AUTHOR AND EDITOR INFORMATION

Section 1 of 9  

• Authors and Editors
• Introduction
• Clinical
• Workup
• Treatment
• Follow-up
• Miscellaneous
• Multimedia
• References

INTRODUCTION

Section 2 of 9  

• Authors and Editors
• Introduction
• Clinical
• Workup
• Treatment
• Follow-up
• Miscellaneous
• Multimedia
• References

Background

Child sexual abuse (CSA) refers to the use of children in sexual activities when, because of their immaturity and developmental level, they cannot understand or give informed consent. A wide range of activities is included in sexual abuse, including contact and noncontact activities. Contact activities included are sexualized kissing, fondling, masturbation, and digital and/or object penetration of the vagina and/or anus, as well as oral-genital, genital-genital, and anal-genital contact. Noncontact activities include exhibitionism, inappropriate observation of child (eg, while the child is dressing, using the toilet, bathing), the production or viewing of pornography, or involvement of children in prostitution. The sexual activities are imposed on the child and represent an abuse of the caregiver's power over the child. The sequence of activities often progresses from noncontact to contact over a period of time during which the child's trust in the caregiver is misused and betrayed.

Since the mid-1970s, health care professionals have paid serious attention to sexual abuse of children. Despite the recognition of the clinical importance of sexual abuse of children, some pediatricians may not feel prepared adequately to perform medical evaluations. However, pediatricians often are in trusted relationships with patients and families and are in an ideal position to offer essential support to the child and family. Thus, pediatricians need to be knowledgeable about available community resources, such as consultants and referral centers for the evaluation and treatment of sexual maltreatment. Several paradigms have been proposed to help professionals understand the events that surround the sexual maltreatment of children.

Preconditions for sexual abuse (Finkelhor, 1984)

• Motivation of perpetrator: The perpetrator is willing to act on impulses associated with sexual arousal related to children.
• Overcoming internal inhibitions: The perpetrator ignores internal barriers against sexually abusing children.
• Overcoming external inhibitions: The perpetrator is able to bypass the typical barriers in the caregiving environment that normally serve to impede the sexual misuse of children.
• Overcoming child resistance: The perpetrator is able to manipulate the child to the point of involving the child in the sexual activity. Manipulation often involves either implicit or explicit coercion to ensure that the child keeps the inappropriate activities a secret.

Longitudinal progression of sexual abuse (Sgroi, 1982)

• Engagement: The perpetrator begins relating to the child during nonsexual activities to gain the child's trust and confidence.
• Sexual interaction: The perpetrator introduces sexual activities into the relationship with the child; the perpetrator often begins with noncontact types of activities and, over time, progresses to more invasive forms of contact activities.
• Secrecy: The perpetrator attempts to maintain access to the child and to avoid disclosure of the abuse by coercing the child to keep the activities hidden. Coercion to keep the secret can be explicit (eg, threatening the child or the child's family's safety) or it can be implicit (eg, manipulation of the child's trust to create a fear of losing the "friendship" or "attention" should the truth become known to others).
• Disclosure: Sexual abuse can become known to others either accidentally, when a symptom from the maltreatment or a third party witnessing the abuse leads to an evaluation, or it can be purposeful, as when the child reveals the abuse that is taking place and seeks help.
• Suppression: The tumult that occurs after the disclosure prompts the people in the child's caregiving environment to think that they are unable to support the child; thus, these people exert pressure on the child to recant what the child has told in order to go back to the perceived "stable" situation that existed prior to the disclosure.

Child sexual abuse accommodation syndrome (Summit, 1983)

• Secrecy: The perpetrator coerces the child, either implicitly or explicitly, to keep the sexual abuse a secret.
• Helplessness: Because the perpetrator often is a trusted family member or adult, the child becomes confused and is unable to seek help from others in his or her environment.
• Entrapment and accommodation: The child's helplessness and the lack of support experienced from the caregiving environment contributes to the child feeling trapped; the child begins to accommodate to the reality of the abusive situation because the child begins to believe that no one would believe him or her even if the child did tell.
• Unconvincing disclosure: The child eventually discloses in a delayed and often conflicted manner, which focuses a significant amount of distress upon the child.
• Retraction: The child's caregiving environment is neither able to offer support nor able to prioritize the protection of the child; therefore, pressure mounts on the child to revert to the helpless and entrapped status that predated the disclosure, and he or she retracts the disclosure. This serves only to confirm the child's worst fear that no one would believe him or her if the child tells about the abuse. The child who is abused learns that protection is not going to occur in the caregiving environment; this belief is only supported by the child's feelings of guilt and low self-esteem.

Sexual abuse typically presents as a pattern of maltreatment that occurs over time. Children or their families usually know the perpetrators, because they usually are either relatives or acquaintances.

Traumagenic dynamics model (Finkelhor, 1985)

• Traumatic sexualization: The child's sexual feelings and attitudes are shaped in a developmentally inappropriate and interpersonally dysfunctional manner. The child learns that sexual behavior may lead to rewards, attention, or privileges. Traumatic sexualization may also occur when the child's sexual anatomy is given distorted importance and meaning.
• Betrayal: The child learns that a trusted individual has caused him or her harm, misrepresented moral standards, or failed to protect him or her properly.
• Powerlessness: This is a process of disempowerment in which the child's sense of self-efficacy and will are consistently thwarted by the perpetrator's coercion and manipulation. The child manifests symptoms of fear, anxiety, and impaired coping.
• Stigmatization: The child's self-image incorporates negative connotations and is associated with words such as bad, awful, shameful, and guilty. This stigmatization is consistent with the "damaged goods" mentality originally described by Sgroi et al (1982), in which the child feels deviant and not as whole as he or she felt prior to the abuse.

