Guidelines for medical care of children evaluated for suspected sexual abuse: an update for 2008

Interpretation of medical findings in suspected child sexual abuse: An update for 2023

Health care professionals who examine children who may have been sexually abused need to be able to recognize, and photo-document any physical signs, and to have access to expert reviewers, particularly when signs concerning for sexual abuse are found. Although the general consensus among practitioners is that children will show few signs of sexual abuse on examination, there is considerable variability and rates of positive exam findings among practitioners of different professions, practice settings, and countries. This review will summarize new data and recommendations regarding the interpretation of medical findings and sexually transmitted infections (STIs); assessment and management of pediatric patients presenting with suspected sexual abuse or assault; and testing and treating patients for STIs. Updates to a table listing an approach to the interpretation of medical findings are presented, and reasons for changes are discussed.

Surgical repair of genital injuries after sexual abuse

Introduction: Genital injuries occur in half of cases of sexual assault through digital or penile penetration as well as the use of objects. Women aged >45 years are more likely to have physical injury and anogenital lesions, transmission of STI and HIV. This review focuses on the evidence about surgical reconstruction of the pelvic floor anatomy of adolescents and adult women sexually assaulted during adolescence or adulthood.

Method: A systematic literature search was performed in PubMed and Orbis plus for articles published in English and German from June 2008 to June 2018. The literature search was performed in October 2018 by topic combining the following Medical Subject Headings: genital trauma, genital injuries, sexual assault, rape, surgical repair, treatment.

Results: 34 records of descriptive studies were identified and 16 full-text articles were included in the present review. Due to the limited number of articles retrieved, articles were not excluded based on methodological design. Superficial genital lesions are common and usually left untreated. For deep vaginal or anal lacerations, intraperitoneal bleeding is usually assessed by means of and additional CT scan or diagnostic colposcopy, cystoscopy, rectoscopy and laparoscopy. Complete reconstruction of the injured is done after. To prevent rectovaginal fistula and uncomplicated primary wound healing a temporary colostomy can be performed.

Conclusion: Although most of genital injuries due to sexual assault do not require any major surgical intervention, there is a lack of good quality evidence regarding the best diagnostic and surgical approach to restore deep lesions of genital organs as well lack evidence on contributors to poor wound healing. Therefore, clinical protocols that standardize examination as well as surgical management are encouraged to be developed.

Impact of mechanical force on posterior hymen - Implications for sexual abuse injury interpretations

BACKGROUND

Residual anogenital findings following sexual abuse are rare. There is a need for further understanding of the interpretation of hymenal findings.

OBJECTIVES

This study evaluates which is more significant with respect to posterior hymenal tissue morphology - previous consensual penile vaginal penetrations or vaginal delivery.

DESIGN

A post hoc study comparing nulliparous and parous hymen in heterosexually active female volunteers, with the focus on healed hymenal defects. Adult posterior hymen configuration was evaluated using labial separation or traction. When needed, the hymenal status was evaluated using a swab. A colposcopy with photography was used for documentation. Experts reviewed all taken photographs and recorded the posterior hymenal defects. Photographs were analyzed to determine the level of agreement.

PARTICIPANTS

Eighty-seven adult female volunteers were recruited to participate in the study by a personal invitation to a gynecological examination to document anogenital findings. The examination was performed following consensual vaginal intercourse. Age ranged from 20 to 53 (median 26.6years).

RESULTS

Single site posterior hymenal transections were significantly more likely in the nulliparous volunteers, compared to the parous volunteers (22/51, 43.1% vs. 4/36, 11.1%, p<0.001). A deep notch, which extends nearly to the base of the hymen was detected in one (2.0%) sexually active nulliparous volunteer, and surprisingly two (3.9%) volunteers had a single, more superficial hymenal notch, that is not considered a sign of previous vaginal penetration. The width of the ridge of the posterior vaginal wall in the vestibule was measured from the anterior part of the navicular fossa to the base of the hymen. The mean width of the ridge of the posterior vaginal wall was 3.1mm (SD2.2, range 0-8) in the photos of 41 nulliparous volunteers. The prevalence of 'double leaf hymen' was 2/87 (2.3%). The inter-rater reliability with a Kappa score of 0.69 indicated strong agreement.

