Recognizing and Managing Child Sexual Abuse
Recognizing and Managing Child Sexual Abuse
Author: Elaine Cabinum-Foeller, MD, Associate Professor of Pediatrics, Brody School of Medicine at East Carolina University; Medical Director, TEDI BEAR Children's Advocacy Center, Greenville, NC.
Peer Reviewer: Jeffrey Linzer Sr., MD, FAAP, FACEP, Assistant Professor of Pediatrics and Emergency Medicine, Emory University School of Medicine, Associate Medical Director for Compliance, Emergency Pediatric Group, Children's Healthcare of Atlanta at Egleston and Hughes Spalding, Atlanta, GA.
Child abuse is not uncommon and frequently presents to the emergency department (ED). Sometimes the presentation is subtle and masked by vague histories and nonspecific physical findings. Considering sexual abuse in the differential diagnosis is important for the child and his or her safety. Understanding techniques for obtaining a directed history and recognizing the physical findings and abnormalities that are associated with abuse will enable the physician to complete a thorough evaluation and to document with confidence. High-risk populations, such as children with special needs, present unique challenges to the clinician. This article reviews the history, physical examination, diagnostic evaluation, and reporting expectations for children with suspected sexual abuse.
Ann M. Dietrich, MD, Editor
Introduction
Child abuse is quite prevalent in our society.1-3 It is estimated that one in four girls and one in six boys will experience some form of child sexual abuse by the time they become 18 years of age.3 The national rate of child sexual abuse is 1.2 per 1,000 children.4 It is believed that child sexual abuse may be underreported for several reasons, such as delayed disclosure, inability to disclose due to developmental level of the child, and the child not recognizing that the abusive act is wrong.2,3
The longitudinal progression of child sexual abuse may shed light on why a child's disclosure may occur so long after the abuse and is particularly informative as to why the disclosure may be problematic or even retracted by the child.4 This progression occurs with the following stages: engagement, sexual interaction, secrecy, disclosure, and suppression.
In the first stage of this progression, the perpetrator engages the child by becoming a friend and spending time with the child. This often involves nonsexual issues and building a relationship. The perpetrator then engages the child in age-inappropriate sexual contact such as showing the child sexual abuse images or fondling the child. This may progress to genital contact in some cases. The perpetrator wants to keep the contact secret or "special" to allow continued access to the victimized child. This secrecy may be the result of overt or indirect threats. Then, the child's disclosure may occur by accident or the child may tell someone about the abuse on purpose. However, once a child has disclosed, many children may retract or suppress the disclosure due to pressure from others or due to consequences of the initial disclosure.
The reasons behind the failure of professionals to recognize the sexual abuse of children are many and include: social and cultural taboos around the notion of adults sexually exploiting children; personal anxiety surrounding discussion of sexual topics in general; collective and personal denial that sexual victimization of children occurs at all; and a relative lack of knowledge about the victimization of children.4
Definition
Child sexual abuse can be defined as "a dominant, more powerful person involving a dependent, developmentally immature child or adolescent in sexual activities for that dominant person's own sexual stimulation or for the gratification of other people, as in child pornography or prostitution."4 The American Academy of Pediatrics defines child sexual abuse as "the engaging of a child in sexual activities that the child cannot comprehend, for which the child is developmentally unprepared and cannot give informed consent, and/or that violate the social and legal taboos of society."5 Children younger than 12 years of age cannot consent to sexual activity with an adult.6 Any sexual contact with coercion or force is reportable to a child protective service agency.6
The essential components of the definition of sexual abuse involve the child's developmental immaturity and inability to consent, and the perpetrator's betrayal of the child's trust. In cases of sexual abuse, the perpetrator has authority and power over the child ascribed by his or her age or position and is thus able, either directly or indirectly, to coerce the child into sexual compliance. In intrafamilial sexual abuse, the involvement of the child in sexual activities violates the social taboos of family roles.4
Child sexual abuse can include fondling of a child's genitals; penetration of the genitals, anus, or mouth; incest; rape; indecent exposure; and the production of pornography.2 State and federal laws define and classify sexual abuse. Some child sexual abuse can be more passive, including viewing pornography or sexual acts at the request of an adult. This also can be part of the "grooming" process that some sexual perpetrators use with their victims. In this, the perpetrator becomes close to the child, gaining his or her trust, and then slowly exposes the child to inappropriate sexual contact or knowledge hoping to break down barriers to future inappropriate sexual contact. This grooming process over a period of time may lead to more active sexual abuse of the child.7
Child sexual abuse is part of a spectrum of coercive sexual acts involving children and adolescents. The following are legal definitions of such coercive acts and help to demonstrate what these acts have in common, as well as the differences, with child sexual abuse.8
Sexual assault is a comprehensive term that includes multiple types of forced or inappropriate sexual activity. Sexual assault includes situations in which there is sexual contact with or without penetration that occurs because of physical force or psychological coercion. This includes touching a person's sexual or intimate parts or the intentional touching of the clothing covering those intimate parts.8
The term molestation is applied when there is noncoital sexual activity between a child and an adolescent or adult. Molestation may include viewing of sexual materials, genital or breast fondling, or oral-genital contact.
From legal and clinical perspectives, rape is defined as "forced sexual intercourse" that occurs because of physical force or psychological coercion. Rape involves vaginal, anal, or oral penetration by the offender. This definition also includes incidents in which penetration is with a foreign object, such as a bottle, or situations in which the victim is unable to give consent because of intoxication or developmental disability.8 Rape is a legal term defined by various statutes, typically seen as a violent act that includes some form or variant of forcible sexual intercourse. Rape includes actual or threatened physical force sufficient to coerce the victim and may include some cases of child sexual assault. The terms acquaintance rape and date rape are applied to those situations in which the assailant and victim know each other.
