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Child Sexual Abuse

Child sexual abuse is defined 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. Sexual abuse may also be committed by another minor when that person is either significantly older than the victim or when the abuser is in a position of power or control over that child child sexual abuse, sex abuse, sexual abuse of children, child abuse, rape

Prevalence rates of adults reporting a history of childhood sexual abuse vary, depending on methodology, definitions, and sampling techniques. Reports of child sexual abuse have increased steadily over the past several years. Researchers disagree as to whether this reflects increased willingness to report inappropriate sexual contacts, true increased victimization, or both child sexual abuse, sex abuse, sexual abuse of children, child abuse. Researchers do agree that child sexual abuse is not uncommon; a reasonable estimate is that 20% of girls and 9% of boys are involved in developmentally inappropriate sexual activities during childhood for the sexual stimulation of 

Increased risk for sexual abuse is not related to socioeconomic status or race. Children are most likely to be abused sexually during preadolescence, from ages 8 to 12 years. Girls are more likely to be sexually abused than boys, although boys are less likely to report abuse. Sexual abuse victims are more likely to be isolated from their peers, although this may be an effect of abuse. Family risk factors associated retrospectively with child sexual abuse include poor parent-child relationships, poor relationships between parents, absence of a protective parent, and presence of a

Most perpetrators of sexual abuse are trusted adult acquaintances of the child who often target children lacking close adult supervision and craving adult attention. Victimization usually is gradual. Typically, children initially are befriended, slowly seduced, and

Children who have been sexually abused come to the attention of the medical profession primarily in three ways: presentation of behavioral changes that are of concern, genital-rectal or medical complaints, or a specific disclosure of developmentally inappropriate sexual contact.

BEHAVIORAL CHANGES

Behavioral indicators that can accompany sexual abuse can be manifestations of other stresses and are not independently diagnostic of child sexual abuse. Sexual acting out and perpetrating sexual abuse on others are the most specific behavioral indicators of past sexual victimization. Acting out involves sexually explicit, developmentally inappropriate activities or play. Such behaviors are not fantasy; they are learned. A child's compulsion to

 

Behavioral Changes: Possible Indicators of Sexual Abuse
Clinging
Temper tantrums
Aggression
Sleep disturbances
Nightmares
Appetite disturbances
Neurotic or conduct disorders
Phobias
Withdrawal
Depression
Low self-esteem
Self-injury
Social problems with peers
Substance abuse
School problems
Promiscuity
Prostitution
Sexual perpetration on others
Sexual acting out

 SEXUAL ABUSE VERSUS SEXUAL PLAY

Differentiation between sexually abusive acts and normal sexual play usually is straightforward. Sexual abuse most often involves persons of different age and gender; activities inconsistent with the developmental level of the children; elements of coercion, force, pressure, or secrecy; a negative victim response; and greater likelihood of physical injury. By contrast, normal sexual play typically involves children of the same

GENITAL-RECTAL OR MEDICAL COMPLAINTS

Only pregnancy and noncongenital syphilis or gonorrhea are independently diagnostic of sexual contact. Nonmenstrual genital bleeding is highly suggestive of acute sexual assault in the absence of adequate accident history or organic illness. Other noted genital-rectal or medical complaints

The medical history and physical examination for suspected child sexual abuse require a patient, unrushed approach. A clinic setting with evaluation by an experienced examiner is always preferable. Begin with a proper introduction and identify your role. Sit at the child's level and engage him or her in nonthreatening social conversation. Establish trust. Discuss the purpose of the visit. Explain that the checkup will include a general physical examination and a very gentle examination of the child's private areas. Inquire about the child's own words for these body areas.

Allow the child to play while you talk with his or her caretakers. The parental interview should include a past medical history, a medical/psychological review of systems, a family history, a social history, and a developmental history. Discuss specific parental concerns regarding sexual abuse, but not in front of the child.

 

TABLE 2 -- Genital-Rectal or Medical Complaints: Possible Indicators of Sexual Abuse
Genital, anal, or urethral trauma
Genital or anal bleeding
Genital or anal itching
Genital infection or discharge
Vulvitis or vulvovaginitis
Anal inflammation
Sexually transmitted disease
Pregnancy
Dysuria
Recurrent urinary tract infection
Abdominal pain
Headaches
Chronic genital or anal pain
Foreign body in the vagina or rectum
Enuresis
Chronic constipation
Painful defecation
Encopresis
Bruises to the hard or soft palate

Child Interview

In studies of legally proven cases of child sexual abuse, a majority of victims had no diagnostic physical findings. Accordingly, an unbiased interview of the child often is the most critical part of the diagnostic evaluation. Pediatricians, social workers, law enforcement officers, and prosecutors experienced in interviewing children must decide how best to coordinate the initial interviews of suspected child sexual abuse victims in their community.