Pathophysiology

The evaluation for suspected CSA may be complicated and often is not straightforward. Frequently, nonspecific behavioral changes are the presenting symptoms prompting an evaluation and leading the health care provider to consider CSA as a possible diagnosis. These nonspecific behaviors are not diagnostic of sexual maltreatment and may be observed in other situations as well. Nonspecific behavior changes that warrant consideration of the possibility of sexual abuse may include (1) sexualized behaviors, (2) phobias, (3) sleep disturbances, (4) poor school performance, (5) running away, (6) truancy, (7) aggressiveness, and (8) symptoms of depression.

When physical signs and symptoms are present, the best procedure is to generate an extensive differential diagnosis (DDx), progress through a careful workup to exclude the diagnostic options, and, eventually, arrive at a diagnosis. A number of medical conditions can mimic the possible findings in persons who have been sexually abused; these may be considered as primarily being in the category II nonspecific findings group as proposed in the Clinical section. An organized approach to the diagnostic process is most useful.

For the purposes of this discussion, the DDx for each of the following 4 genital findings known to be associated with CSA is discussed.

Genital bleeding

Identification of the source for the blood is necessary to exclude serious injury. Blood-tinged vaginal or urethral discharge initially may be confused with frank bleeding. DDx is as follows:

• Local factors, such as injury (either accidental or nonaccidental) and/or foreign body irritation
• Dermatologic conditions, such as lichen sclerosis and/or dermatitis (eg, atopic, contact, seborrhea)
• Infections, including sexually transmitted diseases (STDs), fungal infections, and/or nonspecific vulvovaginitis
• Endocrinologic causes, such as estrogen withdrawal as observed in the neonate and/or precocious puberty
• Neoplastic tissue, such as sarcoma botryoides
• Structural abnormalities, such as vulvar hemangioma

Vaginal discharge

Normal physiologic clear-white mucoid discharge (ie, leukorrhea) should be differentiated from pathologic discharges. DDx is as follows:

• Local irritation from abusive sexual contact, foreign body, chemical irritants, and restrictive clothing
• Infections, including STDs, fungal infections, nonspecific vulvovaginitis, group A streptococci, Staphylococcus aureus, Haemophilus influenzae, and Mycoplasma species
• Physiologic leukorrhea
• Structural abnormality, such as ectopic ureter, fistula, and draining pelvic abscess

Anogenital bruising

Bruising in the anogenital area most often represents some type of anogenital trauma, either accidental or abusive in origin. DDx is as follows:

• Local injury, including straddle injury, accidental impaling injury, accidental blunt trauma, and abusive injury
• Dermatologic conditions, such as mongolian spots, lichen sclerosis, and vascular nevi
• Systemic manifestations of other disorders, such as bleeding diathesis and vasculitis

Anogenital redness

This finding typically represents the result of inflammation. DDx is as follows:

• Local irritation from sexual abuse, poor hygiene, restrictive clothing, and chemicals
• Anatomic/structural factors such as perianal fissuring and rectal prolapse
• Dermatologic conditions, such as lichen sclerosus, psoriasis, and dermatitis (atopic, contact, seborrhea)
• Infections, such as STDs, nonspecific vulvovaginitis, pinworm, scabies, fungal infections with Candida species, and perianal cellulitis or warts
• Systemic manifestations of other disorders, such as Crohn disease, Kawasaki syndrome, and Stevens-Johnson syndrome

Frequency

United States

Data collected for the congressionally mandated Third National Incidence Study of Child Abuse and Neglect (NIS-3) found that, in 1993, an estimated 3.2 per 1000 children (or a total of 217,000) were abused sexually; this represented 29% of the total number of children known to have been abused. NIS-3 used a definition that subsumed a range of behaviors, including intrusion, genital molestation, exposure, inappropriate fondling, and unspecified sexual molestation. NIS-3 is the single most comprehensive source of information about the current incidence of child abuse and neglect in the United States and is based on a nationally representative sample. At best, incidence is an underestimate; however, the cases counted are only those occurrences known to professionals and do not include incidents of sexual abuse that have not been disclosed. With sexual abuse, the number of undisclosed incidents is believed to be large, owing to the stigma and criminal behavior involved.

The 1993 NIS-3 incidence figure of 3.2 per 1000 children represents a statistically significant 68% increase from the 1986 Second National Incidence Study of Child Abuse and Neglect (NIS-2) incidence of 1.9 per 1000 children. In part, this difference is due to increased recognition of sexual abuse in the pediatric population. A classic prevalence study of New England male and female college students, which used a definition that included both contact and noncontact abuse with older perpetrators and children younger than 17 years, revealed that 19.2% of female students (1 in 5 women) and 9% of male students (1 in 10 men) reported sexual misuse during their childhoods. These figures are believed to be conservative estimates; other studies using different methodologies support using these figures as reasonable prevalence estimates.

In 2002, approximately 896,000 children were determined to be victims of child abuse. Of these, about 10%, or close to 90,000, represented cases of CSA that were substantiated by child protective services (CPS).

Professionals in the child abuse field conservatively use Finkelhor's prevalence estimates of 20% of women and 5-10% of men having once experienced sexual abuse as children. Analysis by various experts of 16 prevalence studies of nonclinical North American samples supports setting the upper end of prevalence figures at about 17% for women and 8% for men.

