Child Sexual Abuse in Emergency Medicine

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.

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.

Risk factors for child sexual abuse are as follows:

• Family structure: Children who live with both biological (married) parents are at lowest risk. Children who live with step-parents or single parents are at higher risk (especially children who live with a single parent with a live-in partner). Children living without either biological parent (ie, foster care) are also at higher risk.
• 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.
• Girls are at higher risk than boys
• 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

Frequency

In 2016, 57,329 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] Also, the majority of child abuse victims never report their abuse.

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.

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 5%; in adolescents, the prevalence rate is approximately 14%.

Sexually abused children have significantly higher occurrences of the following:

• Eating disorders
• Suicidal behaviors
• Self-injury
• Psychosis ^[3]

Children who are sexually abused may be at increased risk of reabuse.

Ongoing emotional/psychological problems may be indicative of abused children's false beliefs about themselves and the sexual abuse experience.

Families are usually concerned about injury in the child. Reassurance may involve an explanation that children can be sexually abused and have no physical findings to support their allegations.

For patient education resources, see the Children's Health Center. Also see the patient education article Child Abuse.

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.

The prevalence of sexually transmitted diseases (STDs) in prepubertal children who are examined for possible sexual abuse is low. For this reason, the American Academy of Pediatrics' Committee on Child Abuse and Neglect recommends consideration of testing for STDs in prepubertal children in the following circumstances[5] :

• Child has experienced penetration of the vagina or anus
• Child has been abused by a stranger
• Child has been abused by a person known to be infected with an STD or is at high risk of being infected
• Child has symptoms consistent with an STD
• Child has already been diagnosed with one STD
• Other household member has an STD
• High rate of STD within the community the child resides

Details regarding post-assault testing and treatment should be reviewed in the US Centers for Disease Control and Prevention (CDC) guidelines[21] and an updated online document produced by the New York State Child Abuse Medical Provider (CHAMP) Program, "CHAMP Program Child and Adolescent Sexual Offense Post-Assault Testing and Treatment Guide."[22]

Chlamydia trachomatis testing

Regarding C trachomatis testing, Chlamydia vaginitis or proctitis may be present without obvious signs of discharge, erythema, or inflammation. Oral chlamydia is rare. DNA tests using the nucleic acid amplification test (NAAT) may offer more sensitivity in detection of C trachomatis and Neisseria gonorrhoeae.[23, 24] Since they are often less expensive and may be simpler to obtain than cultures, these tests may be useful for initial screening of urine or vaginal/urethral swabs. Any positive NAAT should be confirmed with a second NAAT that targets a different segment of the bacteria’s genome, or culture tests.[21]

Testing for C trachomatis should be obtained if any of the following are present: symptoms of vaginitis (discharge) in the prepubertal girl, the perpetrator is known to be infected with C trachomatis, the child has physical findings of sexual abuse, or there is patient or parental concern regarding possible infection.

Not all children in whom sexual abuse is suspected require cultures for sexually transmitted infections (STIs). Clinical judgment should be based on the presence of the above factors, as well as the local epidemiology of STIs.

In boys, a urethral swab (premoistened) should be obtained if urethral discharge, dysuria, erythema, or positive urine leukocyte esterase is present.

It is not necessary to test for oral C trachomatis.

N gonorrhoeae testing

Regarding N gonorrhoeae testing, Gonorrhoeae vaginitis infection usually results in a purulent discharge. However, infection, particularly rectal and oral infections, may be subclinical.

Testing for N gonorrhoeae of all three areas (oral, rectal, vaginal/urethral) should be obtained if any of the following are present: symptoms of vaginitis (discharge) in the prepubertal girl, the perpetrator is known to be infected with N gonorrhoeae, the child has physical findings of sexual abuse, or there is patient or parental anxiety regarding possible infection.

Not all children suspected of being abused need tests for STIs, and clinical judgment should be based on the presence or absence of the above factors as well as the local epidemiology of STIs.

In boys, a urethral swab (premoistened) should be obtained if urethral discharge, dysuria, erythema, or positive urine leukocyte esterase is present.

If cultures are obtained instead of NAATs, they should be performed using cotton-tipped swabs inoculated onto Thayer Martin plates and incubated in a carbon dioxide enriched environment. Attention should be given to isolating the appropriate Neisseria species. First-catch urine cultures in male adolescents may be used instead of swabs. Biochemical and enzyme substrate or serologic techniques should confirm isolates.

