Strange and Schafermeyer's Pediatric Emergency Medicine, Fourth Edition (Strange, Pediatric Emergency Medicine), 4th Ed.

CHAPTER 143. Sexual Abuse

Sara L. Beers

HIGH-YIELD FACTS

• Most sexual abuse examinations in children are normal even with known sexual abuse.

• The history is usually the most important piece of evidence in cases of suspected sexual abuse in children.

• All 50 states require reporting suspected child abuse including sexual abuse to a proper investigatory agency (child protective services and/or law enforcement).

• Sexually transmitted diseases (STDs) are extremely rare in cases of pediatric sexual abuse.

• Screening for and empiric treatment of STDs is not routinely recommended in cases of pediatric sexual abuse.

• Forensic evaluation is recommended by the American Academy of Pediatrics (AAP) when the abuse occurred within the previous 72 hours.

• Speculum examinations are not indicated in preadolescent female sexual abuse patients. A thorough external genital examination is sufficient.

ETIOLOGY

The National Center on Child Abuse and Neglect defines child sexual abuse as “contact or interaction between a child and an adult when a child is being used for the sexual stimulation of that adult or another person.” Child sexual abuse includes fondling the child’s genitals, getting the child to fondle an adult’s genitals, mouth to genital contact, rubbing an adult’s genitals on the child, or actually penetrating the child’s vagina or anus. Showing an adult’s genitals to a child, showing the child pornographic material, or using the child as a model to make pornographic material are also forms of child sexual abuse.

Sexual abuse of children is a very real problem in our society. Children are most often abused by adults or older children who are known to them and who can exert power over them. The victim knows the offender in 8 out of 10 reported cases.1 The offender is more frequently male.2 The offender is frequently someone that the child trusts and will often persuade the child with bribes, tricks, or coercion to engage in sex or sexual acts. This can be followed by threats to the child if he or she tells.

Increased risk for sexual abuse of children is not related to socioeconomic status or race.3

EPIDEMIOLOGY

Sexual abuse affects approximately 100,000 children each year in the United States.4 Most abuse goes unreported during childhood. However, it is estimated that 20% of girls and 9% of boys are the victims of sexual abuse during childhood.1,3 Children of all ages are the victims of sexual abuse, but are most likely to be abused sexually during preadolescence, that is, from ages 8 to 12 years.3

PATHOGENESIS

The vast majority of children who are the victims of sexual abuse will have normal examinations without findings of injury. Studies have found that both normal-appearing genital tissues and nonspecific findings are seen in children known to be sexually abused.57 Kellogg et al. found that of 36 adolescents who were pregnant at the time of or shortly before a sexual abuse examination, 22 (62%) had normal or nonspecific examination findings. Only 2 of these 36 girls (6%) had definitive findings consistent with penetration.8

There are many factors that contribute to the majority of examinations being normal even in the face of proven sexual abuse. Most sexual abuse of children occurs without the use of physical force and restraint. The perpetrator generally has no intent of harming the child physically because of a desire to reengage the child in the activities over time. In addition, studies of the healing process of the anogenital area consistently report that most injuries resulting from sexual abuse heal relatively quickly.812 McCann et al. found that the healing of nonhymenal genital injuries in girls was as short as 24 hours for petechia, 2 days for bruising, 3 days for abrasions, and 5 days for edema.12 With frequent delays in disclosure of sexual abuse, injuries that may have been present at the time of the abuse will often have healed by the time the child undergoes a physical examination. Further, genital tissues are mucosal tissues that are elastic in nature, well vascularized, and heal quickly without scarring, making the tissues less prone to permanent tissue injury. This point is particularly pertinent to girls who are undergoing pubertal changes with the presence of estrogen that creates thicker and more redundant tissues, particularly thicker and more redundant hymenal tissue. Also of note, the anus can enlarge to large diameters to pass bowel movements and therefore injuries to the anus from penetrating abuse are infrequent.13

When a child does have physical injuries from sexual abuse, the findings can involve the genitalia, anus, oral cavity, extragenital sites, or any combination of the above. These injuries might include superficial abrasions, bruises, tearing of the hymen, or deeper genital injury. In prepubertal girls, the most common genital injuries include superficial abrasions of the inner aspects of the labia minora, the periurethral area, and the posterior fourchette.13 If an object such as a finger or penis has penetrated through the hymenal orifice, an interruption of the integrity of the hymenal edge may occur. If the hymenal tissue is thought of as the face of a clock (with the child in the supine position), the findings of the hymenal tissue from 3- to 9-o’clock positions are particularly noteworthy when assessing for injuries from abuse. Interruptions, lacerations, or injuries to the hymenal tissue may extend into the vagina or through the fossa navicularis, and in cases of extreme blunt force trauma, may extend onto the perineum.

