Sexual Abuse

Sexual Abuse: Excerpt from The 5-Minute Pediatric Consult

Cindy W. Christian, MDMatthew J. Cox, MD

Sexual Abuse - BASICS

Sexual Abuse - description

Sexual abuse is the involvement of children in sexual activities that they cannot understand, for which they are not developmentally prepared, to which they cannot give informed consent, and/or that violate societal norms. It is due to a complex interaction of societal, familial, and individual factors.

• Associated problems:
  • Physical abuse
  • Domestic violence
  • Neglect
  • Emotional abuse
• Pitfalls:
  • Failing to consider sexual abuse in the differential diagnosis of nonspecific behavioral and physical complaints
  • If cultures are not properly performed, the results may be uninterpretable or misleading.

Sexual Abuse - general prevention

The efficacy of sexual abuse prevention programs is difficult to measure. Although children who are taught about personal safety learn from the experience, it is unknown whether their behavior is changed by such education.

Sexual Abuse - epidemiology

• Children of all ages are victimized, with a peak age of vulnerability between 7 and 13 years.
• Girls are victimized more than boys, although abuse of boys is thought to be underreported. Boys represent ~20% of cases reported to child protection agencies each year.
• Race and socioeconomic status are not believed to play a role in the epidemiology of sexual abuse.

Sexual Abuse - incidence

~150,000 substantiated cases are identified each year in the US. This is likely to be a significant underestimation of the actual numbers.

Sexual Abuse - DIAGNOSIS

Sexual Abuse - signs & symptoms

Sexual Abuse - history

• The physician interview should be detailed, especially if it is the 1st professional interview of the child.
  • Prior to the examination, however, the child may have been interviewed by the police, social service workers, or a forensic interviewer.
  • In this case, the history does not need to include all of the following details, but should include information needed to perform an appropriate medical assessment of the child.
• The interview should be conducted with the child separate from family members; diagnosis often depends on the history obtained from the child.
• Ask open-ended, nonleading questions.
• Use developmentally appropriate language.
• Special questions:
  • Identity of alleged perpetrator/relationship to child
  • Time of last possible contact
  • Method of disclosure
  • Frequency of abuse (one versus multiple occurrences)
  • Specific types of sexual contact included in the abuse
  • Whether the perpetrator ejaculated, if a male
  • Threats made to child by alleged perpetrator
  • Previous official reports of the abuse
  • Review of systems including genital pain, bleeding, dysuria, constipation, painful bowel movements, and behavioral changes

Sexual Abuse - physical exam

• Varies depending on age of child
• Prepubertal children require detailed external genital inspection only.
  • Genital examination can be done with child in supine frog-leg position.
  • Use of the techniques of labial separation and labial traction will allow complete examination of the vulvar structures.
• Adolescent girls may require a full pelvic examination.
  • Prepubertal girls should not have speculum examination unless anesthesia is used.
• Few physical findings are diagnostic of abuse.
  • These include the presence of semen or sperm, acute genital/anal injuries without an adequate accidental explanation, syphilis (excluding perinatal infection), and culture-proven infection with Neisseria gonorrhoeae.
• Look for acute genital injuries and marked disruptions in hymenal tissue.
• Many genital findings are unlikely to be related to abuse. These include small labial adhesions, Candida albicans dermatitis, erythema of the vestibule, and small mounds or projections on an otherwise normal hymen.

Sexual Abuse - tests

Sexual Abuse - lab

• Universal STD screening is not necessary.
• Vaginal cultures are obtained from within the vaginal canal.
  • The unestrogenized hymen is very sensitive, so great care should be taken in inserting a swab through the hymen opening.
  • Allow 10–15 seconds for swabs to absorb secretions.
• Cultures for N. gonorrhoeae from rectum, vagina (prepubertal), cervix (adolescent), penile urethra, and/or throat; misidentification of N. gonorrhoeae can be a problem if confirmatory tests (e.g., sugar fermentation, latex agglutination) are not properly done.
  • Be familiar with the laboratory’s methods of identification and confirmation.
  • Cultures are the gold standard and are the only acceptable method for diagnosing STDs in prepubertal children.
• Chlamydia cultures from rectum, vagina (prepubertal), cervix (adolescent), and/or penile urethra; obtain cells for chlamydia culture by gently scraping the vaginal wall with a swab (in young children).
  • Because of the low prevalence of chlamydia in the prepubertal population and normal flora that can produce false-positive results, culture remains the gold standard for chlamydia testing.
• The use of nucleic acid amplification techniques (NAAT) can be used for the initial screening of at-risk populations with follow-up culture techniques prior to definitive treatment.
  • The NAAT have higher sensitivities than the gold standard culture techniques.
• Routine genital culture
• Rapid plasma reagin (RPR), hepatitis serology, HIV, if indicated
• Forensic evidence collection (for an acute assault)

