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Knowing the signs and symptoms of sexual abuse, techniques of interviewing, the significance of anogenital findings, and which lab tests to order will help you identify victims and intervene effectively.
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Caring for patients who are victims of sexual abuse is particularly challenging. Knowing the signs and symptoms of sexual abuse, techniques of interviewing, the significance of anogenital findings, and which lab tests to order will help you identify victims and intervene effectively.
Each year, about 1% of children experience some form of sexual abuse.1,2 Given this estimate, a primary care provider who treats 2,000 pediatric patients can expect to encounter approximately 20 children annually who have been sexually abused. These patients are challenging to care for in the office because they require significant time, emotional energy, and resources. What's more, sexual abuse is an uncomfortable subject that does not receive adequate emphasis during medical training.3 As a result, many medical providers feel inadequately prepared to address this problem.
Despite these difficulties, primary care providers, by virtue of their ongoing relationship with the child and family, are in a unique position to offer support and guidance when sexual abuse is suspected or has occurred. To do so effectively, physicians need to know the dynamics of sexual abuse, how victims present, elements of the medical evaluation, and when to referall topics we cover in this article.
It is also essential for providers to know how to manage both the medical consequences of sexual abuse (notably, sexually transmitted diseases) and the psychological ones. We cover these topics, along with reporting requirements for abuse, appropriate documentation, and preventive measures, in the article that follows.
Child sexual abuse is defined as engaging a child in sexual activity that the child cannot comprehend, for which the child is developmentally unprepared and cannot give informed consent (due to young age), or that violates societal taboos. It may include exhibitionism, fondling, genital viewing, oral-genital contact, insertion of objects, vaginal or rectal penetration, and pornography.4 Such contact may occur once with an unfamiliar person or may involve a long-standing sexual relationship with a family member or other person known to the child. The victim knows the perpetrator in 70% to 90% of cases of sexual abuse; 50% of cases involve a relative.5
Sexual assault is defined as any sexual act performed by one person on another without that person's consent. It may involve a threat or actual use of force. The victim may not have had the capacity to give consent because of age, mental or physical impairment, or the use of drugs or alcohol.4
The age of consent varies by state. Practitioners should check their state laws to determine the age of consent for sexual activity in the state where they practice.
Although the true extent of child sexual abuse is unknown, an estimated 90,000 substantiated reports of sexual abuse, across all social and economic classes, were made to child protective service agencies across the United States in 1996.6 Such numbers indicate that child sexual abuse is not uncommon.7 Among the risk factors are lack of protective behavior on the part of the parents, drug and alcohol abuse within the family, and social isolation.
Although the true incidence of adolescent sexual assault is unknown, each year approximately 700,000 females report being raped; 61% are under 18 years of age.8 It is commonly believed that most rapes are perpetrated by a stranger but, in fact, about half of adolescent sexual assaults are committed by an acquaintance.9 Male victims are estimated to represent about 5% of reported cases of sexual assault.10 The estimates for both male and female victims may be low because of underreporting.
Children and adolescents who have been sexually abused sometimes reveal this fact to a trusted person, such as a parent, teacher, therapist, or school counselor.11 Such disclosure frequently triggers a family crisis, even if the child or adolescent no longer has contact with the alleged perpetrator and no physical complaints are apparent.
Shortly after disclosure, agencies such as children's services and law enforcement may become involved. The child and family will likely participate in an investigation that includes a forensic interview, and the child will probably have a physical examination, which can be very stressful. In cases of intrafamilial abuse, custody may change and the child may be moved out of the home. A nonoffending parent may have to decide whether to leave an offending partner.
Disclosure may bring up issues for parents that they have not adequately dealt with, such as their own history of child sexual abuse.12 Parents, even those who have not been sexually victimized, often experience intense emotions, such as guilt, depression, and anger, following disclosure. Emotions may be conflicting if the perpetrator is a family member.
Some parents may feel relieved if their child has no signs of physical trauma. However, the absence of medical findings may make it harder for them to believe their childeven when the disclosure is clear, consistent, and credible.