Mortality/Morbidity

A number of psychological and medical consequences have been described as associated with sexual abuse. Psychological disorders are reported as having an increased incidence in those who have been abused sexually and include depression, eating disorders, anxiety disorders, substance abuse, somatization, posttraumatic stress disorder (PTSD), dissociative disorders, psychosexual dysfunction in adulthood, and a number of interpersonal problems, including difficulties with issues of control, anger, shame, trust, dependency, and vulnerability.

• PTSD and its relationship to sexual abuse have received considerable professional attention. The diagnosis of PTSD in the context of sexual abuse requires the occurrence of maltreatment and (1) frequent reexperiences of the event via intrusive thoughts and/or nightmares; (2) avoidance behavior and a sense of numbness toward common events; and (3) increased arousal symptoms, such as jumpiness, sleep disturbance, and/or poor concentration. Note that no universal short-term or long-term impact of sexual abuse has been identified, and the presence or absence of various symptoms or conditions does not indicate nor disprove the occurrence of sexual abuse.
• Medical sequelae of CSA include a number of medical conditions, including functional GI disorders (eg, irritable bowel syndrome, dyspepsia, chronic abdominal pain), gynecologic disorders (eg, chronic pelvic pain, genital or anal tears), and various forms of somatization involving neurologic conditions and pain syndromes. Additionally, children may contract STDs via sexual abuse, and postpubertal females may become pregnant.

Race

No race differences emerged from the 1993 NIS-3 data. This initially may be surprising due to the disproportionate overrepresentation of children of color who are involved with the child welfare system. NIS-3 data were consistent with the 1986 NIS-2 findings, which also failed to demonstrate any evidence of disproportionate victimization in relationship to children's race. Finkelhor has concluded that race, ethnicity, and social class do not appear to be associated with risk of child sexual maltreatment.

Sex

Gender differences exist in the reported incidence of sexual abuse. In the NIS-3, a statistically significant difference was noted, with girls experiencing sexual abuse at more than 3 times the rate of boys: 4.9 per 1000 girls compared to 1.6 per 1000 boys.

Age

Age differences exist in the reported incidence rates of sexual abuse for children aged 0-2 years (incidence is 1 per 1000) compared to children aged 12-14 years (incidence is 2.6 per 1000) and children aged 15-17 years (incidence is 2.7 per 1000). Incidence rates of sexual abuse in children aged 3-11 years were quite variable and made the statistical comparisons unreliable.

CLINICAL

Section 3 of 9  

• Authors and Editors
• Introduction
• Clinical
• Workup
• Treatment
• Follow-up
• Miscellaneous
• Multimedia
• References

History

In incidents of child sexual abuse (CSA), the interview with the child typically is the most valuable component of the medical evaluation. Elicited history frequently is the only diagnostic information that is uncovered. Additionally, if performed in a sensitive and knowledgeable manner, the history-taking process can be a first step in the healing process for the child who is sexually traumatized. Regardless of the history provided, the members of the interdisciplinary team need to demonstrate an open, nonjudgmental, and caring attitude toward the child; the willingness to advocate for the child must be demonstrated as the evaluation unfolds.

• General principles for successful history taking
• • To assist in creating a comfortable and nonthreatening environment, allow an extended period of time when taking the history in children who are suspected of being sexually abused.
  • When interviewing the child, use a developmentally sensitive approach to the questioning so that the child can understand what is being asked and is able to answer as accurately as possible.
  • Rely on nonleading questions as much as possible to permit the child to relate information in a credible and reliable framework.
  • An interview often has a healing value for children, enabling them to start to feel some control with what occurs in their lives in contrast to the abusive situation that took away the control they should have with their own bodies.
  • In an effort to demystify the information-gathering process, consider permitting children to sit where they want to sit, slowing down the pace of the interview if it starts to go too fast, permitting time for play breaks, and encouraging children to use their own words for body parts.
• Initial introduction with efforts to build up trust
• • During the initial meeting, the health care provider and any members of the interdisciplinary team who are involved with the treatment of the child should introduce themselves to the child and caregiver.
  • At this point, the primary health care provider should explain how the evaluation usually proceeds, including the need to first speak alone with the caregiver and then alone with the child.
  • After these initial conversations, ask the caregiver to rejoin the child for a physical examination, which frequently is understood as a "check-up" by the child.
• Caregiver interview
• • Ensure that caregivers who accompany children have an opportunity to describe their concerns, provide information about the children's health, and outline any information they have related to the suspected abuse.
  • By interviewing the caregiver first, the interviewer allows the child an extra bit of time to become familiarized with the clinical setting and, hopefully, to become more comfortable with the environment.
  • Initially explain to the caregiver the extent to which the information elicited during the interview is required to be shared with CPS staff and law enforcement personnel who may be involved with the case.
  • Clarifying the limits of confidentially in suspected incidents of CSA is paramount to avoid feelings of betrayal later if and when information is shared with the various involved agencies.
• Child interview
• • When verbal children are interviewed when the caregivers are not present, the potential exists that these children will provide the most valuable information.
  • Using a sensitive approach and building upon what has been learned in the warm-up and caregiver interview components, begin with nonthreatening topics such as favorite activities, school subjects, and personal interests.
  • Once rapport has been established in the interview, ask the children why they have come to the doctor's office.
  • By focusing on asking simply worded, open-ended, nonleading questions, the person taking the history can progress through the standard "what, when, where, and how" questions, which are so important to the medical evaluation of suspected CSA.
  • The full potential of the interview can be realized by a reliance on such questioning as "tell me more" followed by "and then what happened?"
  • Supporting the child for working hard to answer the questions (but not for the content of the answers) is vital to the credibility of the information elicited.
  • The clinician must understand the developmental capacity of the child and work within the child's abilities to garner the information needed. Thus, children may not know dates but they remember holidays; children may remember something happened before or after school began.
  • Asking children to explain what they mean to avoid misunderstanding important points in the history is always appropriate.
  • Using the child's words for body parts may make the child more comfortable with difficult conversations about sexual activities.
  • Using drawings also may help children describe where they may have been touched and with what they were touched.
  • Meticulous documentation is a necessity for these types of histories, because the documentation may be considered as evidence in subsequent legal proceedings emanating from the overall investigation.
  • To the extent possible, document specific quotes that the child makes about the abusive events.
  • Often, entries made in medical charts by health care providers of children's words detailing their own sexual victimization assist those advocating for children as they argue for suitable protection from people and situations that may be threats to the children's well-being.
  • Consider videotaping or at least audiotaping the interview; these tapes may be admissible evidence in some jurisdictions.
• Wrap-up and preparation for the physical examination
• • After the child interview concludes, the caregiver can be invited back in the room to help facilitate the transition to the physical examination.
  • Being honest and empathetic with the child is critically important.
  • Therefore, do not promise that needles are not to be used unless absolutely sure that a blood draw is not necessary; if not sure, reassure children that blood is drawn only if needed and, if blood is needed, children are told at the end of the examination.
  • Inform children if genital swabs are to be collected; allow them to handle the swabs in order to gain some comfort with the procedure.
  • If a colposcope is to be used during the physical examination, introduce it as a "special camera" that the doctor uses that does not touch the child.
  • After an appropriate discussion, leave the room and allow the child to prepare for the examination by suitable disrobing and putting on a gown with the caregiver's assistance.

