Child Sexual Abuse Treatment & Management

  • Author: Angelo P Giardino, MD, PhD, MPH; Chief Editor: Caroly Pataki, MD   more...
 
Updated: Jan 19, 2012
 

Medical Care

Medical treatment is guided by any conditions uncovered. The incidence of STDs in child sexual abuse (CSA) is low. In prepubertal children, asymptomatic vaginal infections are thought to be increasingly uncommon. Therefore, the Centers for Disease Control and Prevention (CDC) does not recommend prophylaxis for STDs in asymptomatic prepubertal children who are evaluated for possible CSA. In contrast, the CDC recommends that teenaged patients and adults who are sexually abused or assaulted should receive antibiotic prophylaxis for STDs. For more information, see MMWR Recommendation and Report Sexually Transmitted Diseases Treatment Guidelines.

  • Treat STDs with appropriate medications based on the infection and the child's age and weight.
  • In postmenarcheal children, consider the possibility of pregnancy.
  • Recognize the overriding need for emotional support and attention to the psychosocial crisis in which the child and family now find themselves.
  • Health care providers are mandated reporters in all 50 states; once sexual abuse seriously is suspected or diagnosed, a report to the appropriate child protective services (CPS) agency is necessary. Attention to the safety of the child is essential. The AAP recommends reporting in the following situations:
    • When a child makes a clear disclosure of abusive sexual contact, with or without specific findings
    • When individuals present with STDs (see Workup section)
    • When physical examination findings are believed to be the result of abusive sexual contact
  • When sexual abuse is being considered, the AAP suggests the possibility of reporting, depending on the perceived risk to the child. In such cases, discussion with members of an interdisciplinary team may be helpful.
  • Cases of sexual abuse may result in law enforcement action against the alleged perpetrator and possible criminal court proceedings. Well-documented medical records are essential, since legal proceedings may occur over long periods of time. The health care provider cannot rely solely on recollection of the case.
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Consultations

Mental health consultation is warranted to evaluate and treat acute stress reaction and, later, posttraumatic stress disorder (PTSD).

Expert mental health management of stress disorders is warranted because of the burgeoning evidence that psychic trauma in young children has a significant effect.

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Contributor Information and Disclosures
Author

Angelo P Giardino, MD, PhD, MPH  Associate Professor, Baylor College of Medicine; Chief Medical Officer, Texas Children's Health Plan; Chief Quality Officer, Medicine, Texas Children's Hospital

Angelo P Giardino, MD, PhD, MPH is a member of the following medical societies: Academic Pediatric Association, American Academy of Pediatrics, American Professional Society on the Abuse of Children, Harris County Medical Society, Helfer Society, and International Society for Prevention of Child Abuse and Neglect

Disclosure: Bayer Honoraria Review panel membership; Pfizer Grant/research funds Independent contractor; MedImmune Honoraria Review panel membership; Teva Pharmacutical travel & honoraria Managed Care Advisory Panel; CIGNA Honoraria Physician Advisory Council

Coauthor(s)

Reena Isaac, MD  Assistant Professor of Pediatrics, Baylor College of Medicine; Forensic Pediatrician, Child Protection Section of Emergency Department, Texas Children's Hospital, Houston; Staff Physician, Children's Assessment Center, Houston

Reena Isaac, MD, is a member of the following medical societies: American Academy of Pediatrics, Helfer Society, and Texas Pediatric Society

Disclosure: Nothing to disclose.

Eileen R Giardino, RN, MSN, PhD, FNP-BC, ANP-BC  Associate Professor of Nursing, Department of Family Nursing, University of Texas Health Sciences Center Houston, School of Nursing

Eileen R Giardino, RN, MSN, PhD, FNP-BC, ANP-BC is a member of the following medical societies: American Academy of Nurse Practitioners, American College Health Association, American Nurses Association, American Professional Society on the Abuse of Children, and International Society for Prevention of Child Abuse and Neglect

Disclosure: Nothing to disclose.