After a child discloses that she (or he) has been abused, the family may visit the pediatrician for a medical examination and assistance contacting child protective services. Occasionally, child protective services may already be involved with the family and may request that the pediatrician perform a medical evaluation for sexual abuse. Sometimes, a parent or other person has concerns based on behavioral symptoms or physical signs, even though the child or adolescent has not disclosed any sexual abuse. Common behavioral manifestations of sexual abuse are listed in Table 1.13 Physical signs are discussed in detail later in this article.
Whether or not a disclosure has been made, pediatricians need to be able to recognize signs and symptoms of sexual abuse, perform a general history and physical examination to detect it, understand normal genital anatomy to avoid overdiagnosing it, and, if appropriate, screen for sexually transmitted diseases (STDs) and pregnancy. It is also essential to be available for follow-up questions throughout the patient's childhood and adolescence. The physician may be one of the few people familiar to the child, especially if she is placed in foster care.
Not all cases of sexual abuse or assault are appropriate for the primary care setting. Cases in which there is a disclosure of sexual contact within the preceding 72 hours may require a rape kit.14,15 While the contents of these kits may vary from one legal jurisdiction to another, they usually contain swabs and envelopes with instructions for collecting forensic evidence from the child's or adolescent's body. This evidence may be useful in identifying and prosecuting the perpetrator of the abuse. Be prepared to make immediate referral to an emergency department for collection of forensic evidence. Other circumstances that may warrant a referral are listed in Table 2.
|Indication||Type of referral|
|Rape within preceding 72 hours for collection of forensic evidence||Refer immediately to emergency department|
|All cases of rape||Consider referral to a rape crisis team|
|Child reports a history of abuse or is reluctant to talk about suspicious behavioral or physical complaint||Refer to a child abuse program|
|Abnormal or uncertain anogenital finding on physical exam||Refer to a child abuse program for a second opinion exam|
|Significant vaginal bleeding; child is uncooperative||Consider referral to a pediatric center for examination under anesthesia|
If possible, take the medical history from the parents and the child separately.16 Record the date and time of the visit, sources of any information, and the date, time, and place of the alleged abuse or assault.4 Focus your questions on what happened and, specifically, whether genital, rectal, or oral contact occurred. Use developmentally appropriate language that will be easily understood by the patient. Avoid leading questions. Appropriate questions include:
Ask the child about pain or injury occurring at the time of the episode. Consider repeating certain questions during the physical exam; pointing to body parts (rather than just using anatomic terms) may help the child understand what you are asking. With adolescent patients, obtain a menstrual and contraceptive history as well as any history of consensual sexual activity. Avoid the temptation to decide, on the basis of the child's or adolescent's emotional response, whether an assault took place. Many patients are tearful and visibly upset; some are calmer and more controlled. Some very young victims may not even comprehend what took place.
When disclosure hasn't been made and the patient has a suspicious behavioral or physical complaint, it may be necessary to question her. You can begin by asking the child to name her body parts to determine which ones are private, and to define "good touch" and "bad touch." Examples of useful questions include:
Children who have reported a history of sexual abuse during the medical evaluation and those who are reluctant to talk about a suspicious behavioral or physical complaint may need to be interviewed by a trained forensic examiner who will collect more detailed information.11 Consider referral to a child abuse program in such instances.
After obtaining the medical history, inform the patient and family of the need for a complete physical assessment. Explain each step of the exam, including the genital exam, and offer the patient and family an opportunity to ask questions before you begin the assessment. Drawings or a plastic model can be a useful aid. Remember that a victim of sexual abuse has had control taken from her by the perpetrator; it is important for her to be able to set the pace of the exam and to trust that the physician will stop at any point if asked.
Most children want the parent or another trusted adult to remain with them during the physical evaluation, provided that this person is not the alleged perpetrator. The adolescent patient should decide who they want present. A representative of child protective services or law enforcement should not be present for the examination unless the patient requests it.
Start with an assessment of general appearance before proceeding with the anogenital exam. This helps make the patient comfortable with the process. The exam can then be paced so that the evaluation of the anogenital region is less threatening. During assessment of general appearance, look for evidence of injury (bruises, abrasions, lacerations) and document such evidence clearly in the medical record.