Accidental straddle injuries on playground equipment, toys, furniture, etc., often result in physical injuries. The key in discerning such injuries from sexual abuse is that straddle injuries typically include injury to the clitoris, clitoral hood, mons pubis, and labia. Also important to note is that straddle injuries are usually asymmetric and do not involve the hymen.3 Conversely, the posterior fourchette, fossa navicularis, and posterior hymen are the structures/areas that are injured with penetrating traumatic events.3

Table 143-1 summarizes the guidelines and approach to interpreting physical and laboratory findings in suspected child abuse developed by a group of physician experts who met at child abuse conferences yearly between 2002 and 2005 and was published by Joyce Adams, MD, et al. in the Journal of Pediatric and Adolescent Gynecology in 2007. Figures 143-1 to 143-7 illustrate a variety of physical examination findings ranging from normal variants to findings diagnostic of trauma.

TABLE 143-1

Approach to Interpreting Physical and Laboratory Findings in Suspected Child Sexual Abuse

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FIGURE 143-1. Cleft at 7-o’clock position with child in prone knee–chest position; indeterminate finding.

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FIGURE 143-2. Septate hymen; congenital variant.

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FIGURE 143-3. Healed hymenal transection at 6-o’clock position; diagnostic of trauma.

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FIGURE 143-4. Same child as in Figure 143-5 in the prone knee–chest position.

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FIGURE 143-5. Periurethral bands and annular hymen; normal variant.

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FIGURE 143-6. Crescentic hymen; normal varian.

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FIGURE 143-7. Normal anatomy with labels.

RECOGNITION

Most of the time, when there is a concern of sexual abuse of a child presenting to a medical provider, the concern arises when a child discloses the abuse to an adult or a peer. Alternatively, the concern of sexual abuse arises when a parent or caregiver is concerned by an abnormal appearance of a child’s anus or genitals, injury to a child’s anus or genitals, or concern of bleeding or discharge from a child’s anus or genitals. Behavior changes in a child may also alert a guardian or other caregiver of possible sexual abuse of a child. These may include sexual acting out behaviors, sleep disturbances, nightmares, enuresis and encopresis in previously potty-trained children, eating disturbances, and/or tantrums. Any child or adolescent with a sexually transmitted disease (STD) should be evaluated for sexual abuse 14

Much like physical abuse, sexual abuse must be included on the differential diagnosis of emergency medicine physicians and primary care providers who treat children. It is important to remember that sexual abuse of children crosses all socioeconomic statuses and ethnicities. Sexual abuse may present with a variety of symptoms ranging from anogenital pain, itching, bleeding or discharge, abdominal pain, dysuria, constipation, and/or painful defecation.

To recognize abnormal genital findings on physical examination, medical providers must be able to recognize normal genital examinations. Familiarity with normal genital anatomy is often an area of weakness of many physicians.15 In girls, it is important for the clinician to perform a detailed external genital examination noting the appearance of the genital structures including the labia majora, labia minora, urethral meatus, posterior fourchette, fossa navicularis, and the hymen (Fig. 143-7). The genital structures can have varied appearance based on the age and physical development of the patient. In both sexes, the examiner should externally visualize the anal opening, noting the anal folds and rectal tone.

Physician and medical providers who care for children must be able to identify other medical conditions in children that can mimic sexual abuse. These conditions often cause anogenital pruritus and/or irritation.16 The genital area can be more susceptible to chemical and mechanical trauma compared to other areas of the body. Various soaps, shampoos, and lotions may cause chemical irritation. Restrictive clothing may lead to mechanical trauma. Poor hygiene can lead to fecal contamination and cause pruritus. Pinworms and scabies can present as pruritus of the anogenital area. Atopic dermatitis is rarely limited to the anogenital region, but can be part of a generalized eruption. Vulvar lichen sclerosus et atrophicus (LS) presents as hypopigmented, atrophic cutaneous tissue symmetrically distributed in an hourglass pattern around the vagina and anus. Its etiology is unknown but more commonly affects prepubertal and postmenopausal woman. Seborrheic dermatitis, presenting with waxy yellowish scales on an erythematous base, can involve the folds of the vulva in diapered infants. Psoriasis of the vulva is not uncommon and presents as erythematous, well-marginated patches with a red hue covered by grayish scales. Perianal streptococcal dermatitis is a bright red, sharply demarcated tender rash that affects children between 6 months and 10 years of age. It often follows a group A beta-hemolytic streptococcal throat infection. Molluscum contagiosum is a benign viral skin infection characterized small, single, or multiple umbilicated papules that can be found in the anogenital area. Urethral prolapse often presents with vaginal bleeding and swelling and thus may be misdiagnosed as sexual abuse. Candidiasis is uncommon in healthy prepubertal girls, but can be associated with oral antibiotics, diabetes mellitus, and immunodeficiency. Peripubertal and pubertal girls can develop vaginal candidal infections that present with pruritus, inflammation, and a thick white discharge.