Statutory rape involves sexual penetration by a person 18 years or older of a person under the age of consent.8 The age of consent varies from state to state. In some states, there are new statutory rape laws mandating that sexual intercourse and sexual contact now must be reported if certain age differences exist between a minor (usually defined as younger than 18 years) and his or her sex partner (whether minor or adult), even if the sexual act was voluntary and consensual. There is concern that the new laws and mandated reporting statutes may have a significant impact on the interaction between the health care provider and the patient. Adolescents and health care providers may have concerns regarding medical or social history, access to care, and confidentiality, and some adolescents may refuse to seek care or refuse to disclose personal risk information because of possible reporting of sexual partners.8
Child sexual abuse differs from acute sexual assault of adolescents and adults. Sexual abuse of children is a distinct, unique form of victimization.4 Sexual abuse of children is commonly a longitudinal pattern of abusive contacts that may occur over weeks, months, or years prior to ending through disclosure or discovery. In contrast, adult sexual assault often occurs as a single, violent episode. The perpetrator in child sexual abuse is often a trusted caregiver known to the child and family or, much less commonly, a complete stranger. Although the perpetrator in adult sexual assault may be a family member, as seen in cases of domestic violence, or an acquaintance, as in date rape, in some cases, the perpetrator is a stranger not known to the victim. Physical violence is uncommon in child sexual abuse, mainly due to the manipulation of the child's trust and the perpetrator's desire to avoid discovery of the abuse. On the other hand, physical violence is a common component seen in cases of adolescent and adult sexual assault. These distinctions are not absolute and some overlap between what is typically seen can occur.
Presentation
Sexual victimization of children is very different from physical maltreatment in two important dynamics. The first is that most perpetrators do not intend to actually physically harm their victims; because of this, few children present with injuries. The second dynamic is that few children disclose their experience immediately following the sexually inappropriate action, and this lack of disclosure results in some diagnostic challenges in identifying residua and collecting forensic evidence. Therefore, physicians must understand the dynamics of sexual victimization and be able to obtain a medical history from the child in a manner that is nonleading, facilitating, and empathetic. An appropriately obtained medical history will assist the physician in assessing the residual effects, both physical and psychological, as well as directing a treatment plan.
The diagnosis of child sexual abuse is based primarily on the history provided by the patient. Most often there are no physical signs. The child's developmental stage and developmental limitations on event recall make obtaining a child sexual abuse history difficult. The health care provider must rely on a history that, at times, does not seem reliable.
Sexually abused children can present in a variety of ways. There may be nonspecific behavioral changes such as acting out, increased aggressiveness, or withdrawal and depression. Others symptoms are somewhat more specific behavioral changes such as excessive masturbation, acting out adult sexual acts, or perpetrating sexual acts on other children.9 Some physical symptoms are nonspecific such as dysuria, pain in the genital area, or blood in the underwear.9 Symptoms that are commonly associated with nonabusive etiologies, such as irritant vaginitis or urinary tract infections, need to be differentiated from child sexual abuse.
Not all sexually abused children appear to have psychological or behavioral symptoms, at least not at the time of medical assessment. Therefore, abuse is not inevitably pathogenic, and some victims have limited sequelae. It has been demonstrated that children may be more likely to have psychological and behavioral sequelae with repeated episodes of abuse. Post-traumatic stress disorder (PTSD) and other trauma-related symptoms (e.g., dissociation) generally have been lowest among those surviving only one type of abuse (physical or sexual) and highest among those surviving combined abuse. However, more recent studies in adults are showing that adverse childhood events (ACEs) are cumulative and may lead to both mental and physical ailments in adulthood.10
Another way children can present is a parental concern about a child's statements.9 To interpret a child's statements about sexually abusive acts requires that one be familiar with how a child refers to his or her genitalia. A young child might make a statement such as "hurt boo boo" with a gesture to the genital area. An older child might state, "he held me down and put his ding a ling in my coochie." It is important to use quotes when documenting the history obtained and note from whom that history was obtained. The context in which the disclosure arises can be important also. Did the child spontaneously disclose abuse, or was the caretaker questioning the child about whether anyone had hurt him or her? In addition, one must be familiar with child development, as questions may be raised if a child uses language that is more advanced than his or her development. For example, a young child may say "he raped me" and then the examiner must determine what the child means by "rape" and possibly if the child is using a word that has been overheard in adult conversations.
Timing of Examination
The timing of the physical exam is dependent on many variables: physical symptoms such as genital bleeding or discharge, a parent or victim's anxiety about the alleged abuse, and the time of last contact with the perpetrator. If the alleged abuse occurred within 72 hours of presentation or if the child has genital bleeding, discharge, or pain, consideration should be given to performing a comprehensive examination including collection of appropriate forensic specimens.2,9,11-16 Although some residua to genital trauma may last beyond 72 hours, the potential to collect seminal products and other body fluids that could potentially identify a perpetrator is minimal.