Physical

As opposed to adult sexual abuse and in general, authorities agree that more than three fourths of physical examinations of children suspected of having been abused sexually are without definitive findings of sexual abuse. Most recently, Heger et al conducted a comprehensive study that included the review of physical examinations performed on 2,384 girls evaluated for suspected CSA in a regional referral. They found that, overall, only 4% of the girls had abnormal findings. A number of reasons are believed to account for this general lack of findings. First, the child and family typically know the perpetrators, and physical force often is not a major component as in adult sexual assaults. Disclosure of the abuse frequently is delayed, and evaluations may be performed weeks to months after the abusive contact. Finally, mucous membranes that compose the genital structures heal rapidly and, often, without obvious scarring.

The general approach to the physical examination follows the standard examination techniques for a comprehensive physical examination (ie, complete head-to-toe approach). When examining the child who is suspected of being sexually abused, place particular emphasis on the genital and anal examination; however, children should experience this more thorough inspection of their anogenital anatomy only in the context of a complete examination. In this way, children receive messages that their whole bodies and health are important; this helps to avoid any undue focus on their anogenital areas.

• Examining genital and perianal structures: To perform a complete examination of the child's genitalia and perianal structures for abnormalities attributed to abuse, the examiner first must understand the basic anatomy of this body area. Initially considering the female prepubertal genitalia with minimal palpation, externally inspect the vulvar structures. Tissues of interest are mons pubis, labia majora, labia minora, clitoris, urethral meatus, hymen, fossa navicularis, and posterior fourchette. The postpubertal child may require a more extensive examination requiring internal examination of the vagina and cervix, depending on the suspected type of contact. This section focuses on the external examination of the prepubertal female genitalia. Child Abuse & Neglect: Physical Abuse includes a detailed description of the examination of the female adolescent patient. Structure descriptions are as follows:
• • Mons pubis
  • • This genital structure is the skin-covered mound of fatty tissue above the pubic symphysis.
    • Owing to maternal estrogen effect, the neonate's mons pubis appears generous and rounded; however, as the estrogen effect decreases, the roundness is lost until the child's endogenous estrogen level increases at the time of puberty.
    • In response to circulating hormones, the mons pubis is the site for pubic hair growth during pubertal development and adulthood.
  • Labia majora
  • • These bilateral skin-covered longitudinal folds of fatty and connective tissue serve as external protection for the more recessed vulvar structures.
    • The neonate's labia majora are thicker due to maternal estrogen effect, and this decreases over time.
    • The child's labia majora do not cover the internal structures completely.
    • During puberty, pubic hair grows on the skin covering the labia majora as well.
  • Labia minora
  • • These bilateral, thin, mucous membrane longitudinal folds are observed medial and more recessed in relation to the skin-covered labia majora.
    • Because of maternal estrogen, the neonate's labia minora frequently are larger than expected and may protrude beyond the labia majora; however, this decreases over time.
    • Anteriorly, the labia divide into lateral and medial components, with the lateral labial component fusing centrally to form the prepuce of the clitoris.
    • The medial labial components fuse to form the clitoral frenulum.
    • Posteriorly, the labia fuse to form the posterior fourchette.
    • No hair grows on the labia minora.
  • Clitoris
  • • The clitoris is the small, cylindrical, erectile structure comprised of a prepuce, frenulum, glans, and body.
    • Similar to the other structures described above, the maternal estrogen effect causes a transient enlargement of this structure, which decreases over weeks to months after birth.
  • Urethral meatus
  • • This genital structure is the round outlet of the urinary system inferior to the clitoris.
    • This outlet may be difficult to visualize routinely in the child, but urethral tissue occasionally may prolapse, creating a beefy red donut-shaped protrusion at the site of the meatus.
  • Hymen
  • • The hymen is the mucous membrane sheetlike structure that has an opening and is situated at the entrance to the vagina, sitting in a recessed fashion between the medial aspects of labia minora.
    • Hymenal tissue is very sensitive to estrogen, and the estrogenized hymen is pink and opaque compared to the relatively unestrogenized hymenal tissue, which generally is thin, translucent, and reddish with an obvious lacy vascular pattern.
    • The shape of the hymenal orifice is variable, and the various shapes generally are described as crescentic (half-moon), annular (circular), fimbriated (redundant tissue that folds over on itself like excess ribbon around an opening), septate (column of tissue that crosses the opening), and cribriform (series of small openings).
    • The shape of the orifice can be described further by the appearance of clefts, bumps, notches, tags, and the presence of thickening or thinning at the orifice's edge.
    • The observed size of the hymenal orifice is variable, depending on the state of relaxation of the child, the position of the child, and examiner technique.
    • As such, most authorities agree that measurement of the hymenal orifice has limited utility in the evaluation.
  • Posterior fourchette: Formed by the posterior meeting of the labia minora, the posterior fourchette is the floor of the fossa navicularis.
  • Fossa navicularis: The fossa navicularis is the space bounded by the posterior fourchette and the point where the hymen attaches to the inferior aspect of the vaginal wall at its entrance.
• Standard positioning: To expose the prepubertal genital structures as fully as possible, several standard positions are used, namely frog-leg supine, knee-chest, and the left lateral decubitus.