MANAGEMENT

The management of the child with suspected sexual abuse involves both medical management and legal management. All cases of suspected sexual abuse in children are required by law to be reported to child protective services (CPS) and law enforcement. Often a hospital’s social worker is involved and helps with reporting the suspected abuse to law enforcement and CPS. All children should have an immediate medical evaluation if the abuse was within the previous 72 hours or there is bleeding or concern of acute injury. Many communities have designated child sexual abuse teams utilizing specialized nurses, nurse practitioners, and/or physicians that can be a resource for these evaluations. Otherwise, if the child is safe and without symptoms, an appointment can be made at the next earliest convenience with the child’s regular health care provider. A delay in examination should be considered if it means the child will be seen by someone skilled in the field of pediatric sexual abuse.17 In 2006, the American Board of Pediatrics added Child Abuse as a subspecialty in pediatrics. This reflects the depth of knowledge and skills that should be brought to the overall evaluation of this complex entity.17

The emergency department evaluation should begin with an interview of the adult accompanying the child. This interview should take place away from the child. Key information to obtain includes why abuse is suspected, to whom did the child disclose to, what the child said, the type of contact the child described, the timing of the last possible abuse, behavior changes, medical concerns, who lives at home with the child, who cares for the child, and anything the adult has witnessed.

Next, the child should be interviewed. If possible, it is recommended that children with a developmental age of 3 or older should be interviewed alone.18 Children are not likely to disclose information if they believe it will be upsetting to their caretaker. In general, children are more comfortable talking if their caregiver is not in the room.19 The interview of the child should take place in a child-friendly area that is free of distraction. Ideally the interviewer should use open-ended non-leading questions. “W” words (who, what, where, when, and how) are recommended. However, “why” questions should be avoided because they may imply blame on the child. If a skilled social worker has already obtained a detailed history from the child, the physician’s interview can be abbreviated. Occasionally, further questioning of a child can be deleterious. The child may find repetitive questioning unpleasant or threatening, may infer that he or she is not believed, or may modify his or her history in response to repetitive questioning.3The history taken from the child is often the most important part of the overall evaluation. The importance of taking a good history from the child cannot be emphasized enough. The results of a study by Hansen et al. suggests that the child’s statement and not the physical findings were important for legal outcome.20 Great detail should be taken when documenting the history provided, with actual quotes from the child when possible. Upon finishing the interview, the child should be told that he or she did the right thing by telling.

Older children should be asked who they want to be in the room for the examination. This should be asked of the child without family members present. The examination should begin with a general physical examination. Prepubertal children should not have a speculum examination. A detailed external genital examination is sufficient. There are several examination techniques when performing a genital examination. Younger children may be more comfortable and cooperative if seated in a caregiver’s lap. Children 3 years of age and older usually tolerate being placed on an examination table.21 The two most common examination techniques are the supine frog-leg position (the child lies with legs in full abduction and feet in apposition) and the prone knee–chest position (the child kneels on hands and knees and then places his or her head and chest on the examination table). In female patients, utilization of the labial separation and labial traction techniques allows complete visualization of the vulvar structures. This is done by gently grasping the labia majora and pulling the labia outward (toward the examiner) and laterally. Any abnormal finding noted in the supine position should be verified in the knee–chest position because the change in positioning can alter the appearance of the hymenal edge.21 Male patients can be examined in supine or prone positions. An examination of the perianal area is important in both female and male patients. This can be done in either the supine or lateral decubitus positions. The presence of stool in the vault or traction on the anus can cause the anus to dilate. Anal dilation of more than 2 cm without stool in the vault (this can be determined with direct visualization or less commonly a digital examination) may be concerning for possible abuse. As with the history, physical examination findings must be carefully and thoroughly documented in the medical record. Photographic documentation is strongly encouraged, particularly if the examination findings are thought to be abnormal.

