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Pediatrics, Child Sexual Abuse

Author: Ann S Botash, MD, Director, Child Abuse Referral and Evaluation Program, Professor and Vice Chair for Educational Affairs, Department of Pediatrics, State University of New York Upstate Medical University
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Updated: Jul 2, 2008

Introduction

Background

Child sexual abuse affects more than 100,000 children a year. Many of these children present to the emergency department (ED). The following article outlines triage determinants for examinations, examination techniques, and interpretations of genital findings of sexual abuse.

Pathophysiology

Child sexual abuse has been defined by the American Academy of Pediatrics as the engaging of a child in sexual activities that the child cannot comprehend, for which the child is developmentally unprepared and cannot give informed consent, and violate the social taboos of society.¹ In general, children cannot consent to any sexual activity, but the legal age of consent may vary by state.

Sexual activities involving a child may include activities intended for sexual stimulation, such as those involved in contact sexual abuse (eg, touching the child's genitalia or the child touching an adult's genitalia), penetrating injury (eg, penile, digital, and object insertion into the vagina, mouth, or anus), and nonpenetrating injury (eg, fondling, sexual kissing).

Noncontact sexual abuse, which may include exhibitionism, voyeurism, and the involvement of a child in verbal sexual propositions or the making of pornography, often occurs.

Physical findings of sexual abuse are often not present. The most important determinant for abuse is the child's (or a witness's) account of the incident. Physical indicators may be present, such as bruises to the skin (eg, on the arms and legs from pinch marks or force), abrasions to wrists and ankles (eg, from tethering), bruises to the genital area and mucosa, oral palatal bruises and/or petechiae, and rectal abnormalities. Hymenal abnormalities may be present from chronic abuse or acute injury. Sexually transmitted diseases (STDs) may be present in sexually abused children and teenagers.

Frequency

United States

In 2005, 83,850 children in the United States  reported to Child Protective Services, were determined to be suspected victims of child sexual abuse. The actual number is likely to be higher because these numbers reflect only children whose cases are investigated by Child Protective Services.²

Mortality/Morbidity

Although perforation of the vagina or viscera could result in injury and death, death resulting from sexual abuse is unusual.

• Most of the morbidity associated with sexual abuse is a result of emotional and psychological trauma.
• Reactions to sexual abuse can include posttraumatic stress disorder, depression, anxiety, anger, impaired sense of self, dissociative phenomena, suicidal behavior, sexually reactive behaviors that are beyond the scope of normative child sexual development, and indiscriminate sexual behavior.
• STDs may result in further morbidity. However, the prevalence of STDs in sexually abused children varies with geographic location and with the child's age. Most STD prevalence rates in prepubertal children tend to be below 4%; in adolescents, the prevalence rate is approximately 14%.

Sex

It is estimated that 1 in 4 girls and 1 in 6 boys will have experienced an episode of sexual abuse while younger than 18 years. The numbers of boys affected may be falsely low because of reporting techniques.

Clinical

History

Children suspected of being sexually abused require a behavioral, social, gynecologic, and general medical history. Sufficient information about the current incident of sexual abuse is needed to ensure that all needed evidence is properly collected.

• In addition to information obtained from the child, details about the abuse should be obtained from other reliable sources, if possible.
• Obtain a history from the parent or caregiver alone. Social workers and physicians should build rapport with the child in order to establish trust.
• Possible warning signs regarding the social environment include the following:
  • Parents who share intimate feelings and emotions in front of their children
  • Parents who know little about the child's health or have vague recollections of past medical history
  • Parents who are overly concerned with custody issues
  • Social isolation
  • Alcohol and/or drug abuse
  • Intimate partner violence or other violence in the home environment of the child
• The history should also include questions regarding possible behavioral indicators of abuse.
  • Abrupt behavioral changes - Aggression, depression, suicidal behaviors, withdrawal, low self esteem, nightmares, phobias, regression, school problems
  • Self-destructive behaviors - Substance abuse, sleep disorders, prostitution, cutting or other self-mutilation
  • Sexualized behavior inappropriate for developmental level (eg, excessive masturbation, forcing sexual acts on other children)
  • Runaway behavior in teens, loss of memory for events following a social gathering, intimate partner violence
• Physical complaints
  • Foreign bodies in the vagina or rectum, genitourinary complaints, painful defection or urination, vaginal discharge, bleeding or itching, grasp or rope marks, oral complaints, STDs, or possible pregnancy
  • General somatic complaints including headaches, abdominal pain, constipation, diarrhea, encopresis, and general fatigue
• In adolescents, the gynecologic history should always include the following:
  • Date of last menstrual period, number of pregnancies, possible gynecologic surgery or traumatic injury to the genital area
  • Date of the last consensual intercourse and use of contraceptives
  • Prior STDs
• Depending on local protocols, the forensic (investigative) interview may best be performed with the assistance of trained law enforcement officials or social workers from Child Protective Services. The forensic interview differs from a good medical history.
  • This interview is essential to prosecution of a case and is often a critical aspect of the evaluation.
  • The forensic interview is mostly concerned with detailed answers to who, what, where, and when the abuse occurred.
  • The forensic interview should not replace the medical history obtained by the health care provider from the child.
  • If possible, professionals in the field of child sexual abuse should interview children alone.
  • Children may spontaneously disclose abuse to the physicians during the physical examination.
  • The medical record should clearly document who was present when the child disclosed the information, what question or activity prompted the disclosure, and, if possible, the exact words spoken recorded in quotation marks.
  • Questions regarding the incident should be focused but not leading. For example: "What were you touched with?" is an appropriately focused question. "Did he touch you with his fingers?" is a leading question.
  • Children with special communication needs, such as children with developmental disabilities, may require sign language, use of assistive devices, or illustrations.
• Family and social histories are vital to understanding the environment in which the abuse occurred.
• A brief developmental history may be critical in legal aspects of a child's case and should be documented.
• Screening tools for the behavioral and medical history for sexual abuse have been developed and may be utilized.³

Physical

Complete physical examinations in prepubertal children should include an examination of the external genitalia. Children who are suspected of being sexually abused may need an examination emergently, urgently, or electively scheduled for a later time with their own physician. If the child and family are adequately prepared for this examination, it will improve the diagnostic capability of the examiner.