If the child discloses abuse and the last incident of possible contact was more than 72 hours and the child is asymptomatic, the full detailed examination may be scheduled with a specialist in child abuse or the child's primary care physician at a later date.4 However, if the child has presented to an ED with the concern of child sexual abuse, it still may be necessary to conduct a screening examination. Remember that when a child presents to medical care for concerns of sexual abuse, it is often a family in crisis whether or not the patient's needs are classified as a "medical emergency."13
Medical Evaluation
The medical evaluation itself serves many purposes, such as identifying trauma or conditions that require medical care, collecting forensic evidence, reassuring the child and caretakers, and returning control of the child's body to him or her.6,14,17-19 The examination also will allow the examiner to assess the child's mental health and medical needs and make appropriate referrals.6
The evaluation includes obtaining history from the parent or caretaker, if present, and then obtaining a medical history from the child if possible.17,19,20 The physical exam should include a complete physical examination with a focused examination of the genitalia to look for residua to the abuse, such as trauma or sexually transmitted infection (STI).9
Some EDs have protocols in place for response to allegations of child abuse, be it physical or sexual.21 Physicians should be aware of their own hospital or trauma center policies regarding this, if applicable. However, the law on reporting suspected child maltreatment applies to all physicians and exists in all 50 states.19,21 If a mandated reporter, such as medical personnel or a social worker, suspects that a child has been physically or sexually abused, he or she must report those suspicions to the law enforcement or child protective services agency.2,9 State laws may vary in regard to the appropriate agency to notify; therefore, physicians should make themselves aware of the laws in their particular state. Some hospitals have specialists in child abuse available to answer questions or to help evaluate children in acute settings.21
History
From Caretaker. A history from the parent or caretaker should be obtained out of the presence of the child.19,20 Find out what concerns the caretaker has and why. Did the child disclose something to someone? What has made the caretaker suspicious? If the child has disclosed something, exactly what words did she or he say and in what context?6 Has the caretaker noticed any behavioral changes recently? This could include moodiness, increased anger, sexual promiscuity, or running away, depending on the age and developmental level of the child.9 Has the child had any physical symptoms such as genital or rectal bleeding, pain, dysuria, discharge, or itching? Has the caretaker had any other concerns? Who cares for the child? What is the caretaker's biggest concern?
From Child. In cases of alleged child sexual abuse, a child protective services agency and/or law enforcement may become involved. These professionals often need to conduct interviews of the child for their investigation. This, however, does not prevent the physician from obtaining a history from the child. The interview with the child should take place outside the caretaker's presence if at all possible. Sometimes a child will spontaneously blurt out what has happened to him or her. In these cases, it is vital to document exactly what the child said using his or her words.9,20 When talking with children, try to use open-ended and non-leading questions to obtain details of what happened.19,20 Questions such as, "Tell me why you are here?" or "Tell me more about that?" are helpful, especially with older children who can talk more freely. It is helpful to explain that "I am a doctor (or nurse, physician assistant, etc.) who checks children to make sure they are healthy. I need to check you from head to toe including your private area." Asking if the child has told anyone about what has happened is important to ascertain if they are being appropriately protected (this is important for the child protective services agency to know). If the child is frightened or extremely anxious, a detailed history should be deferred.9 If at any time you begin to feel uncomfortable, stop and let the investigating professionals do their interviews. They should be trained in how to question children in cases of suspected abuse. Just remember that the child is the patient and should be the physician's main focus.
The physician should identify who provided the history, including their relationship to the child, and specific words the child used in his or her disclosure.2,9 A physician who interviews the child should clearly document what questions were asked and what the child's words were in response. This can be very important if the case later goes to court. Good documentation of history and examination findings can aid in the prosecution of cases of child sexual abuse.22
Many child sexual abuse victims are younger than 5 years of age. The age and concomitant developmental level of these children present a distinct management challenge. Many children in this preschool group do not have fully formed language skills. Their words for their own sexual anatomy may be rudimentary and imprecise. For example, some children at this age are unable to distinguish between their genitals and their anus. Others use terms such as "peepee" or "hinie" without distinct meaning. Children younger than 5 years also may have difficulty with two other developmental skills: 1) sense of time and 2) sequencing ability. Some children may be unable to differentiate last week or last month from yesterday. Others will be unable to sequence a story as to what happened first, second, third, and so forth. Both of these developmental deficiencies may result in difficult-to-understand histories and what seem to be changing or impossible stories.
Children at older developmental levels may be reluctant to reveal and describe their abuse for fear of negative peer or parental reaction or because of a feeling that they will be seen as being a contributor to the abuse. They may be old enough to realize the embarrassment and shame that come with being a victim, even an innocent victim. A clever perpetrator will know how to gauge a child's developmental level and use the child's developmental stage to the perpetrator's own benefit.
Physical Examination
When examining children, restraint or sedation is rarely needed and some experts believe that procedural sedation is not very helpful in examinations for alleged child sexual abuse.21,23 If the child has a significant injury and the child is unable to cooperate for an examination, procedural sedation or even general anesthesia may rarely be needed.
The exam should include a complete physical exam to look for overall health, other signs of trauma, and disease. The exam should not add emotional distress to the child.9 A supportive adult, who is not suspected of abusing the child, should be present during the examination if possible.5 The child should be prepared for the examination by a professional who can explain what is going to happen in terms the child understands. This is quite helpful in getting children to cooperate for a comprehensive physical examination.9,20 Some hospitals have child life specialists or nurses who can help facilitate this examination.
Examination Positions and Techniques. Some exam positions that may be helpful to visualize the anogenital area are the supine frog leg, supine knee chest, prone knee chest, or dorsal lithotomy position, which is often used in adolescents or women.6,17,24 The ideal examination position is one in which the child feels most comfortable and is most cooperative. Under no circumstances should an uncooperative child be physically restrained for an examination.