In cases with suspected intravaginal injuries or active bleeding without an obvious external source, the internal vaginal examination should be performed only on prepubescent patients using general anesthesia and often requires consultation with a general surgeon who has expertise in examining and treating children.22

The AAP recommends forensic evidence collection if the evaluation is within 72 hours of the sexual abuse.18 However, the yield from such evidence collection significantly drops off after 24 hours. In a study done by Christian et al., no swabs taken from a child’s body were positive for blood after 13 hours or sperm/semen after 9 hours.23 It is important that only medical providers who are experienced in the collection and preservation of forensic evidence perform a forensic evaluation. Part of a forensic evaluation requires that the child’s clothing be collected and placed in a paper bag. DNA evidence may come from clothing. Evidence must be collected and stored properly as it may be used as evidence in legal proceedings.

Universal screening for STDs is not necessary because the incidence of STDs among children who have been sexually abused is low. Approximately 5% of sexually abused children contract an STD from abuse.24 The Centers for Disease Control and Prevention (CDC) recommend testing for STDs in the following situations: when the child has had symptoms or signs of an STD, when a suspected assailant is known to have an STD or to be at high risk for STDs, when a sibling or another child or adult in the household or child’s immediate environment has an STD, when the patient or parent requests testing, or when evidence of genital, oral, or anal penetration or ejaculation is present.25 In nonacute evaluations, careful examinations without STD screening may be acceptable for asymptomatic, prepubertal children who lack clear history or physical examination findings indicative of penetrating sexual abuse.3

Enzyme-linked assays or DNA amplification tests, such as nucleic acid amplification tests (NAATs), for Chlamydia trachomatis and Neisseria gonorrhoeae can be utilized for noninvasive screening. NAATs have several advantages over culture, as noninvasive specimens can be used, they are more easily transported and processed, and they are highly sensitive and specific.26 However, the lack of sufficient clinical studies in prepubescent patients and the risk of false-positive test results limit the utility of these tests for forensic purposes. Routine bacterial and cell cultures remain the gold standard for diagnosis of bacterial STDs. Swabs taken from the external genitalia are sufficient in prepubertal female patients. In adolescent female patients with a history of rape, a speculum examination with cervical cultures is recommended. Again, while the only the minority of sexually abused children require STD screening, if cultures are warranted, cultures should also be taken from the throat and rectum. Blood tests for syphilis, HIV, hepatitis B and C should also be considered in high-risk cases.

Empiric treatment for STDs is usually not necessary. However, empiric treatment may be considered in cases of stranger assaults as well as in adolescent rape victims. Identified STDs should be treated with the appropriate regimens according to the published guidelines set by the CDC (see Chapter 88). Emergency contraception should be offered when female pubertal patients present within 72 hours of an assault that could result in pregnancy.27

Treatment should include a routine follow-up appointment/examination. In cases with positive examination findings, follow-up examination are helpful to assess healing of injuries. Follow-up appointments can also provide opportunity to assess the need for further screening for STDs, as some infections may not have had time to manifest symptoms at the time of initial assessment. Follow-up examinations by specialists affected the interpretation of trauma and detection of STDs in about 23% of pediatric patients undergoing sexual abuse patients in a retrospective study by Gavril et al.28 The follow-up with appointment can also ensure that the child and family are receiving any needed counseling services.

image ANCILLARY STUDIES

Colposcopy provides a noninvasive method for visualizing the anogenital structures. It provides magnification and a light source, both of which can be helpful in identifying injury. The colposcope also allows a video or still image to be recorded for documentation. Photodocumentation of the anogenital examination can provide a means for quality enhancement programs (peer review) and help limit unnecessary repeat examinations.

Alternative light sources can be used during forensic evidence collection to guide collection of possible body fluids on victims. Alternative light sources include the Blue Max 6000 or a Wood lamp. It is important to note though that material other than semen may also fluoresce with a Wood lamp.

REFERENCES

1. American Academy of Pediatrics. Child Abuse and Negl. 2000. http://www.aap.org. Accessed March 2008.

2. Kellog N; Committee on Child Abuse and Neglect. AAP Clinical Report. Pediatrics. 2005;116(2):506–512.

3. Hymel K, Jenny C. Child sexual abuse. Pediatr Rev. 1996;17(7):236–249.

4. U.S. Department of Health and Human Services. Natl Clgh Child Abuse Negl Inf. 2004. http://www.hhs.gov. Accessed March 2008.

