Basics
Description
Sexual abuse is the involvement of children in sexual activities that they cannot understand, for which they are not developmentally prepared, to which they cannot give informed consent, and/or that violate societal norms.
- Ranges from oral, genital, or anal contact; fondling; child pornography; prostitution; exhibitionism; and voyeurism
- Twenty-five percent of perpetrators are parents, and 30% are non-parental relatives.
- Most children sexually abused will have no discernible physical injury.
Epidemiology
- ’ Ό150,000 substantiated cases/year; most likely underestimates the incidence as these include only those cases reported
- Prevalence rates between 10 and 30%. The National Violence Survey reported 27% of adult women and 16 % adult men reported sexual abuse during childhood.
Risk Factors
- Peak age of vulnerability: 7 " 13 years of age
- Girls are victimized more than boys, although abuse of boys is underreported.
- Single-parent households, domestic violence, parental substance abuse and mental illness
- Children who experience other types of abuse are also more likely to be victimized sexually.
- Race and socioeconomic status do not appear to be risk factors for child sexual abuse.
- Risk factors for revictimization: younger aged children; more severe maltreatment; families with mental health and substance abuse problems and violence histories
Diagnosis
History
- Diagnosis is made based on the child 's history because abnormal physical findings or lab tests are infrequent.
- Attempt to limit the number of interviews.
- Interview should be detailed enough to know whether a report to child protection or law enforcement is needed.
- If the medical provider is the first person to which the child has disclosed, then that person is an "an outcry witness, " , and that disclosure can be used in court testimony.
- Answers from the children that are obtained for the medical diagnosis and treatment may be admitted into evidence.
- The interview should be conducted with the child separate from family members.
- Ask open-ended, nonleading questions.
- Use developmentally appropriate language.
- Specific questions important to the triage of the child include the following:
- Identity of alleged perpetrator/relationship to child
- Time of last possible contact
- Specific types of sexual contact
- Review of systems including genital pain, bleeding, dysuria, constipation, painful bowel movements, and behavioral changes
Physical Exam
- Serves to ensure the overall health of a child after an abusive event and to document any injuries or other forensically relevant evidence
- Most exams are normal.
- An emergency exam is indicated if the most recent assault was within 72 hours or if the patient has complaints of pain, dysuria, or bleeding. Beyond 72 hours, the exam can be scheduled at the local child advocacy center.
- A speculum should not be used for a prepubertal sexual abuse exam unless there is acute bleeding and its origin must be determined.
- Use of the techniques of labial separation and labial traction (gently grasping the posterior portion of the labia majora and pulling laterally, down, and toward the examiner) allows for the best visualization of the hymenal edges.
- Normal hymenal configurations: annular, crescentic, and fimbriated
- Newborn hymen: thickened, pale, and redundant
- Prepubertal hymen: thin, less redundant, with sharp well-defined edges.
- Postpubertal hymen: thickened, pale, and redundant
- A few physical findings are diagnostic of abuse:
- Presence of semen or sperm on the victim
- Pregnancy
- Acute genital/anal injuries without an adequate accidental explanation (bruising, lacerations, complete hymenal transaction between 4 and 8 o 'clock along hymenal rim)
- Syphilis and Neisseria gonorrhoeae infection (excluding perinatal infection).
- Chlamydia if the child is older than 3 years of age
- Trichomoniasis in a child older than 1 year of age
- Many genital findings are unlikely to be related to abuse:
- Normal variants including intravaginal ridges, hymenal mounds, linea vestibularis, diastasis ani
- Perineal redness
- Labial adhesions
- Anal fissures
- Venous pooling in perianal area
- Any finding on exam thought to be abnormal or diagnostic of child sexual abuse should be reviewed with a child abuse expert for confirmation.
Diagnostic Tests & Interpretation
Initial Lab Tests
- Forensic evidence collection
- Standard rape kit if the last contact was 72 hours or less
- Always obtain consent.
- In prepubertal children, recovery of useful forensic evidence is rare beyond 24 hours.
- Some experts support forensic evidence recovery up to 5 days from the contact in pubertal children.
- Most positive forensic evidence comes from clothing and linens.
- Sexually transmitted illness (STI) screening: Universal screening is not appropriate unless the victim is a sexually active adolescent.
- AAP and CDC guidelines recommends STI testing when
- Child discloses contact that may have involved genital secretions.
- Child 's symptoms or physical exam suggest presence of STI.
- Abuser is felt to be at risk for STI.
- Community prevalence of STI is high.
- Family member is infected with an STI.
- Patient or family member requests testing.