In young children, having the child sit on the mother's lap with the mom in the lithotomy position and the child's legs lying over mom's can be useful, especially in an apprehensive child. The prone knee chest position is quite helpful to visualize the vaginal canal, especially when looking for foreign bodies. Most children and adolescents tolerate this position well. Helpful techniques for visualization of the female genitalia include labial separation, labial traction, moistened cotton swabs, or Foley catheters.8,18,19 The prepubertal hymen is quite sensitive, and touching it, even accidentally, with a swab can cause great pain and discomfort for the child. In acute examinations, toluidine blue dye may be helpful in documenting superficial tears in the genital or anal areas.25,26 This technique should be done before any digital or speculum examination.26 The dye is taken up by nucleated cells, thus revealing superficial tears.25,26 This dye has even been used at autopsy to help in the detection of injuries from sexual abuse.27
To visualize the anogenital area, one needs a good light source.17 If available, an otoscope or hand-held magnifying glass can be helpful. For documentation, a detailed description and diagrams are adequate. Photographs taken by a camera with macro lens or a colposcope with attached camera or video camera can be helpful, but are not necessary for a good examination.6,17,18,28,29 Photographs are helpful not only for documentation, but also for peer review or second opinions. Even if photographs or video is obtained, one still should maintain a detailed description and diagrams in the medical record.28
The emergency physician should not force the examination on the child or restrain the child. Speculum exams are rarely, if ever, needed in prepubertal girls.9,17 If a speculum exam is needed in a prepubertal girl, it will most likely be done under general anesthesia because the prepubertal hymen is exquisitely sensitive to touch and pain.
Physical Findings
One must remember that all injuries to the anal or genital area may not be the result of sexual abuse. There have been case reports of motor vehicle collisions causing anogenital injuries that can mimic findings in cases of child sexual abuse.30 The literature also has reports of straddle injuries from inline skating and bicycling accidents causing significant genital injuries requiring surgical repair.31,32 Accidental injuries to the hymen do occur, but are quite rare and should have a clear history consistent with the physical exam findings.32 Also, anal tone can be decreased with sedation or stool in the anus and rectum.
Differential diagnosis of genital bleeding in girls includes lichen sclerosus et atrophicus, urethral prolapse, straddle injuries, precocious puberty, or vaginitis.21 Erythema of the genitals is nonspecific and could be caused by hygiene, bacterial infection, or chemical irritation, in addition to trauma, either accidental or inflicted.17 Straddle injuries usually involve injury to the labia or perineum and uncommonly involve the hymen.33 (See Table 1.)
Physicians who are regularly involved in the care of children and adolescents should become familiar with normal anogenital findings in girls and boys and findings that are highly suspicious for child sexual abuse.2,24,34 There have been some recommendations that pediatric emergency physicians receive additional training in the area of child sexual abuse and that all children with abnormal examination finding in an ED have follow-up examinations by a physician with specialty training in child abuse.35 There have been multiple studies looking at normal anogenital anatomy in girls of all ages.36-42 This is important because some findings that were initially thought to be due to sexual abuse now are known to be found in "nonabused" girls.
In evaluating a child for the possibility of sexual abuse, more attention is given to the hymen than any other structure. Unfortunately, there is an exceptional amount of misunderstanding concerning the anatomy of the hymen. A common misconception is that there is a clinical entity known as congenital absence of the hymen. This condition does not exist as an isolated congenital anomaly with otherwise anatomically normal genitalia. The hymenal membrane and orifice may be quite variable in configuration. The appearance of the hymenal membrane and the orifice will change with age and the influence of estrogen. In addition, there is no normal standard for the opening size of the hymen or vaginal orifice. This is why a detailed description of the hymen is much more important than a comment of "enlarged opening" or "intact."
Anal abuse can occur to both girls and boys. The anus itself is designed to relax and contract to allow for the passage of stool. Anal findings that may be concerning for penetrating trauma are perianal scars and lacerations deep to the external anal sphincter.17,34,43 Again, studies suggest that positive anal findings are rare.43
Sexual abuse involving male victims occurs, but seems to occur at a slightly lower rate than that involving female victims.22,33,34 The reporting of male sexual abuse may be more likely to bring up social taboos and/or teasing from other children.22 Injuries to the male genitalia in sexual abuse do occur. They can include bite or pinch marks on the penis or scrotum or inner thighs near the genitalia.17,34 Injuries due to physical abuse also may be seen in the genitalia.44 These may be seen in children around toilet training age and include injuries to the penis or scrotum or immersion burns to the genitalia.45 They also can be seen in older children in the context of bullying, harassment, and gang attacks.44
In the majority of cases, the physical exam will not reveal any findings definitive for sexual contact.24,33,41,46 This can be because trauma to the genital area heals quickly and rarely leaves scars.47-49 This again emphasizes the importance of the child's history. In some cases, the child will have definitive findings for penetrating trauma without a history.9 This may occur due to the delayed disclosure that often occurs in child sexual abuse cases.
Specific Findings of Sexual Abuse
The history is of paramount importance in cases of suspected child abuse. In fact, one recent study suggested that more than 95% of medical examinations in cases of alleged sexual abuse show no definitive findings of sexual contact.50 This finding reiterates the need for good documentation of the child's history (if there is one) in his or her own words. Studies of healing show that acute injuries from trauma resolve quickly.48,49,51
Findings that can be considered definitive for child sexual abuse include pregnancy or sperm found in or on the child's body.17,33 Findings that can be considered clear evidence of penetrating or blunt force trauma include an area of absence of hymenal tissue on the posterior rim between 3 o'clock and 9 o'clock, a complete hymenal transection, bruising on the hymen, or an acute laceration of the hymen.11,17,24,52 The history, in addition to the physical findings, can help differentiate between child sexual abuse and accidental or other injury.19,24,33,53 (See Table 2.)