The rest of the physical exam varies with the patient's age and sex. You may need to obtain specimens for testing for STDs (we discuss these tests in detail later). In all cases, carefully document anogenital abnormalities, using anatomic diagrams if helpful. You can interpret the significance of anogenital findings using either of two classification systems. Muram's system is described in Table 3;17 Adam's system, which is much more detailed, appears in the February 2001 issue of Child Maltreatment.18
Muram's classificationNormal-appearing genitalia
Nonspecific findings Abnormalities of the genitalia that could have been caused by sexual abuse but that also are often seen in girls who are not victims of sexual abuse (i.e, caused by inflammation, scratching). These findings may be sequelae of poor perineal hygiene or nonspecific infection. Included in this category are:
Specific findingsOne or more abnormalities strongly suggesting sexual abuse, including:
This category includes patients with laboratory confirmation of a sexually transmitted disease.
Definitive findingsPresence of sperm
The prepubertal female. Perform a thorough external examination of the genital and anal areas.19,20 First be sure you are familiar with the external genitalia of the prepubertal female child (Figure 1).
Do not use a speculum, which is painful and can be emotionally traumatic. Use an otoscope or a hand-held lens with a bright light source to adequately visualize the hymen. Colposcopy, although not essential, provides photographic documentation. If you do use a colposcope, give the child an opportunity to familiarize herself with the instrument by using it to visualize her fingers or jewelry. Reassure child and parent that the instruments will be used to look "on the outside" of the anogenital area.
Many children tolerate the exam better when the parent stands close or holds their hand. Do not rush, as this may increase the child's anxiety and resistance. If the child is reluctant to be examined, it may help for you to leave the room for a few minutes to give her time to prepare.4 If a child has significant vaginal bleeding and you cannot gain her cooperation, it may be necessary to make immediate referral to a pediatric center for an exam under anesthesia.
When performing the external examination, look for signs of trauma (bruising or abrasions, for example) or lesions suspicious for herpes simplex virus (HSV) or human papillomavirus (HPV). The hymen can usually be readily visualized by placing the child in the frog-leg position (Figure 2), then gently grasping the labia majora and providing gentle separation or traction. A child who is afraid of lying on the examining table can be examined in her parent's lap, with the parent sitting in a chair or in a semireclined position on the exam table (her feet in or out of the stirrups) and the child's legs straddling her thighs (Figure 3). If the hymen is difficult to visualize when the child is supine, the knee-chest position (Figure 4) can be used to see the hymen more clearly. In this position, the vaginal walls and cervix can also be visualized.
There are several normal hymenal variations, including the crescentic, annular, and redundant hymen (Figure 5). Carefully examine the edges of the hymen for transections (tears) or scars in the inferior portion. You can more readily assess a redundant hymen by applying a drop or two of saline to the hymen, which will cause the edges to float. Alternatively, examining the child in the knee-chest position sometimes allows the edges of a redundant hymen to be visualized more clearly.
Imagine the hymen as the face of a clock with the urethra at the 12 o'clock position. Focus your attention on the lower half of the hymenbetween the 3 o'clock and 9 o'clock positions; abnormalities from sexual abuse are generally located in this area. In particular, look for irregularities of the edge of the hymen. If you see any abnormalities in the supine position, confirm them in the knee-chest position.
Be aware that the anal and genital examinations are normal in more than two thirds of victims of sexual abuse.21 Most types of sexual contact do not result in any signs of trauma. Even children who report penile contact often have normal exam findings because the penis is placed between the child's thighs or labia, with no trauma resulting to the hymen. Also, a remarkable healing process takes place in patients who have been sexually abused or assaulted. One study that followed victims of sexual abuse found that many signs of acute injury disappeared within a few days. The most persistent findings were irregular hymenal edges and narrow hymenal tissue at the point of injury. Most injuries with jagged edges tended to smooth out. Injuries to the posterior fourchette also healed with minimal scar tissue. 22
After examining the genital area, examine the anus for signs of trauma. The normal elasticity of this area typically prevents injury from sexual abuse, so the exam is usually normal even in a child who has experienced anal penetration. When anal injury is present, healing may take place within days.23 In one study, superficial lacerations healed in one to 11 days, deeper injuries healed in one to five weeks, and all signs of injury disappeared by 12 to 14 months.24
The adolescent female. Examination of the adolescent female includes all the steps taken for the prepubertal female plus a speculum exam for adolescents who have reached menarche, had vaginal penetration, and can tolerate a speculum.9
Examine the external genitalia for signs of trauma or evidence of HSV or HPV. Before the speculum exam, use a saline-moistened swab to examine the edge of the hymen for transections in the inferior region. In contrast to the prepubertal hymen, the adolescent hymen is thickened, elastic, and redundant because of the effects of estrogen; it can be examined with a moist swab without causing the adolescent discomfort. Alternatively, an experienced examiner can insert a 12-to-14-gauge Foley catheter into the vagina and inflate the catheter bulb with 10 mL of air to visualize the edge of the hymen.25,26
Before using the speculum, insert one gloved finger through the hymenal ring to gauge the elasticity of the hymen and determine whether a Huffman (1 cm) speculum can be inserted without discomfort. For a sexually active adolescent, a Pederson speculum is appropriate.