- Testing for N. gonorrhoeae and Chlamydia trachomatis may be performed with vaginal/urethral culture or nucleic acid amplification techniques (NAATs).
- Cultures have historically been the gold standard method for diagnosing STIs in prepubertal children. NAATs have proven to be sensitive and specific for N. gonorrhoeae and C. trachomatis infection in this age group.
- NAATs are not approved for rectal or pharyngeal specimens.
- NAATs have a higher sensitivity than culture.
- If an NAAT is done, then important not to treat empirically because if the NAAT is positive, the clinician will want to repeat with another NAAT or culture to reconfirm.
- Trichomoniasis in a child 1 year of age or older is diagnostic of child sexual abuse; can be tested for by wet prep, culture, or PCR
- Screen for syphilis (STT/RPR) and hepatitis B in any case, which meets other screening recommendations.
- HIV screening should also be considered.
Special Considerations
- Genital warts are not diagnostic of child sexual abuse. Neonatal transmission is common and human papilloma virus (HPV) may remain latent for several years. Children who present after age 3 " 5 years should have a complete medical evaluation for sexual abuse.
- Herpes simplex infections in the genital area are most commonly (but not always) caused by sexual contact. Most mouth infections are caused by HSV-1 and most genital infections are caused by HSV-2, but this distinction is not absolute.
Follow-Up Tests
- Any positive NAAT needs to be repeated with a different NAAT for confirmation prior to empiric treatment.
- Any positive STT/RPR should be confirmed with a treponemal test.
- If serologic testing for HIV, HBV, and syphilis is negative acutely, they should be repeated at 6 weeks, 3 months, and 6 months.
Differential Diagnosis
- Sexualized behaviors
- Normal behaviors for age (e.g., masturbation)
- Exposure to sexual activity (e.g., media)
- Abnormal GU exam
- Normal variations in hymenal anatomy (e.g., septate, cribriform, imperforate)
- Normal variations in perineal anatomy (e.g., hymenal mound, intravaginal ridge, vestibular bands)
- Linea vestibularis: white streaks that run from inferior hymenal border to posterior commissure
- Failure of midline fusion: presence of mucosal surface between fossa navicularis and anus that commonly resolves at puberty
- Irritant, contact, and seborrheic dermatitis
- Labial adhesions
- Lichen sclerosis et atrophica: thinned white atrophic skin in figure-of-8 appearance which may have bruising or petechiae
- Ureterocele
- Urethral prolapse
- Pearly pink papules in males
- Balanitis in males
- Phimosis or paraphimosis in males
- Accidental trauma, including straddle and impaling injuries
- Accidental tourniquet of genitals by hair
- Abnormal anal exam
- Diastasis ani: absence of muscle fibers in middle of external anal sphincter
- Anal skin tags
- Anal dilatation from constipation or sedation
- Group A streptococcal perianal cellulitis
- Urethral discharge/bleeding
- Foreign body
- UTI
- Nonspecific vulvovaginitis
- Group A Streptococcus
- Haemophilus influenzae
- Staphylococcus aureus
- Mycoplasma hominis
- Gardnerella vaginalis
- Shigella flexneri (discharge commonly bloody)
- Genital ulcers
- EBV, HSV
- Beh §et disease
- Inflammatory bowel disease
- Genital irritation
- Pinworms
- Scabies
- Candida albicans
- Trauma
Treatment
Medication
- Prophylactic antibiotics
- Recommended following sexual abuse/assault in adolescents and adults to prevent N. gonorrhoeae, C. trachomatis, and Trichomonas vaginalis
- Not recommended in prepubertal victims because of the low likelihood of STI and the importance of establishing the diagnosis
- HIV postexposure prophylaxis (PEP)
- Recommend consultation with pediatric infectious disease specialist before initiating PEP.