CONCLUSION

The myth "hymen is present only in virgins" has now been invalidated. The absence of posterior hymen increases delivery by delivery in adult female volunteers. The space between the anterior part of the navicular fossa and the base of hymen, 'the ridge of the posterior vaginal wall' in the vestibule was evaluated for the first time among studies evaluating hymenal status. Careful assessment of the ridge of the posterior vaginal wall is needed to avoid misinterpretations when evaluating the depth of a hymenal defect.

Anogenital Findings in 3569 Pediatric Examinations for Sexual Abuse/Assault

STUDY OBJECTIVE

Accurate interpretation of anogenital examination findings in the context of suspected child and adolescent sexual abuse/assault is essential, because misinterpretation has significant child protection and criminal justice implications. A consensus approach to the interpretation of anogenital examination findings is widely used to support accurate diagnosis; however, a large-scale study using this standardized approach is lacking. The objectives of this study were to: (1) determine the proportion of anogenital examinations for sexual abuse concerns with findings diagnostic of trauma and/or sexual contact; (2) determine whether frequency of diagnostic findings varies according to age, gender, and timing of examination; and (3) characterize diagnostic findings. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: Retrospective records of children aged 0-18 years evaluated for sexual abuse/assault were reviewed. Case details of 3569 patients were extracted and anogenital examination findings were reinterpreted using a published consensus approach.

RESULTS

Anogenital examination findings diagnostic of trauma and/or sexual contact were present in 173 of 3569 patients (4.8%). The prevalence of diagnostic findings was significantly higher in adolescents than in children younger than 12 years of age (13.9%, 114/823 vs 2.2%, 59/2657), in female vs male patients (5.7%, 164/2866 vs 1.5%, 9/614), and in examinations within 72 hours for children younger than 12 years (14.2%, 91/643 vs 4.5%, 45/997). Acute injuries were the most common type of diagnostic finding.

CONCLUSION

Diagnostic findings are present in a small proportion of children and adolescents examined for suspected sexual abuse/assault. It is essential that practitioners who interpret examination findings be adequately trained and familiar with the current consensus approach and are aware of case characteristics associated with higher likelihood of findings.

Anogenital warts in pediatric population

The approach to children with anogenital warts in the context of sexual abuse is a challenge in clinical practice. This study aims to review the current knowledge of anogenital warts in children, the forms of transmission, and the association with sexual abuse and to propose a cross-sectional approach involving all medical specialties. A systematic review of the literature was conducted in Portuguese and English from January 2000 to June 2016 using the ISI Web of Knowledge and PubMed databases. Children aged 12 years or younger were included. The ethical and legal aspects were consulted in the Declaration and Convention on the Rights of Children and in the World Health Organization. Non-sexual and sexual transmission events of human papillomavirus in children have been well documented. The possibility of sexual transmission appears to be greater in children older than 4 years. In the case of anogenital warts in children younger than 4 years of age, the possibility of non-sexual transmission should be strongly considered in the absence of another sexually transmitted infection, clinical indicators, or history of sexual abuse. The importance of human papillomavirus genotyping in the evaluation of sexual abuse is controversial. A detailed medical history and physical examination of both the child and caregivers are critical during the course of the investigation. The likelihood of an association between human papillomavirus infection and sexual abuse increases directly with age. A multidisciplinary clinical approach improves the ability to identify sexual abuse in children with anogenital warts.

Normal Anal Examination After Penetration: A Case Report

BACKGROUND

Physical findings are rare after anal penetration. Furthermore, children delay in disclosing or are reticent to discuss penetration.

CASE REPORT

A 12-year-old boy presented to medical care multiple times over a several-week period complaining of abdominal pain, bloody diarrhea, and poor appetite. On colonoscopy, he was found to have a cylindrical foreign body (measuring 7 cm tall and 7 cm in diameter) in his rectum, which had been present for at least 2 weeks. He initially denied knowing how the object got into his rectum and later stated that he inserted it himself out of curiosity. One week after the object was removed, follow-up examination using video colposcopy revealed a completely normal anal examination; the patient had a normal anal examination despite known anal penetration and removal of the object. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Children can have a normal anal examination despite anal penetration, and do not always disclose anal penetration. The aforementioned concepts can be applied to situations related to child sexual abuse in the emergency department, where physical examinations are frequently normal and children delay in disclosing the abuse. When there is concern for sexual abuse, even in the absence of a disclosure or examination findings, patients should be referred for a child abuse pediatrics evaluation if available.

