Child Sexual Abuse in Emergency Medicine Clinical Presentation

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. ^{[4, 5]}  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, such as the following:

• 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 may include the following:

• 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 used. ^[6]

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. The use of a screening tool as devised by Floyed et al may be helpful to determine which children should be seen emergently in the ED setting and which can be referred to a child abuse evaluation center as an outpatient. ^[7] If the child and family are adequately prepared for this examination, it improves 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, with the following time-frames taken into consideration:

• Emergent evaluation (done without delay): Any child with acute bleeding, pain, or injury should be examined immediately. Children with psychological or safety concerns such as suicidal ideation or human trafficking should also be evaluated emergently. Children with a history of sexual contact within 72 hours (or other state-mandated time interval) of presentation should be examined for evidence of sexual abuse. 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. ^[8]
• Urgent evaluation (done within 1-7 days): Any child with suspected or reported sexual abuse occurring within the previous 2 weeks can be evaluated on an urgent basis. This does not include children with emergency medical, psychological, or safety needs. ^[8]
• Nonurgent evaluation: Any child who discloses abuse, displays sexualized behaviors, family concern for sexual abuse, and contact occurred more than 2 weeks prior can be evaluated on a nonurgent basis. ^[8]

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. This does not include children with emergency medical, psychological, or safety needs. ^[8]

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. ^[9] 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. ^[10] 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 prone knee-chest (PKC) position, and use of the labial-traction technique. Common positions for female pubertal children include supine lithotomy, PKC with gluteal lift, and again, the use of the labial-traction technique. A speculum examination can be done if Tanner Stage 3 or greater. ^[8] Some physicians use a technique with a Foley catheter to get a better view of the hymen or use water to "float" the hymen for better visualization. ^[11]

The male genitalia can be examined with the child supine or standing.

Abnormal findings that are suspicious for sexual abuse are rare. Only 2.2% of sexually abused girls examined nonacutely have diagnostic physical findings, compared with 21.4% who are examined acutely. ^[12]

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. Anal soiling, lacerations, and dilatation also may be present in children with a history of anal penetration and child sexual abuse. ^[13]

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. ^{[14, 15]} 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. ^[16] 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.

The recommended standard of care includes obtaining high-quality images of medical examination findings. Photographs can be taken with a camera attached to a colposcope, a 35-mm macro-lens camera, or a digital camera/camcorder. ^[12]

Please refer to the "2018 Updated Approach to Interpretation of Medical Findings in Suspected Child Abuse" for more information. ^[12]

Complications of sexual abuse may include infection and psychological/social problems.