Forensic Evidence Kits
When collecting forensic evidence, sexual assault kits may be modified for prepubertal children.9,12 Chain of evidence must be maintained. Hospitals often have protocols in place for collection of such evidence.9 Again, good documentation is essential. Many states have kits available for collection of such forensic evidence. One study showed that swabs from the body of prepubertal children were not necessary after 24 hours post assault.12 Two more recent studies have shown that in rare instances, swabs from prepubertal children may have DNA identified. However, both studies also noted that clothing and linens were more likely to have DNA identified if submitted for examination.15,16 Law enforcement sometimes needs to be reminded to collect bedding and clothing, as these often yield the majority of forensic evidence.12,15,16 Some hospitals have sexual assault nurse examiners (SANEs) or forensic nurse examiners (FNEs) available to help with forensic evidence collection.54 A smaller subset of hospitals have SANEs or FNEs with adequate pediatric knowledge and training in collection of forensic evidence in child sexual abuse cases.
Sexually Transmitted Infections
STIs are a rare sequela of child sexual abuse.53,55,56 The clinician who evaluates children or adolescents for suspected sexual abuse should always consider testing for the presence of sexually transmitted organisms. The extent to which a child or adolescent victim of suspected sexual abuse should be evaluated for sexually transmitted organisms should be individualized and based on the circumstances of the abuse, the child's age, the presence of symptoms, the prevalence of an STI in a community, and any information available on the medical conditions and risk status of the perpetrator. If the sexual abuse has resulted in infection, this must be identified and treated. Additionally, the presence of sexually transmitted organisms may be an important piece of medicolegal evidence indicating the need for further investigation and protection of the child.
The following recommendation for scheduling examinations is a general guide.53,57 The exact timing and nature of follow-up contacts should be determined on an individual basis and should be considerate of the child's psychological and social needs. Compliance with follow-up appointments may be improved when law enforcement personnel or a child protective services agency is involved.
Prepubertal Children
During the initial examination and two-week follow-up examination (if indicated), the following should be performed:
All Children
Visual inspection of the genital, perianal, and oral areas for genital warts and ulcerative lesions (selected children if history or examination indicates presence of an STI).
Cultures for Neisseria gonorrhoeae specimens collected from the pharynx and anus in both boys and girls, the vagina in girls, and the urethra in boys. Cervical specimens are not recommended for prepubertal girls. For boys, a meatal specimen of urethral discharge is an adequate substitute for an intraurethral swab specimen when discharge is present.
Cultures for Chlamydia trachomatis from specimens collected from the anus in both boys and girls and from the vagina in girls. Limited information suggests that the likelihood of recovering Chlamydia from the urethra of prepubertal boys is too low to justify the trauma involved in obtaining an intraurethral specimen. A urethral specimen should be obtained if urethral discharge is present. Pharyngeal specimens for C. trachomatis also are not recommended for either sex because the yield is low, perinatally acquired infection may persist beyond infancy, and culture systems in some laboratories do not distinguish between C. trachomatis and C. pneumoniae.
If chlamydial and gonorrhea cultures are not available, nonculture tests, particularly the nucleic acid amplification tests (NAATs), are an acceptable substitute. Nucleic acid amplification tests offer advantages of increased sensitivity if confirmation is available. If a nonculture test is used, a positive test result should be verified with a second test based on a different diagnostic principle. EIA and direct fluorescent antibody are not acceptable alternatives because false-negative test results occur more often with these nonculture tests, and false-positive test results may occur. If needed in court, the examiner should be able to explain what test was done and why the result is valid. This is important due to the serious consequences in cases of child sexual abuse. While culture has been considered the "gold standard," NAATs, when done properly and verified as above, can and have been used in court.
Wet mount and/or culture of a vaginal swab specimen for Trichomonas vaginalis infection. The presence of clue cells in the wet mount or other signs, such as a positive whiff test, suggests bacterial vaginosis in girls who have vaginal discharge.
Collection of a serum sample to be evaluated immediately, preserved for subsequent analysis, and used as a baseline for comparison with follow-up serologic tests. Sera should be tested immediately for antibodies to sexually transmitted agents. Agents for which suitable tests are available include Treponema pallidum, HIV, and hepatitis B and C. The choice of agents for serologic tests should be made on a case-by-case basis. Vaccination for the hepatitis B virus (HBV) should be recommended if the medical history or serologic testing suggests that it has not been received or immunity has waned.
An examination approximately 12 weeks after the last suspected sexual exposure is recommended to allow time for antibodies to infectious agents to develop if baseline tests are negative. Serologic tests for T. pallidum, HIV, and HBsAg should be considered. The prevalence of these infections differs substantially by community, and serologic testing depends on whether risk factors are known to be present in the abuser or assailant. In addition, results of HBsAg testing must be interpreted carefully, because HBV also can be transmitted nonsexually. The choice of tests must be made on an individual basis.
The risk for a child's acquiring an STI as a result of sexual abuse has not been determined. It is believed to be low in most circumstances, although documentation to support this position is inadequate.