Other laboratory testing

A wet prep can be obtained from patients with a vaginal discharge to determine the presence of Trichomonas vaginalis or bacterial vaginosis. A potassium hydroxide (KOH) preparation assists in ruling out a yeast infection. A fishy odor when KOH is added to the discharge indicates bacterial vaginosis. In addition, a Papanicolaou (Pap) smear may show false-positive results for yeast (see Vaginitis).

Any ulcerated lesions should be cultured for herpes simplex virus and typed. In the absence of lesions, routine cultures are not recommended. Isolation of herpes in the genital area of a prepubertal child does not always result in suspicion of sexual abuse. Transmission of herpes can be from autoinoculation of oral lesions for type I or type II in children.

Most prepubertal vaginas harbor bacteria as normal flora. Thus, a Gram stain of discharge in prepubertal females is usually not indicated.

Molluscum contagiosum located in the genital area may be consistent with sexual transmission.

Human papillomavirus (HPV) may be present in prepubertal and pubertal children as a result of congenital transmission (up to 2-3 y), hand contact, household transmission, or sexual transmission. Children with HPV infection may require testing for other STDs, and the HPV should be typed in order to determine if an oncogenic type is present. The diagnosis usually is clinical; however, some laboratories use DNA assays. Biopsy is rarely necessary.

Regarding syphilis, if a genital lesion is present, fluid can be obtained for darkfield microscopy. Serology (eg, Venereal Disease Research Laboratory [VDRL], rapid plasma reagin [RPR], automated reagin test [ART]) should be obtained at the time of abuse (if at risk) and 6-12 weeks later.

For hepatitis B, if the victim is incompletely or previously unimmunized, a hepatitis B vaccine should be given as soon as possible. The patient should also be tested for hepatitis B surface antigen and antibody. If the alleged offender is known to have acute hepatitis B, passive immunoprophylaxis with hepatitis B immune globulin (HBIG) should be given. If the vaccine has already been given, no further treatment for hepatitis B is necessary.

For HIV, if possible, a serologic test should be obtained on the alleged offender. The child should be tested for HIV when in areas of high prevalence of HIV and if the alleged perpetrator is a known drug abuser or is HIV positive. In general, local protocols for HIV prophylaxis and testing should be followed. In New York State, the Department of Health protocol for HIV currently requires testing and prophylaxis for all victims of sexual assault who are evaluated within 36 hours of the incident. The CDC recommends testing and prophylaxis within 72 hours. The testing should occur at the time of the first evaluation (baseline), 4-6 weeks, and at 3 months.

Pelvic ultrasonography may be indicated in children who have a septate hymen and need an evaluation for a bifid genitourinary tract. Children with vaginal discharge without resolution despite appropriate evaluation and treatment may need pelvic ultrasonography to rule out congenital genital tract abnormalities or foreign bodies.

A rape kit should be used if the child presents for an examination within 96 hours of the sexual abuse. Some authors have reported finding evidence in children beyond this time frame.[25, 26] Collection of clothing to examine for forensic evidence is usually indicated within this time frame and possibly beyond. Determination of the need for evidence collection is multifactorial and includes not only timing but accessibility of local resources and providers skilled in obtaining this evidence. The emotional state of the child and family and the individual case history should guide this decision. Most rape kits are available for the adult sexual assault victim and can be adapted for pediatrics. Child sexual abuse victims may not require all of the tests contained within the adult kit.

The rape kit is usually provided by the local law enforcement agency and has a specific protocol, including a chain of evidence procedure. Isolation of areas to swab for semen or other evidence may be enhanced by use of a Woods lamp (which shows the fluorescence of alkaline phosphatase in semen). Other materials may fluoresce with the Woods lamp, including urine. Research has suggested that other methods of screening are more effective for the presence of semen, such as use of a BlueMaxx 500 light source.[27, 28]

Colposcopic photo documentation of genital findings is useful for both clinical and legal purposes.[9, 29] The colposcope is used to document normality and for comparison to cases in which children later return with abnormal findings. The colposcope can also be used to address altered body image, identify discrepancies in examinations, provide information to the nonoffending parent, and assist the examiner by magnifying the image onto a video screen or using optics.