Specialty Editor Board

Chet Johnson  MD, Center for Child Health and Development, Shiefelbusch Institute for Life Span Studies, University of Kansas; Professor and Chair of Pediatrics, University of Kansas Medical Center

Chet Johnson is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Carrie Sylvester, MD, MPH  Senior Child and Adolescent Psychiatrist, Sound Mental Health

Carrie Sylvester, MD, MPH is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry

Disclosure: Nothing to disclose.

Chief Editor

Caroly Pataki, MD  Professor of Clinical Psychiatry and Behavioral Sciences, Department of Psychiatry, Division Chair, Child and Adolescent Psychiatry, Keck School of Medicine of the University of Southern California

Caroly Pataki, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, New York Academy of Sciences, and Physicians for Social Responsibility

Disclosure: Nothing to disclose.

Additional Contributors

The authors acknowledge the consistent support and mentorship by Carol D Berkowitz who, despite multiple clinical, teaching, and administrative responsibilities, has found the time to share her considerable expertise and even took the time out of her busy schedule to provide the photographs used to illustrate the physical findings possible when evaluating cases of suspected child sexual abuse. Dr. Berkowitz exemplifies the characteristics of a committed medical educator who is not limited by organizational or geographic boundaries.

References

  1. Menoch M, Zimmerman S, Garcia-Filion P, Bulloch B. Child abuse education: an objective evaluation of resident and attending physician knowledge. Pediatr Emerg Care. Oct 2011;27(10):937-40. [Medline].

  2. Finkelhor D, Hotaling GT. Sexual abuse in the National Incidence Study of Child Abuse and Neglect: an appraisal. Child Abuse Negl. 1984;8(1):23-32. [Medline].

  3. Sgroi SM, Blick LC, Porter FS. A conceptual framework for child sexual abuse. In: Sgroi SM, ed. Handbook of Clinical Intervention in Child Sexual Abuse. Lexington, MA: Lexington Books; 1982:9-37.

  4. Finkelhor D, Browne A. The traumatic impact of child sexual abuse: a conceptualization. Am J Orthopsychiatry. Oct 1985;55(4):530-41. [Medline].

  5. Floyed RL, Hirsh DA, Greenbaum VJ, Simon HK. Development of a screening tool for pediatric sexual assault may reduce emergency-department visits. Pediatrics. Aug 2011;128(2):221-6. [Medline].

  6. Adams JA. Guidelines for medical care of children evaluated for suspected sexual abuse: an update for 2008. Curr Opin Obstet Gynecol. Oct 2008;20(5):435-41. [Medline].

  7. Child Maltreatment. 2010. Washinton DC: U.S. Department of Health & Human Services Administration for Children and Families Administration on Children, Youth and Families Children's Bureau U.S. Department of Health & Human Services Administration for Children and Families Administration on Children, Youth and Families Children's Bureau; [Full Text].

  8. Fourth National Incidence Study of Child Abuse and Neglect (NIS-4). Washington DC: US Department of Health and Human Services. Administration for Children and Families; [Full Text].

  9. Sedlak AJ, Broadhurst DD. Third National Incidence Study of Child Abuse and Neglect. Final Report NIS-3. US Department of Health and Human Services; 1996.

  10. Finkelhor D, Jones LM, Shattuck A. Updated Trends in Child Maltreatment, 2009. Crimes Against Children Research Center. Crimes Against Children Research Center. Available at http://www.unh.edu/ccrc/pdf/Updated_Trends_in_Child_Maltreatment_2009.pdf. Accessed December 20, 2011.

  11. Felitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, Edwards V, et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. Am J Prev Med. May 1998;14(4):245-58. [Medline].

  12. Heger A, Ticson L, Velasquez O, Bernier R. Children referred for possible sexual abuse: medical findings in 2384 children. Child Abuse Negl. Jun 2002;26(6-7):645-59. [Medline].

  13. Adams JA. Evolution of a classification scale: medical evaluation of suspected child sexual abuse. Child Maltreat. Feb 2001;6(1):31-6. [Medline].

  14. Adams JA, Kaplan RA, Starling SP, Mehta NH, Finkel MA, Botash AS. Guidelines for medical care of children who may have been sexually abused. J Pediatr Adolesc Gynecol. Jun 2007;20(3):163-72. [Medline].