Sexual Abuse - diag proced-surgery

• The labial traction technique (gently grasping labia majora and pulling laterally, down, and toward the examiner) allows for the best visualization of the hymenal edges.
• When available, the use of colposcopy is generally recommended for purposes of magnification and photodocumentation of the examination.

Sexual Abuse - differencial diagnosis

• Infection with genital discharge:
  • N. gonorrhoeae
  • Chlamydia trachomatis
  • Trichomonas vaginalis
  • Group A streptococcus
  • Haemophilus influenzae
  • Staphylococcus aureus
  • Corynebacterium diphtheriae
  • Mycoplasma hominis
  • Gardnerella vaginalis
  • Shigella flexneri (discharge may be bloody)
• Infection with genital bleeding:
  • UTI
  • Vulvovaginitis
• Infection with genital inflammation/pruritus:
  • STDs or STIs
  • Pinworms
  • Scabies
  • Candida albicans (in pubertal girls)
  • Group A streptococcal vulvovaginitis or perianal cellulitis
• Trauma:
  • Accidental trauma, including straddle and impaling injuries
  • Mechanical friction from tight clothing or obesity
  • Accidental tourniquet of genitals by hair
• Congenital:
  • Variations in hymenal configuration (septated, cribriform, microperforate, imperforate hymens)
  • Urethral caruncles; vestibular bands
  • Ectopic ureterocele; hemangiomas
  • Syndromes associated with anogenital anomalies
• Psychosocial:
  • Normal behaviors (masturbation, playing doctor)
  • Exposure to sexual activity (e.g., in which the child witnesses sexual acts)
  • False allegations of sexual abuse
• Dermatologic:
  • Contact dermatitis
  • Seborrhea
  • Diaper dermatitis
  • Lichen sclerosis et atrophica
  • Balanitis xerotica
  • Nevi
• Endocrine:
  • Pseudomenses (neonatal withdrawal bleeding)
  • Physiologic leukorrhea
• Miscellaneous:
  • Nonspecific vulvovaginitis
  • Rectovaginal fistula
  • Labial adhesion (agglutination)
  • Urethral prolapse
  • Phimosis, paraphimosis
  • Foreign body

Sexual Abuse - TREATMENT

Sexual Abuse - general measures

• Ensure the safety of the child.
• Report suspected abuse to the local child welfare agency.
• Report suspected sexual abuse to law enforcement.
• Consult a social worker.
• Inform the parents of the report.

Sexual Abuse - medication

• Prophylactic antibiotics that are effective against common STDs, such as gonorrhea, chlamydia, and syphilis, are generally not used for prepubertal children, because these infections are uncommon.
  • Prophylaxis against STDs may be considered for stranger assaults.
• Identified STDs should be treated with the appropriate regimen according to published guidelines from the Centers for Disease Control and Prevention (CDC).
• Consider pregnancy prevention (e.g., emergency hormonal contraceptive) for adolescents.
• Tetanus booster for patients with acute, serious genital or other injuries
• Sitz baths for comfort

Sexual Abuse - FOLLOW UP

Sexual Abuse - prognosis

• Varies greatly depending on specifics of abuse sustained, available support systems
• More extensive injuries (e.g., deep lacerations, tears) may take weeks to months to heal.
• The emotional impact of sexual abuse is very slow (may take years) to resolve.

Sexual Abuse - complications

• STIs, such as gonorrhea, genital warts, C. trachomatis, syphilis, and herpes simplex virus, are identified in only a small percentage of sexually abused children.
• Emotional problems such as posttraumatic stress disorder (PTSD), feelings of helplessness, impaired trust, low self-esteem, depression, adolescent substance abuse, and suicide attempts are seen in some victims of sexual abuse.
• Aggressive, hypersexual, withdrawn behavioral problems may be consequences of having been abused.