If you are the most capable professional in your community available to conduct the initial interview, obtain a detailed history from the child. A history of sexual abuse obtained in the course of medical diagnosis and treatment may be admissible in court as an exception to laws restricting hearsay testimony. On the other hand, if the child previously has given a thorough disclosure of sexual abuse to an experienced social worker or investigator, your medical history can be 

Occasionally, further questioning of a child may be deleterious. The child may find repetitive questioning unpleasant or threatening, may infer that she or he is not believed, or may modify his or her history in response to repetitive questioning. If such risks appear strong, find out from the

Physical Examination

To instill additional trust, always begin with a patient, gentle, general physical examination, looking for evidence of related physical abuse or neglect. Discuss the components of the genital-rectal examination before proceeding. Girls may be reassured if you demonstrate gentle skin traction on the back of their hands to explain later labial traction. Give an older child a choice about parental presence during this examination. Provide the child adequate gowns and drapes. Introduce the child to the supportive adult chaperone. Demonstrate respect for the child's modesty by leaving the

TECHNIQUES

Examine male genitalia while the patient is supine or standing. Inspect the anus of either sex while he or she is in the lateral recumbent or supine position and holding his or her knees to the chest. The knee-chest position also may be used. To visualize the anus, use warmed, gloved hands to spread the gluteal folds. Begin gently to determine if anal dilation will occur. Apply greater traction thereafter in an effort to inspect the anus thoroughly. In cases of severe or deeper rectal bleeding, arrange an endoscopic evaluation.

In prepubertal girls, a pelvic examination with a speculum is unnecessary unless there is unexplained, active vaginal bleeding. In most cases, thorough visual inspection of the external genitalia, vaginal vestibule, and hymenal structures is sufficient. The vaginal vestibule is the space below the clitoris, above the posterior commissure, and between the labia minora.

The supine frog-leg position is comfortable for most girls. Separate the labia majora by applying gentle traction. Grasp the labia bilaterally between thumb and forefinger and pull gently outward and downward. Because tension of other pelvic muscles can obscure the view of vaginal vestibular structures, allow the child time to relax while you maintain labial traction.

The knee-chest position is tolerated well by most children. While preserving the patient's modesty with drapes, instruct her or him to lie prone on the examining table. Then assist the child to assume a kneeling position while he or she maintains head and chest contact with the table surface and lordosis of the back. Once the child is positioned properly, lift the labia upward and apart gently. Use this examination position routinely to verify normal or abnormal findings first noted when the patient is supine. This technique allows excellent noninvasive visualization of the posterior hymen, vagina, anus, and frequently the cervix.

The redundancy of the estrogenized postpubertal hymen makes close inspection of hymenal tissues for traumatic injury difficult in adolescents. You can separate these


Figure 1. Examination of the female genitalia with patient in the supine frog-leg position and labial traction applied.

Figure 2. Normal prepubertal genitalia visualized while patient is in the supine frog-leg position (labial traction applied). The vaginal vestibule is the space below the clitoris, above the posterior commissure, and between the labia minora. The hymenal morphology is annular, ie, circumferential. The fossa navicularis or posterior fossa is the lower part of the vaginal vestibule below the vaginal orifice, extending to the posterior commissure. In nonabused prepubertal children, the posterior hymen appears uniform without traumatic defect.

redundant hymenal folds with saline drops or a moistened swab.

Figure 2 illustrates normal prepubertal vestibular structures and an annular hymen. An annular hymen extends 360 degrees circumferentially. Figure 3 demonstrates a crescentic hymen, which is the most common morphology. A crescentic hymen has attachments at approximately the 10 o'clock to 11 o'clock and 1 o'clock to 2 o'clock positions and no hymenal tissue at the 12 o'clock position (relating location in the supine position to the face of a clock). Hymenal appearance may vary over time due to the effects of pubertal or exogenous


Figure 3. A prepubertal child in the supine frog-leg position with labial traction applied reveals crescentic hymenal morphology. A crescentic hymen has attachments at approximately the 10 o'clock to 11 o'clock and 1 o'clock to 2 o'clock positions. No hymenal tissue is present at the 12 o'clock position. The crescentic hymenal morphology is the most common variant. The arch-like, symmetric bands lateral to the urethra and connected to the vestibular wall are periurethral bands--a normal finding.


Figure 4. This female, who is at sexual maturity rating 1, is in the knee-chest examination position. The hymen appears thin, almost translucent in this colposcopic photograph.

estrogen, as illustrated in Figures 4 and 5 .