Presumptive treatment for children who have been sexually assaulted or abused is not widely recommended because preadolescent girls appear to be at lower risk for ascending infection than do adolescent or adult women, and regular follow-up usually can be ensured. However, some children or their parent(s) or guardian(s) may be concerned about the possibility of infection with an STI, even if the risk is perceived by the health care provider to be low. Patient or parental/guardian concerns may be an appropriate indication for presumptive treatment in some settings (e.g., after all specimens relevant to the investigation have been collected). Typically, prepubertal children are not routinely given prophylaxis for STIs at acute examination because follow-up after incubation period allows for appropriate specimens to be collected. However, otherwise sexually active adolescents may benefit from STI prophylaxis, as the prevalence of STIs in this population is higher than that in preadolescent children.
Many sexually transmitted infections also can be transmitted vertically from infected mother to child. These include HIV, gonorrhea, Chlamydia, herpes, human papilloma virus, and others.56,58 In child sexual abuse, cultures for gonorrhea and Chlamydia still are considered the legal "gold standard" even with ligase chain reaction (LCR) and polymerase chain reaction (PCR) testing available.55,56
Diagnosis of gonorrhea, syphilis, HIV, or Chlamydia if other modes of transmission have been excluded (i.e., perinatal or related to blood transfusion) is diagnostic of sexual abuse until proven otherwise.9
Adolescents. An initial examination should include the following procedures:57
Nucleic Acid Amplification Test (NAAT) for N. gonorrhoeae and C. trachomatis.
Cultures for N. gonorrhoeae can be collected from oropharynx and rectal area if patient reports penetration or attempted penetration of these sites.
Culture for C. trachomatis can be collected from rectal area if patient reports penetration or attempted penetration of this area.
Wet mount and/or culture of a vaginal swab specimen for Trichomonas vaginalis infection. If vaginal discharge or malodor is evident, the wet mount also should be examined for evidence of bacterial vaginosis and yeast infection.
Collection of a serum sample for immediate evaluation for HIV, hepatitis B, and syphilis.
Although it is often difficult for people to comply with follow-up examinations weeks after an assault, such examinations are essential to: detect new infections acquired during or after the assault; complete hepatitis B immunization, if indicated; and complete counseling and treatment for other STIs. For these reasons, it is recommended that assault victims be reevaluated at follow-up examinations. This also allows for the incubation period to pass for some sexually transmitted infections, which then allows specimen collection.
Examination for STIs should be repeated two weeks after the assault. Because infectious agents acquired through assault may not have produced sufficient concentrations of organisms to result in positive test results at the initial examination, NAAT, culture (or cultures), wet mount, and other tests should be repeated at the two-week follow-up visit unless prophylactic treatment has already been provided. Serologic tests for syphilis and HIV infection should be repeated 6, 12, and 24 weeks after the assault if initial test results were negative.
Some experts recommend routine preventive therapy for adolescents after a sexual assault. Most patients probably benefit from prophylaxis because follow-up of patients who have been sexually assaulted can be difficult, and they may be reassured if offered treatment or prophylaxis for possible infection. The following prophylactic regimen is suggested as preventive therapy:53
Postexposure hepatitis B vaccination (without HBIG) should adequately protect against HBV. Hepatitis B vaccine should be administered to victims of sexual assault at the time of the initial examination. Follow-up doses of vaccine should be administered from 1-2 months and from 4-6 months after the first dose.
An empiric antimicrobial regimen for Chlamydia, gonorrhea, trichomoniasis, and bacterial vaginosis should be administered.
The examining physician should not forget to test girls who have had menarche for pregnancy. The use of pregnancy prophylaxis may be discussed with the child or adolescent and her parents or caretakers (if appropriate).9
One cautionary note about T. vaginalis infections: T. vaginalis can be diagnosed only by wet prep or culture (if available). Occasionally a urine specimen from a child shows "Trichomonas" and this leads to suspicion of child sexual abuse. Trichomonas hominis lives in the gastrointestinal tract and can be found on urine specimens. T. hominis is not indicative of sexual abuse. Only positive wet preps or cultures can diagnose trichomoniasis relevant to child sexual abuse.
The examiner should also remember that all infections in the genital area are not sexually transmitted. It is possible to have non-sexually transmitted bacterial vaginosis and other infections that can be clinically important.
Vaginal Discharge
Vaginal discharge is a common complaint that can raise suspicion of child sexual abuse and may be a presenting symptom. However, there are many other etiologies of vaginal discharge. (See Table 2.)
Shigella infection can cause a bloody vaginal discharge. Foreign bodies also may cause a discharge. A common foreign body is a small piece of toilet tissue that migrates up into the vagina. To help differentiate abuse from other causes, the child needs a good physical exam and laboratory studies as indicated. These could include genital cultures for gonorrhea and Chlamydia, in addition to a routine culture and wet prep (in girls). Candida albicans or yeast can also cause some discharge in the vaginal area.
Children with Special Needs
Specifically looking at child sexual abuse, the incidence for children with special needs was 3.5 per 1000 children, compared with an incidence rate of 2.1 per 1000 for all children and an incidence of 2.0 per 1000 for children without special needs. Using a nationally representative sample of children, this study validated what had long been a clinical observation that children with disabilities were at increased risk for child abuse and neglect, and sexual abuse in particular.3 A number of reasons have been identified that may explain why children with a variety of developmental disabilities may be at increased risk for sexual maltreatment: cognitive impairments and limited capacity for judgment that may place the child with special needs in situations that have a high risk of inappropriate sexual activities; limited language and verbal abilities that may make disclosure more difficult; the likelihood of multiple caregivers throughout the day between home, school, health care setting, and transportation required to get to these settings; the possibility of residing in an institutional setting; a high degree of dependency around typically private behaviors, such as bathing and toileting; and physical impairments that may prevent escape from sexually inappropriate situations.3 Performing the medical evaluation of children with special needs presents a number of unique challenges to the health care provider related to both the interview and the physical examination that require extra attention and additional training.