• • Frog-leg supine position
  • • This position is ideal for optimal visualization of the genital structures and for a fair degree of comfort for the child.
    • The child lays supine on the examining table or on the caregiver's lap and flexes her knees, bringing the heels of her feet together while abducting her hips; thus, her legs can move laterally, providing an excellent view of the external genitalia.
  • Knee-chest position
  • • The knee-chest position provides clear observation of the anus; it also offers an opportunity to examine the vulvar structures, including the hymen, from a different vantage point.
    • This position can be helpful in assessing a difficult-to-visualize hymenal orifice.
    • As the child kneels down, resting her chest against her knees on the examination table and moving her buttocks superiorly, the anterior abdominal wall falls forward, and the hymenal tissues may be extended somewhat more than in the frog-leg supine position.
    • The main disadvantage to this position is that children may feel vulnerable and often are uncomfortable remaining in this position.
  • Left lateral decubitus
  • • This alternative position is most appropriate for anal examination and most commonly is used with boys.
    • The left lateral decubitus position does not offer a clear visualization of the female vulvar structures.
    • The child lies on his left side with knees flexed and buttocks placed toward the examining table's edge and the examiner.
• Calming the child during examination: In addition to positioning, make efforts to keep the child engaged and calm during the examination. Often, calming the child is accomplished by talking to the child and explaining what to expect during the examination. Additionally, proper attention to modesty is necessary, and the use of a quiet room, with adequate privacy, is essential. Use gowns and drapes as appropriate.
• Genital and anal examination: Examiners may find it helpful to progress through the genital and anal examination in a fairly routine sequence, during both the actual examination and the subsequent documentation.
• • General observation and inspection
  • • The genital examination begins with general observation and inspection.
    • With the child in the appropriate position and with adequate light and privacy, look for signs of injury on the skin surfaces, make a judgment about the presence and character of pubic hair for sexual maturity rating purposes, and look for any obvious signs of infections.
    • Note the child's emotional status.
  • Visualizing the more recessed genital structures
  • • Once the inspection is completed with gloved hands, the examiner may use gentle palpation to move the tissues and further visualize the more recessed genital structures.
    • By applying gentle lateral traction to the labia majora, the labia minora and hymen may be observed more clearly.
    • Magnification, provided by a hand-held magnifying glass or colposcope, may be helpful during the genital examination. The colposcope has the advantage of providing an excellent light source and having the capability to take photographs during the examination.
    • Internal examinations and the use of instruments are almost never necessary in the prepubertal examination for suspected CSA.
    • If deemed necessary because of a serious finding (eg, bleeding with no identified source), arrange an examination under anesthesia.
  • Collection of specimens
  • • At this point in the examination, specimens may be collected for STD screening and forensic evidence collection.
    • These procedures are described in more detail in the Workup section.
  • Possible observable findings: Most individuals who have been sexually abused present with essentially normal examination findings. However, possible observable findings include (1) those attributable to acute injury if the examination is performed a relatively short time after the sexual contact or (2) chronic findings that may be residual effects following repeated episodes of genital contact, which have occurred over an extended period of time.
  • • Examples of acute trauma are subtle erythema, abrasions, lacerations, friability, bleeding, and disruption of the hymen. Additionally, if the perpetrator ejaculated on or near the child's genitalia, seminal products may be found. Signs related to the existence of STDs also may be present. These signs may include vaginal discharge, signs of vulvovaginitis, and characteristic lesions, such as the viral lesions observed in genital herpes and the warts observed with human papilloma virus infection (ie, condyloma acuminata).
    • Chronic findings that may be found include scars on the genital skin and mucous membranes, remodeled hymenal tissue from repeated trauma, and disrupted vascular patterns in the translucent tissues. Healing occurs in these tissues. Over months to years of abusive contact, angular margins in hymenal tissue tend to smooth out, and, with the onset of puberty, the appearance of estrogen and resultant hypertrophy of the genital mucous membranes tend to obscure subtle changes.
• Muram diagnostic categorization system: The Muram classic categorization system offers valuable insight into how a variety of prepubertal genital examination findings may assist diagnosis.
• • Category I - Genitalia with no observable abnormalities
  • Category II - Nonspecific findings that are minimally suggestive of sexual abuse but also may be caused by other etiologies
  • Category III - Strongly suggestive findings that have a high likelihood of being caused by sexual abuse
  • Category IV - Definitive findings that have no possible cause other then sexual contact (eg, seminal products in a prepubertal female child's vagina, the presence of a nonvertically transmitted gonorrhea or syphilis infection)
• Alternate classification: Adams and colleagues have built upon the Muram classification approach and have combined it with information from other components of the sexual abuse assessment. Additionally, these investigators proposed a 5-category classification system for anogenital findings in children.
• • Class 1 - Normal
  • Class 2 - Nonspecific findings that may be caused by sexual abuse or by other conditions (history is critical)
  • Class 3 - Suspicious for abuse (should prompt examiner to question about sexual abuse)
  • Class 4 - Suggestive of abuse and/or penetration
  • Class 5 - Evidence of penetrating injury