These images can provide legal evidence, possibly reduce the child's anxiety, and can be used as a teaching and research tool. The colposcope is not necessary for examination of child sexual abuse but is generally considered state of the art for most expert child sexual abuse evaluations.

Using an otoscope can enhance magnification and photographs can be taken with a 35-mm or digital camera.

It may be helpful to keep an outline of steps available for all child sexual abuse evaluations. One quick guide is Suspected Child Sexual Abuse.

Inpatient care is recommended if the child's safety is in jeopardy or if the child has an acute traumatic injury requiring inpatient treatment.

Occasionally, treatment for a STD requires hospital admission and inpatient treatment.

Severe mental or emotional trauma may necessitate inpatient admission and care.

If a child presents within 96 hours of an acute assault or in the case of chronic incidents of abuse, the family should not bathe the child or allow the child to have anything to eat or drink.

Avoid questioning the child about the incident until appropriate interviewing can be arranged.

However, if the child spontaneously discloses, then who is in the room, what prompted the disclosure, and what time the disclosure occurred should be documented.

The most important treatment is the staff's gentle reassurance that the child is now safe and that efforts and steps will be made to ensure further safety.

Reassurance that there is no permanent genital damage (as is true in most cases) is an important aspect of the child's emotional healing.

Care should be taken to avoid promises that cannot be kept.

Treatment for identified sexually transmitted infections (STIs) should be initiated.

Prophylaxis is not usually indicated for STIs in prepubertal children but may be considered in adolescents. STI testing should be considered in accordance with local protocols and epidemiology of these diseases.

Possible pregnancy should be discussed with the pubertal child (see Sexual Assault).

Referral or consultation for mental health or other counseling should be made in almost every case of child sexual abuse.

Prophylaxis for HIV should be considered if the sexual contact was within 36 hours. Treatment depends on local protocols, and in most cases consultation with infectious disease experts is needed.

Consult a medical team on call for sexual abuse evaluations if available.

Other consultations may include the following:

• Child Protective Services or hotline
• Law enforcement agencies
• Rape crisis counselor, victim advocate, and/or other mental health professional
• Infectious disease division regarding HIV prophylaxis protocols

Most sexually abused children should be referred for mental health counseling.

Follow up for medical problems (eg, genitourinary complaints) should be arranged with the child's primary care physician.

If the community has a child abuse referral center, the children should be referred there for follow-up care according to local protocol.

Medical history

Accurate and complete history is essential to making a medical diagnosis of sexual abuse. The history should include physical symptoms; emotional and behavioral symptoms; and past medical, family, and social histories. Information about the abuse needs to be collected to ensure appropriate management.

Examination

Evaluation can be prioritized as emergent (done without delay), urgent (done within 1-7 days), or nonurgent. Forensic evidence collection is recommended within 24 hours (prepubertal children) or 72 hours (adolescents) in cases of sexual contact.[8] Please refer to Physical Examination for details.

Workup

Laboratory testing for chlamydia, gonorrhea, hepatitis B, syphilis, and HIV should be considered. Please refer to Workup for guidance regarding obtaining samples. A rape kit should be done if the child presents for an examination within 96 hours of the sexual abuse.

Treatment

It is most important to reassure the child that he or she is safe and that steps will be taken to further ensure their safety going forward. Confirmed STIs should be treated. Prophylaxis for STIs should be given to adolescents. HIV prophylaxis should be considered in all children suspected of being sexually abused if exposure was within 36 hours (72 hours if using the CDC guidelines). Further workup/treatment should be initiated for any physical trauma.

Documentation

Documentation should always be thorough and include history, physical examination, laboratory testing results, imaging results, and interpretation of results. Use language that can be understood by nonmedical professionals. Including photo documentation, especially in cases with positive findings, is the recommended standard of care.

Consultations

Consult a medical team on call for sexual abuse evaluations if available. Infectious disease consultation is required for children who receive HIV prophylaxis. Always call Child Protective Services and/or law enforcement. Mental health referral for counseling is imperative.

Antibiotics to prevent sexually transmitted diseases may be considered depending on the circumstances of abuse. For more information, see CDC Treatment Guidelines for Sexually Transmitted Diseases.

Prophylactic antibiotics in prepubertal sexually abused children are indicated in rare cases.

Prophylactic antibiotics may be given to pubertal sexually abused children after an acute assault.

Use of postassault pregnancy prevention options should be discussed with the pubertal sexual assault victim.