If the patient has vaginal discharge, obtain KOH and saline wet preps, determine the pH, and examine specimens under a microscope for white blood cells (WBCs), clue cells, or trichomonads. A Pap smear is also important to look for evidence of cytologic abnormalities caused by HPV, especially if the alleged sexual contact occurred several weeks or months ago. If an adolescent declines or cannot tolerate a speculum examination, obtain specimens for culture for gonorrhea and Chlamydia from vaginal swabs or urine samples.
Be aware that the absence of physical findings is common in cases of adolescent sexual assault even if penetration is reported by the victim or perpetrator. This is because of the high degree of elasticity of genital and anal tissue.
As with prepubertal girls, focus your examination on the inferior half of the hymen between the 3 o'clock and 9 o'clock positions, where hymenal trauma from sexual abuse or assault is most likely to occur. If you have any questions about the significance of a specific finding, refer to a child abuse clinic for a second opinion.
The male patient (any age). Carefully examine the penis, scrotum, and anus for signs of injury, such as bruises, lacerations, abrasions, or other lesions. Examine a sample of any penile discharge with a microscope, looking for WBCs and organisms such as Trichomonas.
Most male victims of sexual abuse or assault have a normal physical exam because certain types of sexual contact may not leave physical findings (fondling and oral-genital contact, for instance). As with girls, a male victim of anal penetration may not have abnormal physical findings because of the high degree of tissue elasticity in that area.
In a study of 1,538 children (ages 1 to 12 years) evaluated for sexual abuse between 1981 and 1991, Neisseria gonorrhoeae was found in 2.8%, HPV in 1.8%, Chlamydia trachomatis in 1.2%, Treponema pallidum in 0.1%, and HSV in 0.1%.27 While gonorrhea transmission rates in prepubertal children have not been established, gonococcal infections are common in adolescents. Positive screening cultures have been found in 0.5% to 13% of sexually active adolescents. Rates of infection are higher among adolescents with a history of sexual abuse, those seen in inner city clinics, incarcerated teens, and those who engage in high-risk sexual behaviors.28
The risk of acquiring Chlamydia during sexual assault is estimated to be between 4% and 17%.29 When evaluating a child for possible sexual abuse, keep in mind that congenitally-acquired Chlamydia can persist for many months after birth, whereas congenitally acquired gonorrhea is much less likely to persist that long. Antibiotics used to treat common childhood infections during the first three years of life make persistence of Chlamydia beyond this age less common, increasing the likelihood that Chlamydia in children older than this age has been sexually transmitted.
The Centers for Disease Control and Prevention estimates the rate of syphilis infection as a result of sexual assault to be 0.5% to 3%, although patients who have other STDs are at increased risk.4,30 The risk of acquiring HPV is unknown, although transmission has been documented from a single act of rape.4 The risk of acquiring HIV in one study was 0.25 per 1,000 assessments for child sexual abuse (although the children tested were not randomly selected).31 STDs are believed to be more common in adolescents than in younger children in the setting of sexual abuse, due to physiologic changes of the genital tract that occur during puberty and the higher likelihood of vaginal intercourse occurring during the assault.4
Testing for STDs in prepubertal children in acute sexual assault (defined as having occurred less than 72 hours before presentation) is controversial.32 In most acute cases, cultures are negative; when results are positive, they may not represent new infection.