Conclusion
Child sexual abuse cases will present to physicians who care for children. It is important to remember to approach the case knowing that the history is the most important factor in determining if sexual abuse has likely occurred. Physical findings indicative of abuse are rare, but when present can aid in the protection of children and prosecution of cases. The child's developmental level should be considered when interviewing him or her about symptoms and potential disclosure. Thorough documentation of the history and physical examination is of paramount importance in these cases.
References
1. U.S. Department of Health and Human Services. Child Maltreatment 2002: Reports from the States to the National Child Abuse and Neglect Date System. Washington: U.S. Government Printing Office; 2004.
2. Johnson C. Child sexual abuse. Lancet 2004;364:462-470.
3. Finkel MA. The evaluation. In: Finkel MA, Giardino AP, Eds. Medical Evaluation of Child Sexual Abuse. Elk Grove Village; American Academy of Pediatrics; 2009: 19-36.
4. Giardino AP. The problem. In: Finkel MA, Giardino AP, Eds. Medical Evaluation of Child Sexual Abuse. Elk Grove Village; American Academy of Pediatrics;2009: 1-28.
5. Kechavarz R, Kawashima R, Low C. Child abuse and neglect presentations to a pediatric emergency department. J Emerg Med 2002;23:341-345.
6. Adams J. Medical evaluation of suspected child sexual abuse. J Pediatr Adolesc Gynecol 2004;17:191-197.
7. Sgroi SM, Blick LC, Porter FS. A conceptual framework for child sexual abuse. In: Sgroi SM(ed). Handbook of Clinical Intervention in Child Sexual Abuse. Lexington Books;Lexington, MA;1982: 9-37.
8. American Academy of Pediatrics, Committee on Adolescence. Care of the adolescent sexual assault victim. Pediatrics 2001;107:1476-1479.
9. American Academy of Pediatrics, Committee on Child Abuse and Neglect. Guidelines for the evaluation of sexual abuse in children: Subject review. Pediatrics 1999;103:186-191.
10. Felitti VJ, Anda RF, Nordenberg P, et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) study. Am J Prev Med 1998;14:245-258.
11. Adams J. Sexual abuse and adolescents. Pediatr Ann 1997;26:299-304.
12. Christian C, Lavelle J, DeJong AR, et. al. Forensic evidence findings in prepubertal victims of sexual assault. Pediatrics 2000;106:100-104.
13. Botash A. Examination for sexual abuse in prepubertal children: An update. Pediatr Ann 1997;26:312-320.
14. Christian CW. Timing of the Medical Examination. J Child Sexual Abuse 2011;20:505-520.
15. Thackeray JD, Hornor G, Benzinger EA, et al. Forensic evidence collection and DNA identification in acute child sexual assault. Pediatrics 2011;128:227-232.
16. Girardet R, Bolton K, Lahoti S, et al. Collection of forensic evidence from pediatric victims of sexual assault. Pediatrics 2011;128:233-238.
17. Adams J. In: Training: Medical evaluation of suspected child sexual abuse. J Pediatr Adolesc Gynecol 2004;17:191-197.
18. Atabake S, Paradise J. The medical evaluation of the sexually abused child: Lessons from a decade of research. Pediatrics 1999;104:178-186.
19. Fortin K, Jenny C. Sexual abuse. Pediatrics Rev 2012;33:19-32.
20. Jain A. Emergency department evaluation of child abuse. Emerg Med Clin North Amer 1999;17:575-593.
21. Robinson AJ. Sexually transmitted organisms in children and child sexual abuse. Internat J STDs AIDS 1998;9:501-511.
22. Gray-Eurom K, Seaberg DC, Wears RL. The prosecution of sexual assault cases: Correlation with forensic evidence. Ann Emerg Med 2002;39:39-46.
23. Muram D, Levitt CJ, Frasier LD, et al. Genital injuries. J Pediatr Adolesc Gynecol 2003;16:149-155.
24. Berkoff MC, Zolotor AJ, Makoroff KL, et al. Has this prepubertal girl been sexually abused? JAMA 2008;300(23):
2779-2792.
25. McCauley J, Gorman R, Guzinski G. Toluidine blue in the detection of perineal lacerations in pediatric and adolescent sexual abuse victims. Pediatrics 1986;78:1039-1043.
26. Jones J, Dunnuck C, Rossman L, et al. Significance of toluidine blue positive findings after speculum examination for sexual assault. Am J Emerg Med 2004;22:201-203.
27. Bays J, Lewman L. Toluidine blue in the detection at autopsy of perineal and anal lacerations in victims of sexual abuse. Arch Pathol Lab Med 1992;116:620-621.
28. Hobbs CJ, Wynne JM, Thomas AJ. Colposcopic genital findings in prepubertal girls assessed for sexual abuse. Arch Dis Childhood 1995;73:465-471.
29. Muram D, Elias S. Child sexual abuse – Genital tract findings in prepubertal girls II. Comparison of colposcopic and unaided examinations. Amer J Obstet Gynecol 1989;160:333-335.