Genital Findings in Cases of Child Sexual Abuse: Genital vs Vaginal Penetration

STUDY OBJECTIVE

To (1) examine the prevalence of abnormal genital findings in a large cohort of female children presenting with concerns of sexual abuse; and (2) explore how children use language when describing genital contact and genital anatomy.

DESIGN

In this prospective study we documented medical histories and genital findings in all children who met inclusion criteria. Findings were categorized as normal, indeterminate, and diagnostic of trauma. Logistic regression analysis was used to determine the effects of key covariates on predicting diagnostic findings. Children older than 4 years of age were asked questions related to genital anatomy to assess their use of language.

SETTING

A regional, university-affiliated sexual abuse clinic.

PARTICIPANTS

Female children (N = 1500) aged from birth to 17 years (inclusive) who received an anogenital examination with digital images.

INTERVENTIONS AND MAIN OUTCOME MEASURES

Physical exam findings, medical history, and the child's use of language were recorded.

RESULTS

Physical findings were determined in 99% (n = 1491) of patients. Diagnostic findings were present in 7% (99 of 1491). After adjusting for age, acuity, and type of sexual contact reported by the adult, the estimated odds of diagnostic findings were 12.5 times higher for children reporting genital penetration compared with those who reported only contact (95% confidence interval, 3.46-45.34). Finally, children used the word "inside" to describe contact other than penetration of the vaginal canal (ie, labial penetration).

CONCLUSION

A history of penetration by the child was the primary predictor of diagnostic findings. Interpretation of children's use of "inside" might explain the low prevalence of diagnostic findings and warrants further study.

Pediatric Urology for the General Surgeon

Pediatric urology spans the neonatal period through the transition into early adulthood. There are a variety of common pediatric urologic conditions that overlap significantly with pediatric surgery. This article reviews the pertinent pathophysiology of a few key disease processes, including the pediatric inguinal hernia and/or hydrocele, cryptorchidism, and circumcision. General surgeons may find themselves in the position of managing these problems primarily, particularly in rural areas that may lack pediatric subspecialization. An understanding of the fundamentals can guide appropriate initial management. Additional focus is devoted to the management of genitourinary trauma to guide the general surgeon in more acute, emergent settings.

Updated Guidelines for the Medical Assessment and Care of Children Who May Have Been Sexually Abused

The medical evaluation is an important part of the clinical and legal process when child sexual abuse is suspected. Practitioners who examine children need to be up to date on current recommendations regarding when, how, and by whom these evaluations should be conducted, as well as how the medical findings should be interpreted. A previously published article on guidelines for medical care for sexually abused children has been widely used by physicians, nurses, and nurse practitioners to inform practice guidelines in this field. Since 2007, when the article was published, new research has suggested changes in some of the guidelines and in the table that lists medical and laboratory findings in children evaluated for suspected sexual abuse and suggests how these findings should be interpreted with respect to sexual abuse. A group of specialists in child abuse pediatrics met in person and via online communication from 2011 through 2014 to review published research as well as recommendations from the Centers for Disease Control and Prevention and the American Academy of Pediatrics and to reach consensus on if and how the guidelines and approach to interpretation table should be updated. The revisions are based, when possible, on data from well-designed, unbiased studies published in high-ranking, peer-reviewed, scientific journals that were reviewed and vetted by the authors. When such studies were not available, recommendations were based on expert consensus.

Biological Evidence Management for DNA Analysis in Cases of Sexual Assault

Biological evidence with forensic interest may be found in several cases of assault, being particularly relevant if sexually related. Sexual assault cases are characterized by low rates of disclosure, reporting, prosecution, and conviction. Biological evidence is sometimes the only way to prove the occurrence of sexual contact and to identify the perpetrator. The major focus of this review is to propose practical approaches and guidelines to help health, forensic, and law enforcement professionals to deal with biological evidence for DNA analysis. Attention should be devoted to avoiding contamination, degradation, and loss of biological evidence, as well as respecting specific measures to properly handle evidence (i.e., selection, collection, packing, sealing, labeling, storage, preservation, transport, and guarantee of the chain custody). Biological evidence must be carefully managed since the relevance of any finding in Forensic Genetics is determined, in the first instance, by the integrity and quantity of the samples submitted for analysis.