  15. AAP. Guidelines for the evaluation of sexual abuse of children: subject review. American Academy of Pediatrics Committee on Child Abuse and Neglect. Pediatrics. Jan 1999;103(1):186-91. [Medline]. [Full Text].

  16. Christian CW, Lavelle JM, De Jong AR, et al. Forensic evidence findings in prepubertal victims of sexual assault. Pediatrics. Jul 2000;106(1 Pt 1):100-4. [Medline].

  17. Girardet R, Bolton K, Lahoti S, et al. Collection of forensic evidence from pediatric victims of sexual assault. Pediatrics. Aug 2011;128(2):233-8. [Medline].

  18. Thackeray JD, Hornor G, Benzinger EA, Scribano PV. Forensic evidence collection and DNA identification in acute child sexual assault. Pediatrics. Aug 2011;128(2):227-32. [Medline].

  19. Paolucci EO, Genuis ML, Violato C. A meta-analysis of the published research on the effects of child sexual abuse. J Psychol. Jan 2001;135(1):17-36. [Medline].

  20. Paradise JE, Rostain AL, Nathanson M. Substantiation of sexual abuse charges when parents dispute custody or visitation. Pediatrics. Jun 1988;81(6):835-9. [Medline].

  21. Adams JA. Medical evaluation of suspected child sexual abuse. J Pediatr Adolesc Gynecol. Jun 2004;17(3):191-7. [Medline].

  22. Adams JA, Harper K, Knudson S. A proposed system for the classification of anogenital findings in children with suspected sexual abuse. J Pediatr Adolesc Gynecol. 1992;5:73-5.

  23. Adams JA, Harper K, Knudson S, Revilla J. Examination findings in legally confirmed child sexual abuse: it's normal to be normal. Pediatrics. Sep 1994;94(3):310-7. [Medline].

  24. Atabaki S, Paradise JE. The medical evaluation of the sexually abused child: lessons from a decade of research. Pediatrics. Jul 1999;104(1 Pt 2):178-86. [Medline].

  25. Bays J. Conditions mistaken for child abuse. In: Reece RM, Ludwig S, eds. Child Abuse: Medical Diagnosis and Management. 2nd ed. Baltimore, MD: Lippincott Williams & Wilkins; 2001:287-306.

  26. Bays J, Chadwick D. Medical diagnosis of the sexually abused child. Child Abuse Negl. Jan-Feb 1993;17(1):91-110. [Medline].

  27. Bays J, Jenny C. Genital and anal conditions confused with child sexual abuse trauma. Am J Dis Child. Dec 1990;144(12):1319-22. [Medline].

  28. Berenson AB. Normal anogenital anatomy. Child Abuse Negl. Jun 1998;22(6):589-96; discussion 597-603. [Medline].

  29. Berkowitz CD. Medical consequences of child sexual abuse. Child Abuse Negl. Jun 1998;22(6):541-50; discussion 551-4. [Medline].

  30. Briere JN, Elliott DM. Immediate and long-term impacts of child sexual abuse. Future Child. Summer-Fall 1994;4(2):54-69. [Medline].

  31. Burgess AW, Groth AN, Holmstrom LL, Sgroi SM. Sexual Assault of Children and Adolescents. New York, NY: Lexington Books; 1978.

  32. CDC. Sexually Transmitted Diseases Treatment Guidelines. Centers for Disease Control and Prevention. Available at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5106a1.htm.

  33. Cooper A. Thoracoabdominal trauma. In: Ludwig S, Kornberg AE, eds. Child Abuse: A Medical Reference. 2nd ed. Churchill Livingstone; 1991:131-50.

  34. De Jong AR, Rose M. Frequency and significance of physical evidence in legally proven cases of child sexual abuse. Pediatrics. Dec 1989;84(6):1022-6. [Medline].

  35. De Jong AR, Rose M. Legal proof of child sexual abuse in the absence of physical evidence. Pediatrics. Sep 1991;88(3):506-11. [Medline].

