psychologist Carl E. Pickhardt, Ph.D. By practicing assertive communication, he writes, adolescents who speak up may affirm their sense of personal value: "I have something worth saying, I am worth listening to, I am worth being known, and I intend to be heard." He suggests activities to help children and teens learn to speak up:

  • Family meal times are used for discussion times.

  • Bed-time talks encourage recapping events of the day.

  • Adolescents are expected to converse with parental friends.

  • Arguing with parents is welcomed.

  • Parents coach adolescents in how to talk with school personnel when problems arise.

  • Students participate in speech and debate and drama classes.

  • Students run for elective office at school.

  • Parents expect adolescents to convincingly state their case to get more personal freedom.

Don't worry, parents, you are not all alone with this daunting task. Your child's doctor or other health care provider will ask about sexual violence. That brings me to my last point. More than nine percent of U.S. teens aged 12 to 17 years have not seen a doctor or other health care provider for a year or more, according to the CDC. Perhaps I'm preaching to the choir (and I hope that I am), but if you are a parent who has not taken your child for a medical check-up for a while, I suggest that you make an appointment.

If you have read this article and are thinking of ways to help your child speak up — and if you are picking up your phone to make your child's important medical appointment — then my time in writing this and your time in reading it have been well spent.