WORKUP

Section 4 of 9  

• Authors and Editors
• Introduction
• Clinical
• Workup
• Treatment
• Follow-up
• Miscellaneous
• Multimedia
• References

Lab Studies

• Children who have been abused sexually are at risk of contracting STDs including gonorrhea, chlamydia, syphilis, condyloma acuminata, herpes simplex virus, human immunodeficiency virus (HIV), pediculosis pubis, and trichomoniasis vaginalis.
• Rapid tests are not appropriate in the context of a child sexual abuse (CSA) evaluation because of their higher potential for false-positive results.
• Cultures remain the criterion standard and are valuable from a forensic evidence standpoint.
• Depending on the contact suspected and the clinical situation recommended, testing includes the following:
• • Gram stain of vaginal and/or anal discharge
  • Genital, anal, and pharyngeal culture for gonorrhea
  • Genital and anal culture for chlamydia
  • Serology for syphilis
  • Wet prep of vaginal discharge for Trichomonas vaginalis
  • Culture of lesions for herpes virus
  • Serology for HIV (based on suspected risk)
• The American Academy of Pediatrics (AAP) views nonvertically transmitted gonorrhea, syphilis, chlamydia, and HIV as diagnostic of sexual abuse in the prepubertal child.
• In a child, the AAP views the presence of T vaginalis as highly suggestive of sexual abuse.
• Nonvertically transmitted condyloma acuminata and herpes with no clear history of autoinoculation also are suggestive of sexual abuse.

Other Tests

• The collection of forensic evidence, via the rape kit, may be indicated if the child presents within 72 hours of last sexual contact with the perpetrator and if a belief exists that the perpetrator may have left evidence on the child's body. The 72-hour standard that triggers forensic evidence collection in cases of suspected CSA is derived from adult pathology studies of adult sexual assault cases. As more pediatric studies are performed based on the timing of forensic evidence collection, this 72-hour standard may be changed to reflect the unique issues present in most cases of CSA.
• For example, in 2000, Christian et al evaluated forensic evidence in prepubertal victims of sexual assault. Forensic evidence was found in 25% of children, all of whom were evaluated within 44 hours of assault. Sixty-four percent of evidence was found on their clothing and linens. However, only 35% of children in the study had their clothing collected for analysis. No swabs from the children's bodies were positive for blood after 13 hours or for semen after 9 hours.
• In addition, consider obtaining a urine toxicology screen if the abuse or assault was substance facilitated, especially in the setting of dating violence.
• • Carefully follow procedures outlined in standard forms that are included in the rape kit.
  • Maintain a documented "chain of custody"; the actual kit is extremely important.
  • Cultures for STDs are not part of the rape kit and should be handled separately based on the typed culture procedures.
  • Finally, place clothing in a paper bag and not in plastic, which may seal in moisture and lead to evidence degradation.
  • Evidence that may be collected includes the following:
    • Child's clothing that was worn at the time of the sexual contact
    • Swabs for semen, sperm, and acid phosphatase
    • Fingernail scrapings from underneath the child's nails
    • Pubic hairs found on the child's body (If the child has pubic hair, sampling 5-10 hairs, which then are placed in separate envelopes for comparison, is necessary.)
    • Debris found on the child
    • Child's samples of saliva and blood to determine blood type and secretor status

TREATMENT

Section 5 of 9  

• Authors and Editors
• Introduction
• Clinical
• Workup
• Treatment
• Follow-up
• Miscellaneous
• Multimedia
• References

Medical Care

Medical treatment is guided by any conditions uncovered. The incidence of STDs in child sexual abuse (CSA) is low. In prepubertal children, asymptomatic vaginal infections are thought to be increasingly uncommon. Therefore, the Centers for Disease Control and Prevention (CDC) does not recommend prophylaxis for STDs in asymptomatic prepubertal children who are evaluated for possible CSA. In contrast, the CDC recommends that teenaged patients and adults who are sexually abused or assaulted should receive antibiotic prophylaxis for STDs. For more information, see MMWR Recommendation and Report Sexually Transmitted Diseases Treatment Guidelines.