Sexual Abuse - patient monitoring

• Cases will be investigated by child welfare and/or the police.
• Need for foster care placement and/or ongoing supervision is decided by child welfare investigators.
• Most children are referred for short- or long-term counseling.
• Persistent physical/genital complaints, which may indicate ongoing abuse, an STD, or psychologic problems
• Patient victimizing younger child: Young perpetrators are often victims of previous abuse.
• It is important to get help for the child perpetrator so that the pattern of abuse does not continue.

Sexual Abuse - bibliography

1. Berenson AB, Chacko MR, Wiemann CM, et al. A case-control study of anatomic changes resulting from sexual abuse. Am J Obstet Gynecol. 2000;182:820–834.
2. Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines. MMWR Morb Mortal Wkly Rep. 2006;55:1–100.
3. Christian CW, Lavelle JM, De Jong AR, et al. Forensic evidence findings in prepubertal victims of sexual assault. Pediatrics. 2000;106:100–104.
4. Girardet RG, Lahoti S, Parks D, et al. Issues in pediatric sexual abuse—what we think we know and where we need to go. Curr Probl Pediatr Adolesc Health Care. 2002;32:216–246.
5. Gushurst CA. Child abuse: Behavioral aspects and other associated problems. Pediatr Clin North Am. 2003;50:919–938.
6. Heger A, Ticson L, Velasquez O, et al. Children referred for possible sexual abuse: Medical findings in 2384 children. Child Abuse Neglect. 2002;26:645–659.
7. Kellogg N; American Academy of Pediatrics Committee on Child Abuse and Neglect. The evaluation of sexual abuse in children. Pediatrics. 2005;116:506–512.
8. Kellogg ND, Baillargeon J, Lukefahr J, et al. Comparison of nucleic acid amplification techniques and culture techniques in the detection of Neisseria nonorrhoeae and Chlamydia trachomatis in victims of suspected child sexual abuse. J Pediatr Adolesc Gynecol. 2004;17:331–339.

Sexual Abuse - CODES

Sexual Abuse - icd9

• 995.5 Child maltreatment syndrome
• 995.53 Child sexual abuse

Sexual Abuse - FAQ

• Q: What does “intact hymen” mean?
• A: “Intact hymen” is not a medical term and should be avoided in describing the medical examination of the genitals. The hymen is a membranous structure at the entrance to the vaginal canal. It should have an opening that varies in size depending on the child, the child’s age, the position in which the child was examined, and so on. The hymen should be inspected for signs of trauma. There is a wide variation of normal hymenal appearances, and caution should be used in interpreting findings.
• Q: Can there be penetration without physical findings?
• A: Yes. Although full penetration of an erect penis into the prepubertal vaginal canal (through the hymen) will likely leave injury, the healing properties of the vulvar tissues are great, so that past injuries are sometimes difficult or impossible to identify. Furthermore, penetration may be partial (as in vulvar coitus) and may not leave any injuries to the tissue. For these reasons, physical injuries may not be identified despite a history of penetration.
• Q: Are STDs always transmitted sexually?
• A: No. All STDs may be transmitted vertically (from mother to infant). The incubation periods of different infections vary, so they are expressed at different ages accordingly. Casual transmission of STDs is postulated for some organisms, but not for others. Gonorrhea and syphilis are considered diagnostic of sexual abuse outside of congenital infection. Chlamydia, herpes simplex virus 2, and trichomonas are probably due to sexual abuse and should be reported for evaluation. Condyloma acuminata is controversial at this time, is probably related to sexual abuse in school-aged and older children, and should be referred for evaluation. Herpes simplex virus type 1 and bacterial vaginosis are nonspecific infections that are not usually related to sexual abuse. Candida is unlikely to be related to sexual abuse.
• Q: How often do sexually abused children have physical evidence of the abuse?
• A: In most cases, there are no specific physical indicators of abuse. Only a few patients (4–14%) have physical evidence considered diagnostic of abuse. Many children have nonspecific abnormalities of the physical examination, and many have normal examinations.

Book Source Details

• Book Title: The 5-Minute Pediatric Consult
• Author(s): M. William Schwartz MD; et al.
• Year of Publication: 2008
• Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: The 5-Minute Pediatric Consult Authors: M. William Schwartz MD; et al. Publisher: Lippincott Williams & Wilkins Copyright: 2008 ISBN: 0-7817-7577-9

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