One option is to perform cultures on prepubertal patients in whom signs of an STD are obvious or who disclose genital-genital contact. Cultures may also be indicated if anogenital injury is present, the perpetrator is known to have an STD, or there are multiple perpetrators.33 All adolescent victims should be cultured because of the high rate of STDs from sexual assault and consensual sexual activity.4 One study found that 43% of pubertal female victims of rape had at least one STD when examined within 72 hours of the assault. When followed up within five months later, the incidence of new disease was 4% for gonorrhea, 2% for Chlamydia, 12% for trichomoniasis, and 19% for bacterial vaginosis. The authors concluded that the prevalence of pre-existing STDs in this group is high and the risk of acquiring STDs as a result of the assault substantial.34
If you decide to test for STDs, obtain oral, genital, and anal cultures for gonorrhea and genital and anal cultures for Chlamydia. Take swabs of these areas and plate them on standard culture media. Gonorrhea specimens should be plated directly on Thayer-Martin-Jembec or other appropriate transport media. Chlamydia specimens should be obtained using calcium alginate or polyester swabs and placed into an adequate growth or transport media such as minimal essential media. Swab any lesions suspicious for HSV and send them for culture.
When possible, only culture methods should be used in children and adolescents who have been sexually abused or assaulted.35 If only nonculture methods, such as DNA probes and polymerase chain reaction assays, are available, perform an initial screen and obtain a culture if results are positive. Nonculture methods may be more sensitive but less specific than culture methods. For this reason, further research on the use of nonculture methods in prepubertal children would be helpful to clinicians. When obtaining cultures, baseline serologic testing, including rapid plasma reagin and hepatitis B surface antigen tests, are also recommended. Testing for HIV is controversial: The CDC does not state that HIV testing is required, although the American Academy of Pediatrics recommends it for victims of rape.9,36
Prophylactic therapy and treatment strategies for STDs are reviewed in "Sexual abuse: Management strategies and legal issues."
The prevalence of child sexual abuse is such that any physician who has pediatric patients may find himself caring for a child or adolescent who has been victimized. Familiarity with the indicators of abuse and an ability to perform a thorough and accurate medical assessment are paramount to getting the patient the help she needs. Be sure to refer to a child abuse expert for a second opinion if you note abnormal findings or are uncertain about whether the anogenital exam is normal. In addition, stay abreast of guidelines for assessing and managing child sexual abuse by reading the most current literature.
1. National Study on the Incidence of Child Abuse and Neglect. Washington, D.C., US Department of Health and Human Services, 1988
2. American Academy of Pediatrics, Committee on Child Abuse and Neglect: Guidelines for the evaluation of sexual abuse of children. Pediatrics 1991;87:254
3. Leder M, Emans SJ, Hafler JP, et al: Addressing child sexual abuse in the primary care setting. Pediatrics 1999;104:270
4. Emans SJ: Sexual abuse, in Emans SJ, Laufer MR, Goldstein DP (eds): Pediatric and Adolescent Gynecology, ed 4. Philadelphia, Lippincott-Raven, 1998, pp 751-794
5. Finkelhor D: Current information on the scope and nature of child sexual abuse. Future Child 1994;4:31
6. Alexander R: Statistics of child abuse, in Jones J (ed): A Guide to References and Resources in Child Abuse and Neglect. Elk Grove Village, Ill., American Academy of Pediatrics, 1998, pp 181-185
7. Koverola C, Friederich W: Psychological effects of child sexual abuse, in Heger A, Emans SJ, Muram D (eds): Evaluation of the Sexually Abused Child. New York, Oxford University Press, 2000, pp 21-40
8. National Victim Center and Crime Victims Research and Treatment Center: Rape in America: A Report to the Nation. Arlington, Va., 1992, pp 1-6