• Treat STDs with appropriate medications based on the infection and the child's age and weight.
• In postmenarcheal children, consider the possibility of pregnancy.
• Recognize the overriding need for emotional support and attention to the psychosocial crisis in which the child and family now find themselves.
• Health care providers are mandated reporters in all 50 states; once sexual abuse seriously is suspected or diagnosed, a report to the appropriate CPS agency is necessary. Attention to the safety of the child is essential. The AAP recommends reporting in the following situations:
• • When a child makes a clear disclosure of abusive sexual contact, with or without specific findings
  • When individuals present with STDs (see Workup section)
  • When physical examination findings are believed to be the result of abusive sexual contact
• When sexual abuse is being considered, the AAP suggests the possibility of reporting, depending on the perceived risk to the child. In such cases, discussion with members of an interdisciplinary team may be helpful.
• Cases of sexual abuse may result in law enforcement action against the alleged perpetrator and possible criminal court proceedings. Well-documented medical records are essential, since legal proceedings may occur over long periods of time. The health care provider cannot rely solely on recollection of the case.

Consultations

Mental health consultation is warranted to evaluate and treat acute stress reaction and, later, PTSD. Expert mental health management of stress disorders is warranted because of the burgeoning evidence that psychic trauma in young children has a significant effect.

FOLLOW-UP

Section 6 of 9  

• Authors and Editors
• Introduction
• Clinical
• Workup
• Treatment
• Follow-up
• Miscellaneous
• Multimedia
• References

Prognosis

• For recovery from the emotional trauma associated with child sexual abuse, prognosis varies depending on a number of abuse-specific and individual and environmental factors. These factors include the following:
• • The child's inherent coping mechanisms and response to trauma and its aftermath
  • Response evident in the child's environment to the victimization
  • Age when the abuse occurred
  • Relationship of the perpetrator to the child
  • Length of time over which the abuse occurred
  • Pattern of the abuse
• The response within the caregiving environment to the victimization appears to have an important impact on the ability of the child to work through the difficult issues raised by the sexual abuse.
• Looking at children 5 years after presentation for sexual abuse and comparing them to a similarly aged group of children who were not abused, one study found that the children who were sexually abused displayed the following:
• • More disturbed behavior
  • Lower self-esteem
  • Increased tendency for depression
  • Increased tendency for anxiety
• Retrospective studies of adults with severe personality disorders characterized by dissociation, impaired interpersonal relationships, and self-mutilation have found a high and significant correlation with histories of sexual abuse.
• Prognosis related to any physical injury or infection resulting from the sexual abuse is expected to follow a typical healing course and respond to standard medical interventions.

Patient Education

• For excellent patient education resources, visit eMedicine's Children's Health Center and Public Health Center. Also, see eMedicine's patient education articles Child Abuse and Sexual Assault.

MISCELLANEOUS

Section 7 of 9  

• Authors and Editors
• Introduction
• Clinical
• Workup
• Treatment
• Follow-up
• Miscellaneous
• Multimedia
• References

Medical/Legal Pitfalls

• How to report child sexual abuse (CSA) is detailed in each state's child abuse reporting laws. Health care providers are mandated to report known incidents of abuse. When these reports are made in good faith, with the well-being of the child in mind, health care providers typically are granted immunity should any legal action occur. This is true especially in cases in which, after investigation, the occurrence of abuse cannot be determined. Physicians may be required to provide testimony in court proceedings. Often, law enforcement personnel are involved since criminal prosecution of the perpetrator may be pursued.
• The physician called to court generally may serve in 2 roles.
• • A physician may serve as a lay fact witness and provide first-hand information about what occurred during the child's medical evaluation, including what was seen and heard during the evaluation. Accurate and detailed medical records are vital to this function, since the court appearance may occur many months to several years after the visit.
  • Physicians with advanced training or considerable experience with CSA may be called as expert witnesses who offer opinions to the court on the specifics of the evaluations they performed. Unlike the fact witness who is limited to the specifics of the evaluation performed with the child, the expert witness may draw upon knowledge of the child abuse field and interpret issues related to the case. Meticulous documentation during the evaluation of suspected CSA is of great assistance to the physician called to testify; ultimately, documentation's best potential is to serve the child's interests.
• For additional details related to child maltreatment that also can be applicable to CSA, please see Child Abuse & Neglect: Physical Abuse.

Special Concerns

• Health care evaluation versus investigation
• • The health care evaluation of suspected CSA includes a history, physical examination, laboratory assessment, and observations of the caregiver and child that lead to a differential diagnoses and diagnostic impression. The multidisciplinary team that ideally handles cases of suspected sexual abuse is typically composed of a physician, nurse, and social worker, and information collected during the health care evaluation is then relayed to the police and CPS workers. The health care evaluation completed by this clinical team is related to, but distinct from, the investigation completed by CPS and/or law enforcement (ie, the police).
  • However, the health care information obtained during the clinician's evaluation is central to the investigation process and focuses on assessing the child's health status and treatment to restore health when necessary. The physician should focus on the health care and well being of the child and family while documenting and relaying any information obtained during the medical history that will help the investigators and law enforcement individuals prosecute the case.
  • On the other hand, the investigators are individuals from various disciplines and agencies mandated by laws and regulations to explore allegations of suspected maltreatment. The police determine whether or not a crime has been committed and begin appropriate legal action. CPS agencies and CPS workers operate alongside the police to protect children, as well. CPS's role in the investigation of child abuse focuses on the family's functioning and ability to protect the child. CPS agencies provide support services to families in need and may ultimately remove children from environments that are determined to be unsafe.
• Allegations of CSA during custody battles
• • Allegations of sexual abuse during ongoing custody disputes are a particular challenge to the professionals working with the child and family. The custody issues further complicate the evaluation of an already difficult situation. Questions arise such as the following: "Did the child actually sustain these injuries or did the other parent prompt the child to make the accusations? Did the presenting parent overreact to a set of events that might have been thought innocent if there was no custody battle?"
  • Despite professional cynicism, these cases warrant the same comprehensive evaluation as other allegations of sexual abuse and should not be dismissed. The American Bar Association reports that few divorces involve custody disputes and that very few involve allegations of sexual abuse. Paradise et al (1988) found that, in cases of custody disputes, allegations of sexual abuse were substantiated 67% of the time. Therefore, the clinician should proceed in the evaluation as directed by all aspects of the history, keeping in mind that delayed disclosure is not uncommon in cases of childhood sexual abuse.