  36. DeLago C, Deblinger E, Schroeder C, Finkel MA. Girls who disclose sexual abuse: urogenital symptoms and signs after genital contact. Pediatrics. Aug 2008;122(2):e281-6. [Medline].

  37. Douglas Em, finkelhor D. Child Sexual Abuse Fact Sheet. Crimes against Children Research Laboratory, University of New Hampshire. Available at http://www.unh.edu/ccrc/factsheet/pdf/CSA-FS20.pdf. Accessed September 2007.

  38. Emans SJ, Goldstein DP. Pediatric and Adolescent Gynecology. 3rd ed. Boston, MA: Little Brown & Co Inc; 1990.

  39. Feldman W, Feldman E, Goodman JT, et al. Is childhood sexual abuse really increasing in prevalence? An analysis of the evidence. Pediatrics. Jul 1991;88(1):29-33. [Medline].

  40. Finkel M. Physical examination. In: Finkel M, Giardino A, eds. Medical Evaluation of Child Sexual Abuse: A Practical Guide. Thousand Oaks, CA: SAGE Publications; 2001:39-98.

  41. Finkel M. The evaluation. In: Finkel M, Giardino A, eds. Medical Evaluation of Child Sexual Abuse: A Practical Guide. Thousand Oaks, CA: SAGE Publications; 2001:23-37.

  42. Finkel MA. "I can tell you because you're a doctor". Pediatrics. Aug 2008;122(2):442. [Medline].

  43. Finkel MA. Sexual abuse: The medical evaluation. In: Giardino AG, Alexander R, eds. Child Maltreatment: A Clinical Guide and Reference. St Louis, MO: GW Medical Publishing Inc; 2005:253-88.

  44. Finkel MA. Technical conduct of the child sexual abuse medical examination. Child Abuse Negl. Jun 1998;22(6):555-66. [Medline].

  45. Finkel MA, DeJong AJ. Medical findings in child sexual abuse. In: Reece RM, Ludwig S, eds. Child Abuse: Medical Diagnosis and Management. 2nd ed. Boston, MA: Lippincott Williams & Wilkins; 2001:207-86.

  46. Finkelhor D. Current information on the scope and nature of child sexual abuse. Future Child. Summer-Fall 1994;4(2):31-53. [Medline].

  47. Finkelhor D. Epidemiological factors in the clinical identification of child sexual abuse. Child Abuse Negl. Jan-Feb 1993;17(1):67-70. [Medline].

  48. Finkelhor D, et al. A Sourcebook on Child Sexual Abuse. London UK: Sage Publications; 1988.

  49. Finkelhor D, Moore D, Hamby SL, Straus MA. Sexually abused children in a national survey of parents: methodological issues. Child Abuse Negl. Jan 1997;21(1):1-9. [Medline].

  50. Finkelhor DH. Child sexual abuse: New Theory and research. New York, NY: Free Press; 1984.

  51. Friedrich WN. Behavioral manifestations of child sexual abuse. Child Abuse Negl. Jun 1998;22(6):523-31; discussion 533-9. [Medline].

  52. Gorey KM, Leslie DR. The prevalence of child sexual abuse: integrative review adjustment for potential response and measurement biases. Child Abuse Negl. Apr 1997;21(4):391-8. [Medline].

  53. Gushurst CA. Child abuse: behavioral aspects and other associated problems. Pediatr Clin North Am. Aug 2003;50(4):919-38. [Medline].

  54. Dubowitz H, DePanfilis D, eds. Handbook for Child Protection Practice. Thousand Oaks, CA: SAGE Publications; 2000.

  55. Jones LM, Finkelhor D, Halter S. Child maltreatment trends in the 1990s: why does neglect differ from sexual and physical abuse?. Child Maltreat. May 2006;11(2):107-20. [Medline].

  56. Kellogg ND, Parra JM, Menard S. Children with anogenital symptoms and signs referred for sexual abuse evaluations. Arch Pediatr Adolesc Med. Jul 1998;152(7):634-41. [Medline].

  57. Kempe CH. Sexual abuse, another hidden pediatric problem: the 1977 C. Anderson Aldrich lecture. Pediatrics. Sep 1978;62(3):382-9. [Medline].