The hymenal opening size varies, depending on examination technique, degree of patient relaxation, and the patient's age. There is a wide range of normal hymenal opening sizes among prepubertal children selected for non-abuse. A significantly enlarged hymenal opening is diagnostic of penetrating sexual abuse only in the presence of posterior hymenal defects confirmed in two separate examination positions.

Routine examination of genital-rectal structures during well child care visits offers an opportunity to learn the many normal variations. Colposcopy offers an additional learning opportunity. The widespread use of colposcopic photography in the medical evaluation of child sexual abuse has allowed extensive peer review of such photos at educational conferences and in the medical literature. Significant concurrence on "normal" versus "abnormal" findings has resulted. Excellent color atlases of colposcopic photographs are available for review (see Chadwick DL, et al, and Heger A and Emans SJ in Suggested Reading).

PHYSICAL FINDINGS FOLLOWING SEXUAL ABUSE

For many reasons, most sexual abuse leaves no visible scars. Perpetrators may avoid physical injury to the child. Vaginal vestibular tissues are elastic. Figures 6 and 7 illustrate that genital injuries often heal rapidly.

Figure 5. This female in the supine frog-leg position is at a sexual maturity rating of 5. The estrogenized hymen of this postpubertal female appears thick, redundant, and paler or more pinkish in color than perihymenal tissues. An estrogenized hymen may be seen in neonates or after use of estrogen cream or other exogenous estrogens.

Figure 6. Labial traction in the supine frog-leg position of a 9-year-old rape victim examined within 72 hours of her assault reveals mucosal lacerations of the fossa navicularis, posterior commissure, and the base of the hymen between the 6 o'clock and 8 o'clock positions.

Figure 7. Repeat examination 2 weeks later reveals total healing. Thus, normal genital-rectal examination neither confirms nor excludes sexual abuse.

Digital fondling commonly causes no tissue damage. The anus was designed to stretch. Early pubertal estrogen effects increase hymenal elasticity, hymenal redundancy, and physiologic vaginal secretions, all of which lessen the likelihood of traumatic hymenal tearing. Longitudinal studies of sexually abused prepubertal children reveal that hymenal defects become less visible following puberty. Some children who have normal genital

DIFFERENTIATION FROM ACCIDENTAL GENITAL INJURIES

Female genital trauma from accidental straddle injuries most commonly affects the clitoris, clitoral hood, mons pubis, and labial structures. These anterior structures are injured when squeezed between the offending object and the underlying pubic bone. Usually, straddle injuries are asymmetric and do not involve the hymen. Conversely, when penetrating sexual abuse of girls results in tissue damage, the injuries involve

ANAL FINDINGS

Sexually abused boys rarely demonstrate abnormal findings. When present, these injuries most often involve the anus and are readily visible on careful inspection. Penile or scrotal injuries are uncommon. Acute anal findings in either sex can include swelling, redness, abrasions, and occasionally multiple fissures extending to the anal verge. These superficial injuries heal rapidly. Rectal lacerations from forceful penetration are

Figure 8. The posterior hymen of a 7-year-old sexual maturity rating 1 female 1 day after acute rape. The child is in the supine frog-leg position. A cotton-tipped applicator marks the location of the hymenal opening. The posterior hymen is lacerated acutely, and the torn hymenal tissue edges are edematous and erythematous from early changes of healing.

Figure 9. This 2-year-old photographed while supine was acutely sodomized, which caused lacerations with bleeding. The midline anal tag is not specific for penetrating sexual abuse. Anal lacerations often heal completely.

CLASSIFICATION OF PHYSICAL FINDINGS

Laboratory Findings

STD SCREENING

The Centers for Disease Control and Prevention (CDC) recommend asking the following questions when deciding whether to test children for sexually transmitted disease (STD) after alleged sexual assault or abuse: 1) Does the suspected offender have an STD or is he or she considered at high risk? 2) Does the child have signs or symptoms of STD? 3) Is STD prevalent in the community? The presence of vaginal discharge or a history of vaginal discharge following sexual abuse increases the likelihood of STD. Prevalence rates of STDs among sexually abused children generally do

Acute Sexual Assault

INDICATIONS FOR URGENT SEXUAL ASSAULT EXAMINATION

Parents or police occasionally bring to the emergency department children who have a history of acute sexual assault. Evidence of seminal fluid is found infrequently in sexually abused children and is not likely to persist beyond 72 hours after sexual contact. Therefore, if sexual assault has occurred within the prior 72 hours, evaluate the child immediately and perform a forensic rape examination.

Additional indications for urgent evaluation include genital or anal injuries requiring treatment (eg, vaginal or rectal bleeding), reported depression or suicidal ideation, or ongoing danger of reabuse or reprisal by the perpetrator. If the child exhibits extreme fatigue, stress, or anxiety, the examination may be deferred for a few hours, but avoid prolonged delays.