5. Adams JA, Harper K, Knudson S, Revilla J. Examination findings in legally confirmed child sexual abuse: it’s normal to be normal. Pediatrics. 1994;94(3):310–317.

6. Heger A, Ticson L, Velasquez O, Bernier R. Children referred for possible sexual abuse: medical findings in 2384 children. Child Abuse Negl. 2002;26(6–7):645–659.

7. Botash AS. Examination for sexual abuse in prepubertal children: an update. Pediatr Ann. 1997;26(5):312–320.

8. Kellogg ND, Menard SW, Santos A. Genital anatomy in pregnant adolescents: “normal” does not mean “nothing happened.” Pediatrics. 2004;3(1):67–69.

9. McCann J, Voris J, Simon M. Genital injuries resulting from sexual abuse; a longitudinal study. Pediatrics. 1992;89(2):307–317.

10. Finkel MA. Anogenital trauma in sexually abused children. Pediatrics. 1989;84(2):317–322.

11. Herger AH, McConnell G, Ticson L, Guerra L, Lister J, Zaragoza T. Healing patterns in anogenital injuries associated with sexual abuse, accidental injuries, or genital surgery in the preadolescent child. Pediatrics. 2003;112(4):829–837.

12. McCann J, Miyamoto S, Boyle C, Rogers K. Healing of nonhymenal genital injuries in prepubertal and adolescent girls: a descriptive study. Pediatrics. 2007;20(5):1000–1011.

13. Giardino A, Finkel M. Evaluating child sexual abuse. Pediatr Ann. 2005;34(5):382–394.

14. Bechtel K. Sexual Abuse and Sexually transmitted infections in children and adolescents. Curr Opin Pediatr. 2010;22:94–99.

15. Lentsch KA, Johnson CF. Do physicians have adequate knowledge of child sexual abuse? The results of two surveys of practicing physicians, 1986 and 1996. Child Maltreatment. 2000;5:72–78.

16. Hornor G. Common conditions that mimic findings of sexual abuse. J Pediatr Health Care. 2009;23:283–288.

17. Alexander R. Medical advances in child sexual abuse. J Child Sex Abuse. 2011;20:481–485.

18. American Academy of Pediatrics Committee on Child Abuse and Neglect. Guidelines for the evaluation of sexual abuse of children: subject review. Pediatrics. 1999;103(1):186–191.

19. Alexander R. Conducting the medical history. J Child Sex Abuse. 2011;20:486–504.

20. Hansen L, Mikkelson S, Sabroe S, Charles AV. Medical findings and legal outcomes in sexually abused children. J Forens Sci. 2010:55(1):104–109.

21. Girardet R, Lahoti S, Parks D, McNeese M. Issues in pediatric sexual abuse-what we know and where we need to go. Curr Probl Pediatr Adolesc Health Care. 2002;32:211–246.

22. Adams J, Kaplan R, Starling S, et al. Guidelines for medical care of children who may have been sexually abused. J Pediatr Adolesc Gynecol. 2007;20:163–172.

23. Christian C, Lavelle J, De Jong A, Loiselle J, Brenner L, Joffe M. Forensic evidence findings in prepubertal victims of sexual assault. Pediatrics. 2000;106(1):100–107.

24. Kellogg N. Committee on Child Abuse and Neglect, American Academy of Pediatrics. Clinical report-the evaluation of sexual behaviors in children. Pediatrics. 2009:124(3):992–998.

25. Centers for Disease Control and Prevention. Sexually Transmitted Diseases Treatment Guidelines 2006. Atlanta, GA: Centers for Disease Control and Prevention. Department of Health and Human Services. 2006. http://www.cdc.gov/std/treatment/2006/sexual-assualt.htm. Accessed March 2008.

26. Esernio-Jenssen D, Barnes M. Nucleic acid amplification testing in suspected child sexual abuse. Journal of Child Sexual Abuse. 2011;20:612–621.

27. Fortin K, Jenny C. Sexual abuse. Pediatrics in Review. 2012:33(1):19–32.

28. Gavril A, Kellogg N, Nair P. Value of follow-up examinations of children and adolescents evaluated for sexual abuse and assault. Pediatrics. 2012:129(2):282–289.