- High-risk exposures: disclosure of penile anal or penile vaginal penetration by known HIV positive perpetrator
- Moderate-risk exposures: disclosure of penile anal or penile vaginal penetration and the HIV status of perpetrator is unknown but there is no anogenital trauma but multiple assailants were involved; perpetrator is from a high-risk population; or there is coexisting infection in perpetrator or victim
- PEP is not recommended in disclosures that do not involve anal, vaginal, or oral penetration; oral penetration without ejaculation
- N. gonorrhoeae treatment according to CDC guidelines
- Adolescents: ceftriaxone 125 mg IM once or cefixime 400 mg PO once
- Prepubertal child: ceftriaxone 125 mg IM once
- C. trachomatis treatment according to CDC guidelines
- Adolescents: azithromycin 1 g PO one time or doxycycline 100 mg PO b.i.d. 7 days
- Prepubertal child
- Weight less than 45 kg: erythromycin 50/mg/kg/day divided into 4 daily doses for 14 days
- Weight greater than 45 kg but less than 8 years: azithromycin 1 g PO 1; age greater than 8 years: azithromycin 1 g PO one time or doxycycline 100 mg PO b.i.d. 7 days
- Syphilis treatment according to CDC guidelines: parenteral penicillin G; dose depends on stage of disease and child age
- Trichomoniasis treatment: metronidazole 2 g PO once
- Hepatitis B vaccination for unimmunized patients
- Hepatitis B immune globulin for patients with recent sexual contact with known positive perpetrator
- Consider pregnancy prevention (e.g., emergency hormonal contraceptive) for adolescents after ensuring the patient is not pregnant.
- Tetanus booster for patients with acute, serious genital or other injuries.
Additional Treatment
General Measures
Cases of child sexual abuse require a multidisciplinary approach that includes medical, social services, law enforcement, and states attorney expertise.
Admission Criteria
- Consider in children with injuries that require operative care
- Consider in cases where the clinician wants to ensure protection of the child and external forces preclude that assurance
- Consider in cases where there is a significant mental health concern
Ongoing Care
Follow-up Recommendations
Patient Monitoring
Most children should be followed by a mental health provider.
Prognosis
Varies greatly depending on specifics of abuse sustained and available support systems
Complications
- Posttraumatic stress disorder
- Depression
- Domestic violence and revictimization
- Substance abuse
- Chronic pelvic pain
- Males are more likely to have concerns about sexual orientation.
Additional Reading
- Adams JA. Medical evaluation of suspected child sexual abuse: 2011 update. J Child Sex Abuse. 2011;20(5):588 " 605. [View Abstract]
- Berenson AB, Chacko MR, Wiemann CM, et al. A case-control study of anatomic changes resulting from sexual abuse. Am J Obstet Gynecol. 2000;182(4):820 " 834. [View Abstract]
- Christian CW. Timing of the medical evaluation. J Child Sex Abuse. 2011;20(5):505 " 520. [View Abstract]
- Gavril AR, Kellogg ND, Nair P. Value of follow-up examinations of children and adolescents evaluated for sexual abuse and assault. Pediatrics. 2012;129(2):282 " 289. [View Abstract]
- Hammerschlag MR. Sexual assault and abuse of children. Clin Infect Dis. 2011;53(Suppl 3):103 " 109. [View Abstract]
- Kellogg N, American Academy of Pediatrics Committee on Child Abuse and Neglect. The evaluation of sexual abuse in children. Pediatrics. 2005;116(2):506 " 512. [View Abstract]
- Workowski KA, Berman S, Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines. MMWR Recomm Rep. 2010;59(RR-12):1 " 110. [View Abstract]
Codes
ICD09
- 995.53 Child sexual abuse
ICD10
- T74.22XA Child sexual abuse, confirmed, initial encounter
- T76.22XA Child sexual abuse, suspected, initial encounter
SNOMED
- 700229002 Victim of child sexual abuse (finding)
FAQ
- Q: How could there have been penetration with a normal physical examination?
- A: The vast majority of child sexual abuse exams are completely normal even with a history of penetration. The healing properties of genital tissues are quick and complete; past injuries are often difficult to detect on physical exam.
- Q: What should I do if I examine a patient with no history of sexual abuse and detect an anatomic abnormality that I think is suggestive of sexual abuse?
- A: Always have exams confirmed by a child abuse expert in your area, as nuances of exams can be hard to discern.
- Q: If child abuse evaluations rarely reveal any abnormalities, why should I subject my patient to such an invasive evaluation?
- A: The vast majority of sexual abuse medical evaluations are normal, but in the small percentage that are abnormal, the information derived can be important medically and forensically. Importantly, the exams allow for detection of other medical conditions which may have gone unnoticed secondary to lack of medical access. Exams also serve to reassure families and children that they are healthy.
- Q: Is an STI diagnosed in a prepubertal patient always indicative of abuse?
- A: No. All STIs may be transmitted vertically (from mother to infant). The incubation periods of different infections vary, so they are expressed at different ages accordingly. Gonorrhea and syphilis are considered diagnostic of sexual abuse outside of congenital infection. Chlamydia, herpes simplex virus 2, and Trichomonas are probably due to sexual abuse and should be reported for evaluation. Condyloma acuminata is probably related to sexual abuse in school-aged and older children but may be transmitted to younger children innocently during toileting or diaper changes.