Genito-anal injury patterns and associated factors in rape survivors in an urban province of South Africa: a cross-sectional study

Background

The prevalence of genito-anal injuries in rape survivors varies significantly and the factors associated with the absence of injuries are not well understood. This plays a major role in the conviction of cases as the absence of injury is equated with a lack of assault. In such cases, health care providers face major challenges in presenting and defending their findings. The aim of this paper is to describe the absence of genito-anal injuries by site in a group of rape survivors and to identify factors associated with the absence of these injuries.

Methods

In a cross-sectional study rape cases reported to the police in one province in South Africa were randomly sampled using a two stage sampling procedure. Data were obtained on the survivor, the circumstances of the rape and the findings of the medicolegal examination. Descriptive statistics were conducted for the prevalence of genito-anal injuries by site and logistic regression models were built to identify factors associated with the absence of genito-anal injuries for all survivors and those reported to be virgins.

Results

In the sample of 1472 women injuries ranged from 1% to 36%. No significant injuries were reported for 749 (51%) survivors. In the multivariable model there was a significantly lower odds of having no injuries in survivors who were virgins, those raped by multiple perpetrators and those examined by a doctor with additional qualifications. In the model for survivors who were virgins, those with disabilities had a greater odds of having no injuries while those between the ages of 8 and 17 years had a lower odds of having no injuries compared to survivors below four years of age.

Conclusions

This study found that being a virgin, multiple perpetration rape and the examiner’s qualifications were significantly associated with the absence of genito-anal injuries. Health providers should thus be aware that in all other respects there was no difference in survivors who had injuries and those who did not. It is important to reiterate the message that the presence of injuries does not necessarily prove that rape occurred nor does the absence disprove the fact.

[Practical guide to the examination and interpretation of genital lesions of minor female victims of sexual assault]

Through a comprehensive review of the literature on sexual assault, the authors propose to clarify the different stages of the exam and help the practitioner to the forensic interpretation of lesions. The authors describe the basic principles that make consensus in how to interview victims in order to increase the reliability of the information collected. The various medical data that must be collected allowing to guide diagnosis (urogenital symptoms, sexual behaviour disorder) or facilitate the interpretation of lesions (age of puberty, use of tampons…) are specified as well as the different positions of examination and their association to other complementary techniques (Foley catheter, colposcopy, toluidine blue). The authors present a simple decision tree that can help the practitioner to interpret the laceration of the hymen. They detail the description and forensic interpretation of all genital lesions that may be encountered as a result of sexual assault, and the pitfalls to avoid. Finally, two main problems in the interpretation of lesions are described, the absence of injury after penetration and the accidental genital lesions.

The Amsterdam Sexual Abuse Case (ASAC)-study in day care centers: longitudinal effects of sexual abuse on infants and very young children and their parents, and the consequences of the persistence of abusive images on the internet

BACKGROUND

Little research has been done on the signs of child sexual abuse (CSA) in infants and very young children, or on the consequences that such abuse - including the persistence of the abusive pornographic images on the internet - might have for the children and their parents. The effects of CSA can be severe, and a variety of risk- and protective factors, may influence those effects. CSA may affect the psychosocial-, emotional-, cognitive-, and physical development of children, their relationships with their parent(s), and the relations between parents. In the so called 'the Amsterdam sexual abuse case' (ASAC), infants and very young children were victimized by a day-care employee and most of the victims were boys. Research involving the children and their parents would enable recognition of the signs of CSA in very young children and understanding the consequences the abuse might have on the long term.

METHODS/DESIGN

The proposed research project consists of three components: (I) An initial assessment to identify physical- or psychological signs of CSA in infants and very young children who are thought to have been sexually abused (n = 130); (II) A cross-sequential longitudinal study of children who have experienced sexual abuse, or for whom there are strong suspicions; (III) A qualitative study in which interviews are conducted with parents (n = 25) and with therapists treating children from the ASAC. Parents will be interviewed on the perceived condition of their child and family situation, their experiences with the service responses to the abuse, the effects of legal proceedings and media attention, and the impact of knowing that pornographic material has been disseminated on the internet. Therapists will be interviewed on their clinical experiences in treating children and parents. The assessments will extend over a period of several years. The outcome measures will be symptoms of posttraumatic stress disorder (PTSD), dissociative symptoms, age-inappropriate sexual behaviors and knowledge, behavioral problems, attachment disturbances, the quality of parent-child interaction, parental PTSD, parental partner relation, and biological outcomes (BMI and DNA).