  58. Kerns DL, Terman DL, Larson CS. The role of physicians in reporting and evaluating child sexual abuse cases. Future Child. Summer-Fall 1994;4(2):119-34. [Medline].

  59. Ladson S, Johnson CF, Doty RE. Do physicians recognize sexual abuse?. Am J Dis Child. Apr 1987;141(4):411-5. [Medline].

  60. Larson C, Terman DL, Gomby DS, et al. Sexual abuse of children: recommendations and analysis. Future Child. Summer-Fall 1994;4(2):4-30. [Medline].

  61. Lentsch KA, Johnson CF. Do physicians have adequate knowledge of child sexual abuse? The results of two surveys of practicing physicians, 1986 and 1996. Child Maltreat. Feb 2000;5(1):72-8. [Medline].

  62. Leventhal JM. Epidemiology of sexual abuse of children: old problems, new directions. Child Abuse Negl. Jun 1998;22(6):481-91. [Medline].

  63. Levitt C. Further technical considerations regarding conducting and documenting the child sexual abuse medical examination. Child Abuse Negl. Jun 1998;22(6):567-8; discussion 569-71. [Medline].

  64. Ludwig S. Child abuse. In: Fleisher GR, Ludwig S, eds. Textbook of Pediatric Emergency Medicine. 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2000.

  65. Marshall WN, Locke C. Statewide survey of physician attitudes to controversies about child abuse. Child Abuse Negl. Feb 1997;21(2):171-9. [Medline].

  66. McCann J, Voris J, Simon M. Genital injuries resulting from sexual abuse: a longitudinal study. Pediatrics. Feb 1992;89(2):307-17. [Medline].

  67. Muram D. Child sexual abuse: relationship between sexual acts and genital findings. Child Abuse Negl. 1989;13(2):211-6. [Medline].

  68. Myers JE. Adjudication of child sexual abuse cases. Future Child. Summer-Fall 1994;4(2):84-101. [Medline].

  69. Myers JE. Legal Issues in Child Abuse and Neglect Practice (Interpersonal Violence). 2nd ed. SAGE Publications; 1998.

  70. Myers JE. Expert testimony. In: Briere J, Berliner L, Buckley JA, et al, eds. The APSAC Handbook on Child Maltreatment. Sage Publications; 1996:319-40.

  71. Nadal FM, Giardino AP. Differential diagnosis: conditions that mimic child maltreatment. In: Giardino ER, Giardino AP. Nursing Approach to the Evaluation of Child Maltreatment. St. Louis, MO: GW Medical Publishing; 2003:215-50.

  72. Nicholson EB, Bulkley J. Sexual Abuse Allegations in Custody and Visitation Cases: A Resource Book for Judges and Court Personnel. Washington, DC: American Bar Association; 1988.

  73. Pence DM, Wilson CA. Reporting and investigating child sexual abuse. Future Child. Summer-Fall 1994;4(2):70-83. [Medline].

  74. Royal College of Paediatrics and Child Health. The Physical Signs of Child Sexual Abuse. An Evidence-Based Review and Guidance for Best Practice. London UK: Stephan Austin & Sons Ltd; 2008.

  75. Russell DE. The incidence and prevalence of intrafamilial and extrafamilial sexual abuse of female children. Child Abuse Negl. 1983;7(2):133-46. [Medline].

  76. Sgroi SM. Sexual molestation of children. The last frontier in child abuse. Child Today. May-Jun 1975;4(3):18-21, 44. [Medline].

  77. Swanston HY, Tebbutt JS, O'Toole BI, Oates RK. Sexually abused children 5 years after presentation: a case-control study. Pediatrics. Oct 1997;100(4):600-8. [Medline].