9. American Academy of Pediatrics, Committee on Adolescence: Sexual assault and the adolescent. Pediatrics 1994;94:761
10. Greydanus DE, Shaw RD, Kennedy EL: Examination of sexually abused adolescents. Semin Adolesc Med 1987;3:59
11. Bourg W, Broderick R, Flagor R, et al: Interviewer training, in Bourg W, Broderick R, Flagor R, et al (eds): A Child Interviewer's Guidebook. Thousand Oaks, Calif., Sage Publications, 1999, pp 10-18
12. Hiebert-Murphy D: Emotional distress among mothers whose children have been sexually abused: The role of a history of child sexual abuse, social support, and coping. Child Abuse & Neglect 1998;22:423
13. Krugman R: Recognition of sexual abuse in children. Pediatr Rev 1986;8:28
14. American Academy of Pediatrics, Committee on Child Abuse and Neglect: Guidelines for the evaluation of sexual abuse of children: Subject review. Pediatrics 1999; 103:186
15. Christian CW, Lavelle JM, DeJong AR, et al: Forensic evidence findings in prepubertal victims of sexual assault. Pediatrics 2000;106:100
16. Frasier L: The pediatrician's role in child abuse interviewing. Pediatric Annals 1997;26:306
17. Muram D: Classification of genital findings in prepubertal girls who are victims of sexual abuse. Adolesc Pediatr Gynecol 1988;1:151
18. Adams JA: Evolution of a classification scale: Medical evaluation of suspected child sexual abuse. Child Maltreatment 2001;6(1):31
19. Emans SJ: Office evaluation of the child and adolescent, in Emans SJ, Laufer MR, Goldstein DP (eds): Pediatric and Adolescent Gynecology, ed 4. Philadelphia, Lippincott-Raven, 1998, pp 1-48
20. Kahn J, Emans SJ: Gynecologic examination of the prepubertal girl. Contemporary Pediatrics 1999;16(3):148
21. Adams JA, Harper K, Knudson S, et al: Examination findings in legally confirmed child sexual abuse: It's normal to be normal. Pediatrics 1994;94:310
22. McCann J, Voris J, Simon M: Genital injuries resulting from sexual abuse: A longitudinal study. Pediatrics 1992;89:306
23. Finkel M: Anogenital trauma in sexually abused children. Pediatrics 1989;84:317
24. McCann J, Voris J: Perianal injuries resulting from sexual abuse: A longitudinal study. Pediatrics 1993;91:390
25. Starling S, Jenny C: Forensic examination of adolescent female genitalia: The Foley catheter technique. Arch Pediatr Adolesc Med 1997;151:102
26. Persaud D, Squires J, Rubin-Remer D: Use of Foley catheter to examine estrogenized hymens for evidence of sexual abuse. J Pediatr Adolesc Gynecol 1997;10:83
27. Ingram D, Everett V, Lyna P: Epidemiology of adult sexually transmitted disease agents in children being evaluated for sexual abuse. Pediatr Infect Dis J 1992;11:945
28. Muram D, Stewart D: Sexually transmitted disease, in Hegar AM, Emans SJ, Muram D (eds): Evaluation of the sexually abused child. New York, Oxford University Press, 2000, pp 187-223.
29. Schwarcz S, Wittington W: Sexual assault and sexually transmitted diseases: Detection and management in adults and children. Rev Infect Dis. 1990;12 (suppl 6):S682
30. Rawstron S, Bromberg K, Hammerschlag M: STD in children: Syphilis and gonorrhea. Genitourin Med 1993; 69:66
31. Gellert G: Pediatric acquired immunodeficiency syndrome: Testing as a barrier to recognizing the role of child sexual abuse (editorial). Arch Pediatr Adolesc Med 1994;148:766
32. American College of Emergency Physicians: Evaluation and Management of the Sexually Assaulted or Sexually Abused Patient. Dallas, Texas, ACEP, 1999
33. Atabaki S, Paradise J: The medical evaluation of the sexually abused child: Lessons from a decade of research. Pediatrics. 1999;104(1Pt 2):178
34. Jenny C, Hooton T, Bowers A, et al: Sexually transmitted disease in victims of rape. N Engl J Med 1990;322;713
35. Hammerschlag M, Ajl S, Laraque D: Inappropriate use of nonculture tests for the detection of Chlamydia trachomatis in suspected victims of child sexual abuse: A continuing problem. Pediatrics. 1999;104:1137
36. Centers for Disease Control and Prevention, 1998 Guidelines for Treatment of Sexually Transmitted Diseases. MMWR 1998;47(No. RR-1)
John Knight, M. Ranee Leder, S. Jean Emans. Sexual abuse: When to suspect it, how to assess for it. Contemporary Pediatrics 2001;5:59.