DISCUSSION

The ASAC-project would facilitate early detection of symptoms and prompt therapeutic intervention when CSA is suspected in very young children.

Advocacy opportunities for pediatricians caring for maltreated children

Pediatricians are advocates for children. It is one of the central elements of the job description. In the course of their work, pediatricians have many opportunities to advocate for abused and neglected children. The most effective form of advocacy that most pediatricians will engage in with regard to child abuse and neglect is by being highly skilled doctors who provide excellent clinical care to children and families, knowing how to recognize child abuse and what to do when they encounter it, and being familiar with the resources of their communities.

Multiple perpetrator rape among girls evaluated at a hospital-based child advocacy center: seven years of reviewed cases

The aim of this study was to describe contextual events, abuse experiences, and disclosure processes of adolescents who presented to a hospital-based Child Advocacy Center for medical evaluation and evidentiary collection as indicated after experiencing multiple perpetrator rape during a single event (n=32) and to compare these findings to a group of single perpetrator sexual assaults (n=534). This study used a retrospective mixed-methods design with in-depth, forensic interviews and complete physical examinations of gang-raped adolescents. Patients ranged from 12 to 17 years (M=14 years). Girls who experienced multiple perpetrator rape during a single event were more likely to have run away, to have drunk alcohol in the past month, and to have participated in binge drinking in the past 2 weeks. Acute presentation of these victims were rare but 30% had hymenal transections and 38% had sexually transmitted infections (STIs). Forensic interviews revealed alcohol was a common weapon used by offenders, and its use resulted in victims experiencing difficulty in remembering and reporting details for police investigation or physical and mental health care. Most victims were raped at parties they attended with people they thought they could trust, and they felt let down by witnesses who could have helped but did not intervene. Although relatively rare, multiple perpetrator rape during a single event is a type of severe sexual assault experience and has significant risks for deleterious health outcomes. These victims require health care by trained providers to diagnose physical findings, treat STIs, screen for trauma, and support victims.

Child maltreatment: a review of key literature in 2013

PURPOSES OF REVIEW

This review summarizes new findings in the field of maltreatment, addressing epidemiology, physical abuse, abusive head trauma, sexual abuse, sequelae, and prevention.

RECENT FINDINGS

Many articles this year focus on establishing a framework for thinking about how to evaluate a child for maltreatment, the consequences of maltreatment, and the current understanding of prevention efforts. Interestingly, some research has helped to reinforce some concepts that were clinically appreciated, especially related to retinal hemorrhages.

SUMMARY

The volume, quality, and breadth of research relating to child maltreatment continue to improve and expand our understanding of child abuse pediatrics. These authors summarize notable advances in our understanding of child maltreatment over the past year.

Child sexual abuse--Medical statement conclusions in criminal legal process

OBJECTIVES

To evaluate medical statement conclusions in the criminal-legal process in suspected cases of child sexual abuse (CSA).

STUDY DESIGN

An observational study of a random sample of 130 medically examined, police reported CSA suspected cases during 2001-2009. Medical statements were evaluated and their conclusions were analyzed with an end-point in the legal process. The data consists of official investigation documents from the University Hospital records, the Police, crime laboratories, the State Prosecutor, and the Courts of Law.

RESULTS

The median age of the children was 5.3 years (range 11 months-17.3 years) at the time of the suspected sexual abuse. In most cases (76.2%, 99/130) medical statement conclusions neither supported nor excluded the suspicion of CSA. Twenty-one (16.2%) medical statements supported and in 10 cases (7.7%) the conclusion did not support the suspected CSA. Of the suspected CSA cases a hundred (76.9%) proceeded to the Prosecutor. The charge filing rate was 41.5% (54/130). The final conviction rate was 30.8% (40/130) and 74% in the charged cases. Medical statements were mentioned as evidence in the Prosecutor's decision to file charges in 18 (33.3%) of suspected CSA cases and in 15 (36%) of verdicts. A child's clear disclosure of CSA (p<0.001) and medical statements (p=0.037) had a significant role in decision making on convictions.