  78. US Dept of Health and Human Services. Child Maltreatment 2002: Summary of Key Findings. 2002. Washington DC: 2004.

 
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Possible factors influencing the decline in substantiated cases of child sexual abuse.
Adverse Childhood Experience (ACE) Pyramid.
Infant girl in frog-leg supine position. Genital examination reveals translucent hymenal membrane with significant redundant tissue making hymenal orifice difficult to appreciate in this photo. With further traction applied to both labia majora, the hymenal orifice could be observed. Photo courtesy of Carol D. Berkowitz, MD.
Infant girl in frog-leg supine position. Hymenal orifice is crescentic (little time is present at 12-o'clock posterior). Hymen is thin and translucent with vessels visible. Hymenal edge is regular and without interruption. Photo courtesy of Carol D. Berkowitz, MD.
Girl in knee-chest position. Hymenal orifice is crescentic, thin, translucent, and without interruption or scarring. Photo courtesy of Carol D. Berkowitz, MD.
Infant girl in frog-leg supine position. Hymenal orifice is annular, with tissue present around entire opening. Some redundancy is present. Photo courtesy of Carol D. Berkowitz, MD.
Infant girl in frog-leg supine position. Hymenal orifice is annular with a "bump" at 1-o'clock position and a small "notch" at 10-o'clock position. Hymenal membrane is thin and translucent, with no interruption or scarring. Photo courtesy of Carol D. Berkowitz, MD.
Girl in frog-leg supine position, exhibiting annular hymenal orifice. Tissue is thin and translucent without disruption or scarring. Photo courtesy of Carol D. Berkowitz, MD.
Girl in frog-leg supine position exhibiting hymenal orifice, which is crescentic and has symmetric attenuation at lateral margins. No scarring is present. Photo courtesy of Carol D. Berkowitz, MD.
Girl in frog-leg supine position exhibiting hymen. Hymen is septate; a band of tissue crosses the hymenal orifice. Tissue is thin with no scarring present. Photo courtesy of Carol D. Berkowitz, MD.
Adolescent girl in supine position demonstrating estrogenized tissue. Hymen is thicker, pink, and fairly opaque with no vessels visible. Tissue is redundant. Photo courtesy of Carol D. Berkowitz, MD.
Genital examination of adolescent girl revealing estrogenized hymenal tissue that is pink, thick, and opaque. Orifice appears irregular, secondary to significant redundancy of tissue. Photo courtesy of Carol D. Berkowitz, MD.
Genital examination of adolescent girl demonstrating estrogenized hymenal tissue that is pink, thick, and opaque. Orifice is irregular due to areas of redundancy, especially at the 9-o'clock position. Photo courtesy of Carol D. Berkowitz, MD.
Prepubertal girl with foul-smelling bloody discharge. On examination, a foreign body in the vagina was found just past the hymenal orifice. The foreign body is lodged in vagina and appears to be toilet tissue that is colonized with bacteria, causing a vulvovaginitis. The foreign body was dislodged with gentle water flushing during examination. Photo courtesy of Carol D. Berkowitz, MD.
Genital examination of prepubertal girl with foul-smelling bloody discharge. On examination, a foreign body in the vagina was found lodged just past the hymenal orifice and appears to be toilet tissue that is colonized with bacteria, causing a vulvovaginitis. The foreign body was dislodged with gentle water flushing during examination. Photo courtesy of Carol D. Berkowitz, MD.
Infant girl with imperforate hymen and absence of a hymenal orifice. Photo courtesy of Carol D. Berkowitz, MD.
Genital examination of girl revealing bruising on medial aspects of labia minora, hymenal trauma with disruption of hymenal tissue, and fresh blood. Photo courtesy of Carol D. Berkowitz, MD.
Infant girl with significant bruising that involved labia minora and labia majora, hymenal trauma with disruption of hymen, and fresh blood. Photo courtesy of Carol D. Berkowitz, MD.
Genital examination 10 days after infant girl presented with significant bruising that involved labia minora and labia majora, hymenal trauma with disruption of hymen, and fresh blood. Bruising on vulvar structure is nearly resolved. Hymen is healing and no blood is observed. Photo courtesy of Carol D. Berkowitz, MD.
Genital examination of girl in frog-leg supine position after genital trauma. Examination reveals suture in place at 6-o'clock position to stop bleeding from injury. Hymenal edge is irregular and asymmetric. Photo courtesy of Carol D. Berkowitz, MD.
US maltreatment trends, 1990-2010.
 
 
 
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