30. Boos S, Rosas AJ, Boyle C, et al. Anogenital injuries in child pedestrians run over by low-speed motor vehicles: Four cases with findings that mimic child sexual abuse. Pediatrics 2003;112:
e77-e84.
31. Herrmann B, Crawford J. Genital injuries in prepubertal girls from inline skating accidents. Pediatrics 2002;110:e16.
32. Dowd MD, Fitzmaurice L, Knapp JF, et al. The interpretation of urogenital findings in children with straddle injuries. J Pediatric Surgery 1994;29(1):7-10.
33. Bays J, Chadwick D. Medical diagnosis of the sexually abused child. Child Abuse Negl 1993;17:91-110.
34. Adams J. Evolution of a classification scale: Medical evaluation of suspected child sexual abuse. Child Maltreat 2001;6:31-36.
35. Makoroff K, Brauley JL, Brandner AM, et al. Genital examination for alleged sexual abuse of prepubertal girls: Findings by pediatric emergency medicine physicians compared with child abuse trained physicians. Child Abuse Negl 2002;26:
1235-1242.
36. Heger AH, Ticson L, Guerra L, et al. Appearance of the genitalia in girls selected for nonabuse: Review of hymenal morphology and nonspecific findings. J Pediatr Adolesc Gynecol 2002;15:27-35.
37. Berenson A, Heger A, Andrews S, et al. Appearance of the hymen in newborns. Pediatrics 1991;87:458-465.
38. Berenson A. Appearance of the hymen at birth and one year of age: A longitudinal study. Pediatrics 1993;91:820-825.
39. Berenson A. A longitudinal study of hymenal morphology in the first 3 years of life. Pediatrics 1995;95:490-496.
40. Berenson A, Grady J. A longitudinal study of hymenal development from 3 to 9 years of age. J Pediatrics 2002;140:
600-607.
41. Berenson AB, Heger AH, Hayes JM, et al. Appearance of the hymen in prepubertal girls. Pediatrics 1992;89:387-394.
42. Berenson A. Normal anogenital anatomy. Child Abuse Negl 1998;22:589-596.
43. Adams J, Harper K, Knudson S, et al. Examination findings in legally confirmed child sexual abuse: It's normal to be normal. Pediatrics 1994;94:310-317.
44. Finkelhor D, Wolak J. Nonsexual assaults to the genitals in the youth population. JAMA 1995;274:1692-1697.
45. Feldman K. Inflicted penile incision injuries [letter, comment]. Child Abuse Negl 1997;21:253-254.
46. Muram D. Child sexual abuse: Relationship between sexual acts and genital findings. Child Abuse Negl 1989;13:211-216.
47. Heppenstall-Heger A, McConnell G, Ticson L, et al. Healing patterns in anogenital injuries: A longitudinal study of injuries associated with sexual abuse, accidental injuries, or genital surgery in the preadolescent child. Pediatrics 2003;112:829-837.
48. McCann J, Miyamoto S, Boyle C, et al. Healing of hymenal injuries in prepubertal and adolescent girls: A descriptive study. Pediatrics 2007;119:e1094-e1106.
49. McCann J, Miyamoto S, Boyle C, et al. Healing of nonhymenal genital injuries in prepubertal and adolescent girls: A descriptive study. Pediatrics 2007;120:1000-1011.
50. Heger A, Ticson L, Velasquezo Bernier R. Children referred for possible sexual abuse: Medical findings in 2384 children. Child Abuse Negl 2002;26:645-659.
51. McCann J, Voris J, Simon M. Genital injuries resulting from sexual abuse: A longitudinal study. Pediatrics 1992;
89:307-317.
52. Berenson A, Chacko MR, Wiemann CM, et al. A case-control study of anatomic changes resulting from sexual abuse. Am J Obstetr Gynecol 2000;182:820-834.
53. Stewart DC. Sexually transmitted infections in child and adolescent sexual assault and abuse. In: Finkel MA, Giardino AP (eds). Medical Evaluation of Sexual Abuse A Practical Guide. 3rd edition. Elk Grove Village, Illinois; American Academy of Pediatrics; 2009: 147-169.
54. Green W, Panacek E. Sexual assault examinations in evolution. J Emerg Med 2003:25:97-99.
55. Kellogg N, Baillargeon J, Lukefahr JL, et al. Comparison of nucleic acid amplification tests and culture techniques in the detection of Neisseria gonorrhoeae and Chlamydia trachomatis in victims of suspected child sexual abuse. J Pediatr Adolesc Gynecol 2004;17:331-339.
56. Robinson AJ, Watkeys JEM, Ridgway GL. Sexually transmitted organisms in sexually abused children. Arch Dis Childhood 1998;79:356-358.
57. Centers for Disease Control and Prevention. Sexually Transmitted Diseases Treatment Guidelines 2010. MMWR 2010;59(RR-12):90-95.
58. Robinson AJ. Sexually transmitted organisms in children and child sexual abuse. Internat J STD AIDS 1998;9:501-511.
Child abuse is not uncommon and frequently presents to the emergency department (ED). Sometimes the presentation is subtle and masked by vague histories and nonspecific physical findings. Considering sexual abuse in the differential diagnosis is important for the child and his or her safety. Understanding techniques for obtaining a directed history and recognizing the physical findings and abnormalities that are associated with abuse will enable the physician to complete a thorough evaluation and to document with confidence. High-risk populations, such as children with special needs, present unique challenges to the clinician. This article reviews the history, physical examination, diagnostic evaluation, and reporting expectations for children with suspected sexual abuse.Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.