CONCLUSION

In medical statement conclusions, physical findings with proper documentation and interpretation are needed to avoid misunderstandings in the legal process. The present study supports a routine medical statement peer review to minimize the risk of neglect caused by lack of knowledge among authorities working with sexually abused children.

Forensic evaluation in alleged sibling incest against children

Sibling incest is a serious form of intrafamilial sexual abuse with health, social, and legal relevance. A retrospective study was conducted through the analysis of forensic medical reports of the alleged sibling incest of victims under 18 years old (n = 68) from 2004 to 2011 as well as the respective judicial outcomes. Results demonstrated that sibling's sexual abuse is associated with several circumstances that might exacerbate its severity such as vaginal, anal, and/or oral penetration. Moreover, the victim's young age, the proximity between victim and abuser, and the fact that it is committed at the victim's and/or abuser's home and by using physical violence and verbal threats justify a late detection of these cases.

Pattern and medical care of child victims of sexual abuse in Ekiti, south-western Nigeria

BACKGROUND

Child sexual assault (CSA) is a global health problem which affects many children and is often under-reported in developing countries. Data on CSA are few in these countries.

AIMS AND OBJECTIVES

This study aimed to review the pattern and medical care of victims of CSA in a tertiary hospital over a 39-month period.

METHODS

This is a retrospective, descriptive study. Case files of 28 cases of CSA were retrieved from those of 6535 patients seen in the paediatric out-patient department of Ekiti State University Teaching Hospital between 1 January 2010 and 31 March 2013.

RESULTS

Victims of CSA accounted for 0.43% of new patients seen during the period under review with a yearly increase over that time. Victims were all female with a median age of 11.5 years and the age range was 4-17. They all had genito-urinary findings and 3.6% had an anal tear. The assailants were all male, mostly adults. A school-teacher and school-friends were the perpetrators in 3.6% and 10.8% of cases, respectively. All were screened for HIV, but only 60.7% were screened for hepatitis B and C. Only 60.7% received HIV post-exposure prophylaxis and none was given prophylaxis against viral hepatitis B and C. Of those eligible for post-exposure emergency contraception, only 43.8% received it. Antibiotics and analgesics were routinely given in 89.3% cases. Only one of the patients attended for follow-up. None had repeat serological screening tests. The police were involved in 60.7% of cases but there was no prosecution.

CONCLUSION

Perpetrators of CSA are protean and, in the study area, there are gross inadequacies in the care provided for victims. Standard treatment protocols and additional training for health-care providers involved in the management of CSA victims are required.

The evaluation of children in the primary care setting when sexual abuse is suspected

This clinical report updates a 2005 report from the American Academy of Pediatrics on the evaluation of sexual abuse in children. The medical assessment of suspected child sexual abuse should include obtaining a history, performing a physical examination, and obtaining appropriate laboratory tests. The role of the physician includes determining the need to report suspected sexual abuse; assessing the physical, emotional, and behavioral consequences of sexual abuse; providing information to parents about how to support their child; and coordinating with other professionals to provide comprehensive treatment and follow-up of children exposed to child sexual abuse.

The risk of misinterpreting genital signs of sexual abuse in cadavers: a case report

The significance of genital findings in a case of suspected child sexual abuse has been widely debated in the past decades, as shown by the different classifications available in literature. In the case of postmortem examination, the search for signs of sexual abuse is considerably more difficult because of the superimposition of postmortem modifications, which may determine tissue modifications that can be mistaken for traumatic lesions. This study aims at reporting a case where presumed findings of the first autopsy were denied by histological analysis; in detail, what looked like a possible bruise of the hymen was correctly recognized as hypostasis (livor) of the hymenal tissue by histological analysis. This case report suggests caution in the analysis and discussion of genital lesions found during postmortem examination since the superimposition of cadaveric modifications may radically modify the morphology of soft tissues.

Abuse experiences, substance use, and reproductive health in women seeking care at an emergency department

INTRODUCTION

Abuse experiences can have negative health consequences for women. Many women present to the emergency department for episodic, nonemergent care and may have unique needs as survivors of abuse. The purpose of this study was to describe child sexual abuse experiences, intimate partner violence, substance use, and reproductive health outcomes in a sample of adult women who were seeking care from a rural emergency department to better understand the health care needs of this unique population.