Under ideal circumstances the complete evaluation of an acutely sexually assaulted child will take 1 to 2 hours. Often the victim has been traumatized physically and emotionally. To avoid victimizing the child again, the examiner must employ extraordinary patience and empathy while obtaining an objective, nonleading history and performing a thorough, gentle examination.

RAPE KIT

The emergency department or local police can provide an adult rape kit that specifies methods for collecting the forensic evidence. These instructions may require some modification for children. Collection, handling, and storage of forensic specimens to maintain the "chain of custody" is important to preserve the admissibility of the evidence in later court proceedings.

Follow the instructions to collect the clothes or shoes worn by the victim, fingernail scrapings and clippings, and trace evidence such as dirt or grass on the victim's body. These items typically are stored in paper bags that are sealed and labeled. Uncomfortable blood sampling and removal of head and pubic hair may be deferred until clearly necessary or until the child has recovered from the acute trauma. If hair samples are not obtained, instruct the caretakers not to cut, color, or chemically process the child's hair until the investigator determines whether samples are required.

PREGNANCY PROPHYLAXIS

Complications

INITIAL EFFECTS

The initial short-term effects of child sexual abuse may be defined arbitrarily as those reactions occurring within 2 years. The most common one noted in empiric studies is fear. Internalized sequelae can include sleep and eating disturbances, phobias, depression, guilt, shame, and anger. Externalized manifestations can include school problems, delinquency, aggression and hostility, antisocial behavior, inappropriate sexual behavior, and running away.

LONG-TERM EFFECTS

Depression is the symptom reported most commonly by adults molested as children. In addition, adult victims of child sexual abuse can demonstrate signs of anxiety, tension, and self-destruction. Sleep problems and eating disorders may result. Dissociation experiences have been reported in up to 21% of sexual abuse survivors. Finally, sexual abuse victims commonly report feelings of isolation and stigmatization, poor self-esteem, problems with interpersonal relationships, negative impact on later sexual functioning, and a tendency toward revictimization and substance abuse.

TABLE 6 -- Differential Diagnosis of Child Sexual Abuse
Dermatologic Conditions
Lichen sclerosis
Diaper dermatitis
Pinworms
Poor hygiene
Bubble bath
Nonabusive bruising
Seborrheic, atopic, or contact dermatitis
Lichen simplex chronicus
Lichen planus
Psoriasis
Bullous pemphigoid
Perianal venous congestion
Congenital Conditions
Labial fusion
Hemangioma
Midline defects
Prominent medial raphe
Linea vestibularis
Perianal hyperpigmentation
Midline anal skin tags
Diastasis ani
Injuries
Straddle injury
Splitting injury
Female circumcision
Hair tourniquet
Seat belt or motor vehicle accident injury to genitalia
Anal Conditions
Crohn disease
Postmorten anal dilation
Chronic constipation
Rectal prolapse
Hemolytic-uremic syndrome
Rectal tumor
Infections
Streptococcal vaginitis
Perianal cellulitis
Perinatally acquired warts
Varicella
Candida
Urethral Conditions
Prolapse
Caruncle
Hemangioma
Sarcoma botryoid
Ureteocele
Other
Behcet disease

Victimization from child sexual abuse continues long after the abusive acts cease.

The long-term negative impact from sexual abuse is increased if the child feels responsible, if coercion was used to maintain silence, if sexually abusive acts involved penetration, if the frequency or duration of sexual abuse was excessive, and if the perpetrator was a close family member.

Management

REPORTING LAWS

In all 50 states, a physician is mandated by law to report all cases of suspected child sexual abuse to the appropriate child protection system agency. American Academy of Pediatrics guidelines for deciding to report sexual abuse of children are reproduced in Table 7 . Failure to report can result in legal penalties. Pediatricians should report cases of sexual assault to local law enforcement officials as well.

ACUTE SUPPORT

Child sexual abuse can trigger intense emotional trauma in the child, the family, the accused perpetrator, the examining pediatrician, and other child protection system professionals. The primary initial concern must be for the child's physical and emotional well being. Do not blame the child or a family member. Tell the child that what happened was not his or her fault. Reassure the child that she or he did nothing wrong. Tell the child that she or he is normal. Older children can be reassured that they "look just like other kids their age" and "can grow up and get married and have babies if they were meant to." Children who have sustained physical injuries from sexual abuse should be reassured that they will heal. Provide this direct reassurance in the presence of parents. Discuss the anticipated intervention of the child protection and investigative system. Be supportive of the family, but remain objective. Do not offer premature reassurance about the outcome; your role is