MULTIMEDIA

Section 8 of 9  

• Authors and Editors
• Introduction
• Clinical
• Workup
• Treatment
• Follow-up
• Miscellaneous
• Multimedia
• References

Media file 1:  Infant girl in frog-leg supine position. Genital examination reveals translucent hymenal membrane with significant redundant tissue making hymenal orifice difficult to appreciate in this photo. With further traction applied to both labia majora, the hymenal orifice could be observed. Photo courtesy of Carol D. Berkowitz, MD.
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Media file 2:  Infant girl in frog-leg supine position. Hymenal orifice is crescentic (little time is present at 12-o'clock posterior). Hymen is thin and translucent with vessels visible. Hymenal edge is regular and without interruption. Photo courtesy of Carol D. Berkowitz, MD.
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Media file 3:  Girl in knee-chest position. Hymenal orifice is crescentic, thin, translucent, and without interruption or scarring. Photo courtesy of Carol D. Berkowitz, MD.
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Media file 4:  Infant girl in frog-leg supine position. Hymenal orifice is annular, with tissue present around entire opening. Some redundancy is present. Photo courtesy of Carol D. Berkowitz, MD.
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Media file 5:  Infant girl in frog-leg supine position. Hymenal orifice is annular with a "bump" at 1-o'clock position and a small "notch" at 10-o'clock position. Hymenal membrane is thin and translucent, with no interruption or scarring. Photo courtesy of Carol D. Berkowitz, MD.
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Media file 6:  Girl in frog-leg supine position, exhibiting annular hymenal orifice. Tissue is thin and translucent without disruption or scarring. Photo courtesy of Carol D. Berkowitz, MD.
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Media file 7:  Girl in frog-leg supine position exhibiting hymenal orifice, which is crescentic and has symmetric attenuation at lateral margins. No scarring is present. Photo courtesy of Carol D. Berkowitz, MD.
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Media file 8:  Girl in frog-leg supine position exhibiting hymen. Hymen is septate; a band of tissue crosses the hymenal orifice. Tissue is thin with no scarring present. Photo courtesy of Carol D. Berkowitz, MD.
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Media file 9:  Adolescent girl in supine position demonstrating estrogenized tissue. Hymen is thicker, pink, and fairly opaque with no vessels visible. Tissue is redundant. Photo courtesy of Carol D. Berkowitz, MD.
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Media file 10:  Genital examination of adolescent girl revealing estrogenized hymenal tissue that is pink, thick, and opaque. Orifice appears irregular, secondary to significant redundancy of tissue. Photo courtesy of Carol D. Berkowitz, MD.
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Media file 11:  Genital examination of adolescent girl demonstrating estrogenized hymenal tissue that is pink, thick, and opaque. Orifice is irregular due to areas of redundancy, especially at the 9-o'clock position. Photo courtesy of Carol D. Berkowitz, MD.
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Media file 12:  Prepubertal girl with foul-smelling bloody discharge. On examination, a foreign body in the vagina was found just past the hymenal orifice. The foreign body is lodged in vagina and appears to be toilet tissue that is colonized with bacteria, causing a vulvovaginitis. The foreign body was dislodged with gentle water flushing during examination. Photo courtesy of Carol D. Berkowitz, MD.
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Media file 13:  Genital examination of prepubertal girl with foul-smelling bloody discharge. On examination, a foreign body in the vagina was found lodged just past the hymenal orifice and appears to be toilet tissue that is colonized with bacteria, causing a vulvovaginitis. The foreign body was dislodged with gentle water flushing during examination. Photo courtesy of Carol D. Berkowitz, MD.
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Media file 14:  Infant girl with imperforate hymen and absence of a hymenal orifice. Photo courtesy of Carol D. Berkowitz, MD.
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Media file 15:  Genital examination of girl revealing bruising on medial aspects of labia minora, hymenal trauma with disruption of hymenal tissue, and fresh blood. Photo courtesy of Carol D. Berkowitz, MD.
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Media file 16:  Infant girl with significant bruising that involved labia minora and labia majora, hymenal trauma with disruption of hymen, and fresh blood. Photo courtesy of Carol D. Berkowitz, MD.
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Media file 17:  Genital examination 10 days after infant girl presented with significant bruising that involved labia minora and labia majora, hymenal trauma with disruption of hymen, and fresh blood. Bruising on vulvar structure is nearly resolved. Hymen is healing and no blood is observed. Photo courtesy of Carol D. Berkowitz, MD.
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Media file 18:  Genital examination of girl in frog-leg supine position after genital trauma. Examination reveals suture in place at 6-o'clock position to stop bleeding from injury. Hymenal edge is irregular and asymmetric. Photo courtesy of Carol D. Berkowitz, MD.
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REFERENCES

Section 9 of 9

• Authors and Editors
• Introduction
• Clinical
• Workup
• Treatment
• Follow-up
• Miscellaneous
• Multimedia
• References

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Article Last Updated: Jun 16, 2006