METHODS

One hundred forty-five adult women (18-45 years old) were recruited at an emergency department in the southeastern United States. Questionnaires were used to assess for demographic characteristics, history of child sexual abuse (CSA), intimate partner violence, reproductive health, and substance use.

RESULTS

In the sample, 42.8% of women (n = 62) reported a positive history of CSA and 34.7% of women (n = 49) experienced intimate partner physical violence during the past year. More than 46% of the women (n = 65) had harmful drinking patterns in the past year and more than 50% reported some type of substance use in the past 3 months. Women who experienced CSA had a significantly greater number of lifetime sexual partners, were more likely to report pain with sexual intercourse, and were more likely to report a medical history of an abnormal Papanicolaou smear.

DISCUSSION

The women in this sample had high rates of abuse, harmful drinking patterns, and substance use and were at risk for sexually transmitted infections. Through screening for lifetime violence, including sexual violence, emergency nurses can be an important liaison between women who have experienced CSA and appropriate referrals within the health care system.

Anal findings in children with and without probable anal penetration: a retrospective study of 1115 children referred for suspected sexual abuse

Interpreting the significance of anal findings in child sexual abuse can be difficult. The aim of this study is to compare the frequency of anal features between children with and without anal penetration. This is a retrospective blinded review of consecutive charts of children seen for suspected sexual abuse at a regional referral center from January 1. 2005 to December 31. 2009 Based on predetermined criteria, children were classified into two groups: low or high probability of anal penetration. The charts of 1115 children were included, 84% girls and 16% boys with an age range from 0.17 to 18.83 years (mean 9.20 year). 198 children (17.8%) were classified as belonging to the anal penetration group. Bivariate analysis showed a significant positive association between the following features and anal penetration: Anal soiling (p=0.046), fissure (p=0.000), laceration (p=0.000) and total anal dilatation (p=0.000). Logistic regression analysis and stratification analysis confirmed a positive association of soiling, anal lacerations and anal fissures with anal penetration. Total anal dilation was significantly correlated with a history of anal penetration in girls, in children examined in the prone knee chest position and in children without anal symptoms. Several variables were found to be significantly associated with anal penetration, including the controversial finding of total anal dilatation. Due to limitations in the study design, this finding should still be interpreted with caution in the absence of a clear disclosure from the child.

Anogenital Warts in Childhood - Always a Marker for Sexual Abuse?

Human papilloma viruses (HPV) are common pathogens associated with a wide range of cutaneous and mucosal infections in childhood. Different HPV types can cause common warts and anogenital warts. Condylomata acuminata in children may be, but are not necessarily, an indicator of sexual abuse. Each individual case therefore requires careful examination, with consideration of other possible means of transmission. Diagnosis of anogenital warts is generally by means of clinical examination. Additional histological, serological or molecular genetic investigation may be indicated occasionally. The high rate of spontaneous remission and the rate of recurrence after treatment should be considered. The available topical and surgical treatment options are discussed.

Hymenal characteristics in girls with and without a history of sexual abuse

This article reviews the recent literature on physical findings related to the hymen in pubertal and prepubertal girls with and without a history of sexual abuse. Characteristics of normal hymenal anatomy, acute traumatic findings, and characteristics of healed trauma are discussed, particularly with regard to changes in the interpretation of these findings that have occurred over time.

Medical evaluation of suspected child sexual abuse: 2011 update

The medical evaluation of children with suspected sexual abuse includes more than just the physical examination of the child. The importance of taking a detailed medical history from the parents and a history from the child about physical sensations following sexual contact has been emphasized in other articles in the medical literature. The examination is important, however, and medical providers who examine children need to be aware of published research on findings in nonabused children, studies of healing of injuries, and studies documenting the association between sexual contact and the diagnosis of sexually transmissible infections in children. This article reviews the current approach to interpreting findings in children who may have been sexually abused and why additional research is needed.

Development of a screening tool for pediatric sexual assault may reduce emergency-department visits

OBJECTIVE

To define the characteristics of a novel screening tool used to identify which prepubertal children should potentially receive an initial evaluation for alleged sexual assault in a nonemergent setting.