• Following an initial phone call from a parent or from a person from Child Protective Services, pediatric patients may be triaged for a medical examination to find evidence of sexual abuse.
  • Emergent examinations: Any child with acute bleeding or injury should be examined immediately. Children with a history of sexual contact within 96 hours of presentation should be examined for evidence of sexual abuse. Children in severe emotional or psychological crisis also deserve an emergent examination. Children exposed to HIV-positive alleged perpetrators need to begin HIV postexposure prophylaxis within 36 hours of exposure. Adolescents who wish to obtain pregnancy prevention need to be evaluated within 120 hours.
  • Urgent examinations may take place within 2-3 days of an incident of sexual abuse. Indications for an urgent examination include vaginal discharge, the possibility of STDs, and pregnancy in the pubertal child.
  • Delayed presentations are most common because children generally do not disclose abuse until they feel safe. This may occur months or years after the incident of abuse.
  • Other children may not disclose the abuse at all, and only behavioral indicators will be present.
  • If persons from Child Protective Services or law enforcement agencies request examinations of children with nonemergent cases, the examination can be deferred to a scheduled office visit or be referred to a child sexual abuse team.
  • The examination of a child who is involved in a custody situation is challenging. Whether the allegations of abuse are true or not, children involved in sexual abuse allegations must be considered to be victimized. An examination is almost always indicated.
• Preparation of the child and family should be a part of every examination for sexual abuse.⁴
  • The discussion should include the following:
    • Information regarding the need for an external examination of the genitalia
    • The fact that almost all prepubertal children do not need a speculum or internal examination
    • Information on the use of cotton-tipped swabs to check for infections (if determined that these will be needed)
  • If a colposcope will be used for the examination, children should be allowed to look at the equipment and look through the eyepieces or at the video screen.⁵ Parents and older children should be informed of the use of the equipment and given opportunities to consent to the use of photographs for legal documentation. Note: Consent for photographs may not be necessary if the case is under investigation by Child Protective Services, but it is recommended.
• The examination of the external genitalia should occur as part of the natural progression of the complete head-to-toe pediatric examination.
  • Proper positioning of the child for the genitalia examination enables better visualization. Common positions for female prepubertal children include the supine-frog-leg position, the knee chest position, and use of the labial traction technique.
  • Some physicians utilize a technique with a Foley catheter to get a better view of the hymen or utilize water to "float" the hymen for better visualization.⁶
  • The male genitalia can be examined with the child supine or standing.
• Abnormal findings that are suspicious for sexual abuse are rare.
  • Findings of sexual abuse in boys may include injuries to the glans, shaft of the penis, or scrotum. Anal findings are unusual but may include scars (most apparent if located off the midline), distorted or irregular folds, flattening of the anal folds, and poor anal tone.
  • Most cases of suspected or substantiated sexual abuse of prepubertal girls have normal examination findings. This may be due to elasticity of the hymenal tissue and genital mucosa and rapid healing of any injuries.^7,8
    • In most cases, children who are sexually abused are not physically injured (as in fondling), and the abuse does not leave physical evidence.
    • The normal crescent-shaped hymen is most common in prepubertal girls.
    • Other normal findings may include midline avascular areas, periurethral bands, longitudinal intravaginal ridges, superior and lateral notches, and some bumps and hymenal tags.
    • Other anatomical configurations of the hymen, which may normally be observed in prepubertal girls, include an annular hymen, fimbriated hymen, septate hymen, and microperforate hymen.
• Physical findings in sexually abused prepubertal girls may include lacerations and bleeding of the genital area or more subtle chronic findings. Findings on the hymen should be documented by noting the location with the analogy of the hands of a clock. Findings may be significant for abuse.⁹
  • A hymenal tear may result in a healed transection of the hymen. However, over time, a hymenal tear may heal completely, leaving no signs of trauma or scarring.
  • Absence of all or part of the hymen, particularly in the posterior portion of the hymenal ring should be confirmed using different examination positions or techniques. For example, hymenal tissue may be adherent to part of the vaginal wall. Using a moist swab or drops of water to loosen the edge should clarify the finding.
  • Measuring the vaginal introital diameter is not necessary. When the examiner notices a subjectively large diameter, the hymenal rim should be observed for signs of narrowing and attenuation or absence of tissue. However, superficial notches in the hymen may be a normal finding.
  • Fresh lacerations or tears located in the genital area without a history of accidental trauma should be noted.
• Other areas of the body should be inspected for signs of injury, including the oral pharynx for bruises to the hard or soft palate and grasp, rope, or tie marks on the extremities.

Causes

• Risk factors
  • Parent abused as a child: Most perpetrators are not strangers but are known to the child (eg, stepfathers, uncles, mother's paramour). Female perpetrators are reported less often. Parents who have been abused do not always abuse their own children, but the risk for continued familial abuse is present.
  • Multiple caretakers for the child
  • Caretaker or parent who has multiple sexual partners
  • Drug and/or alcohol abuse
  • Stress associated with poverty
  • Social isolation and family secrecy
  • Child with poor self-esteem or other vulnerable state
  • Other family members (eg, siblings, cousins) abused
  • Gang member associations

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