Sexual abuse is an important diagnosis to confirm for both the child and family so that appropriate treatment can begin. Remember though that some physical findings that may be suggestive of abuse, may not be definitive
Sexual abuse is an important diagnosis to confirm for both the child and family so that appropriate treatment can begin. Remember though that some physical findings that may be suggestive of abuse, may not be definitive: Excerpt from Avoiding Common Pediatric Errors
Author:
Yolanda Lewis-Ragland, MD
What to Do - Interpret the Data
There is a wide range of nonabusive causes of physical and behavioral
symptoms that serve as presenting complaints of sexual abuse victims; likewise, the physical findings are often vague and nonspecific, with many
having other likely causes. For example, although erythema of the vaginal vestibule could be a tell-tale sign of sexual abuse, it is seen commonly
in asymptomatic, nonabused, prepubescent girls, and in girls with irritant
vulvovaginitis.
Normal Variants
After years of anatomical analysis of female genitalia, it is accepted that there
is wide variation in normal hymenal configuration and of vaginal orifice
shape. It is important, therefore, to keep in mind some of the following
presentations as normal variants:
• Septal remnants, seen as tags near the midline on either the anterior or
posterior portion of the hymenal membrane
• Anterolateral hymenal flaps
• Periurethral bands
• Intravaginal ridges
• Thin labial adhesions.
Nonabusive Causes of Irritation
• Vulvovaginitis (due to chemical irritation, poor perineal hygiene or aeration, nonabusive frictional trauma, and contact dermatitis or itching and
scratching due to pinworms or fomites)
• Urethral prolapse
• Lichen sclerosus et atrophicus
• Straddle injuries
• Foreign bodies
• Anal fissures/anal tags (often associated with constipation).
When to Suspect Abuse
The diagnosis of child sexual abuse can often be made on the basis of a
child'shistory.Sexualabuseisrarelydiagnosedonthebasissolelyonphysical
examination or laboratory findings. As stated previously, physical findings
are often absent even when the perpetrator admits to penetration of the
child'sgenitalia.Manytypesofabuseleavenophysicalevidence,andmucosal
injuries often heal rapidly and completely. In a recent study of pregnant
adolescents, only two of 36 had evidence of penetration. Occasionally, a
child presents with clear evidence of anogenital trauma without an adequate
history. The difficulty of diagnosis is further complicated, since children
may deny abuse.
Suspicious Physical Findings
Findings that are concerning include:
• Abrasions or bruising of the genitalia
• An acute or healed tear in the posterior aspect of the hymen extending to
the hymen's base
• A markedly decreased or absent hymenal tissue posteriorly
• Injurytoorscarringoftheposteriorfourchette,fossanavicularis,orhymen
• Anal bruising or lacerations.
The interpretation of physical findings continues to evolve as evidence-
based research becomes available. Certain positive findings, however, serve
as very likely if not definitive indications of abuse. For example, the presence
of semen, sperm, or acid phosphatase; a positive culture for Neisseria gonorrhoeae or Chlamydia trachomatis; or a positive serologic test for syphilis or
human immunodeficiency virus infection make the diagnosis of sexual abuse
a near certainty even in the absence of a positive history, if perinatal transmission of the sexually transmitted diseases has been excluded. However, it
is important to recognize that because of its prolonged incubation period,
the human papillomavirus may not produce lesions until several months to
years after delivery, despite transmission at birth and, therefore, may need
further investigation of the unsuspecting mother who often is unaware of
her own infection.
Reporting a Crime
The medical evaluation is first and foremost an examination by a medical
professional with the primary aim of diagnosing and determining treatment
for a patient's complaint. When the complaint involves the possible commission of a crime, however, the physician must recognize legal concerns. The
legal issues confronting pediatricians in evaluating sexually abused children
include mandatory reporting of suspected abuse, with penalties for failure
to report; involvement in the civil, juvenile, or family court systems; involvement in divorce or custody proceedings; and involvement in criminal
prosecution of defendants in criminal court.
The fact remains that whatever the associated family dynamics, the
situation of sexual abuse is always a delicate one and must be handled with
the least inflammatory words and actions as possible. It is essential that the
physician's role be clearly defined as an advocate for the child and that the
physician remains nonaccusatory of parents or guardians until the facts have
been obtained and other likely causes have been ruled out.
Suggested Readings
Kellogg N, and the Committee on Child Abuse and Neglect. The evaluation of sexual abuse
in children. Pediatrics. 2005;116:506–512. (doi:10.1542/peds.2005-1336). www.pediatrics.
aappublications.org/cgi/content/full/116/2/506. Accessed December 28, 2007.
Lahoti SL, McClain N, Girardet R, et al. Evaluating the child for sexual abuse. Am Fam
Physician. 2001;63(5):889–892. Published March 1, 2001. www.aafp.org/afp/20010301/
883.html. Accessed December 28, 2007.
Sexual Assault in Children and Adolescents. www.respyn.uanl.mx/especiales/2005/ee-112005/documentos/73.pdf
Topics in Emergency Medicine-Full text: Volume 24 (4) Dec. www.pt.wkhealth.com/pt/re/
tme/fulltext.00007815-200212000-00007.htm
Book Source Details
- Book Title: Avoiding Common Pediatric Errors
- Author(s): Anthony D Slonim MD, DrPH; Lisa Marcucci MD
- Year of Publication: 2008
- Copyright Details: Avoiding Common Pediatric Errors, Copyright © 2008 Lippincott Williams & Wilkins.
More About Child abuse
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: Avoiding Common Pediatric Errors
Authors: Anthony D Slonim MD, DrPH; Lisa Marcucci MD
Publisher: Lippincott Williams & Wilkins
Copyright: 2008
ISBN: 0-7817-7489-6
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