METHODS

Electronic medical records were retrospectively reviewed from 2007 to 2008. Visits with a chief complaint or diagnosis of alleged sexual assault for patients aged 12 years or younger were identified. Complete records, those with no evaluation before pediatric emergency-department arrival, and those with child advocacy center follow-up were included. Records were reviewed to answer the following: (1) Did the incident occur in the past 72 hours, and was there oral or genital to genital/anal contact? (2) Was genital or rectal pain, bleeding, discharge, or injury present? (3) Was there concern for the child's safety? (4) Was an unrelated emergency medical condition present? An affirmative response to any of the questions was considered a positive screen (warranting immediate evaluation); all others were considered negative screens. Those who had positive physical examination findings of anogenital trauma or infection, a change in custody, or an emergency medical condition were defined as high risk (having a positive outcome).

RESULTS

A total of 163 cases met study criteria; 90 of 163 (55%) patients had positive screens and 73 of 163 (45%) had negative screens. No patients with negative screens were classified as high risk. The screening tool has sensitivity of 100% (95% confidence interval: 93.5-100.0).

CONCLUSIONS

This screening tool may be effective for determining which children do not require emergency-department evaluation for alleged sexual assault.

Collection of forensic evidence from pediatric victims of sexual assault

OBJECTIVE

To determine the time period after sexual assault of a child that specimens may yield evidence using DNA amplification. Secondary questions included the comparative laboratory yields of body swabs versus other specimens, and the correlation between physical findings and laboratory results.

PATIENTS AND METHODS

Data from evidence-collection kits from children 13 years and younger were reviewed. Kits were screened for evidence using traditional methods, and DNA testing was performed for positive specimens. Laboratory data were compared with historical information.

RESULTS

There were 277 evidence-collection kits analyzed; 151 were collected from children younger than 10; 222 kits (80%) had 1 or more positive laboratory screening test, of which 56 (20%) tested positive by DNA. The time interval to collection was <24 hours for 30 of the 56 positive kits (68% positives with a documented time interval), and 24 (43% of all positive kits) were positive only by nonbody specimens. The majority of children with DNA were aged 10 or older, but kits from 14 children younger than 10 also had a positive DNA result, of which 5 were positive by a body swab collected between 7 and 95 hours after assault. Although body swabs were important sources of evidence for older children, they were significantly less likely than nonbody specimens to yield DNA among children younger than 10 (P = .002). There was no correlation between physical findings and laboratory evidence.

CONCLUSIONS

Body samples should be considered for children beyond 24 hours after assault, although the yield is limited. Physical examination findings do not predict yield of forensic laboratory tests.

Medical evaluation for child sexual abuse: what the PNP needs to know

Sexual abuse is a problem of epidemic proportions. Pediatric nurse practitioners (PNPs) will most likely encounter sexually abused children in their practice, both those who have been previously diagnosed and others who are undiagnosed and require identification by the PNP. This continuing education article will discuss the medical evaluation of children with concerns of suspected sexual abuse. Acute and non-acute sexual abuse/assault examinations will be discussed. Physical findings and sexually transmitted infections concerning for sexual abuse/assault will also be discussed.

[Guidelines and evidence. Recent developments in medical child protection]

Medical child protection comprises different types of involvement of physicians in order to protect children and adolescents from abuse and neglect. This review gives an overview of historical and recent developments in medical child protection. The professional foundation of medical involvement in this field requires a debate on the following questions: Is there evidence for the diagnostic criteria of child abuse and neglect? How far are the principles of evidence-based medicine applicable to the development of guidelines in child protection?

Sexual abuse and sexually transmitted infections in children and adolescents

PURPOSE OF REVIEW

Sexual abuse is unfortunately common in the United States. The presence of a sexually transmitted infection in a child or adolescent should prompt an evaluation to exclude sexual abuse.

RECENT FINDINGS

The present article reviews the demographics of sexual abuse, the prevalence of specific sexually transmitted infections, such as Neisseria gonorrhoeae, Chlamydia trachomatis, HIV, human papillomavirus (HPV) and herpes simplex virus (HSV) and which children and adolescents are at highest risk for contracting such infections. The use of nonculture methods, such as nucleic acid amplification tests (NAATs), to evaluate prepubertal children for N. gonorrhoeae or C. trachomatis, and the use of HIV postexposure prophylaxis are discussed.

SUMMARY

Any child or adolescent with a sexually transmitted infection should be evaluated for sexual abuse. Specific infections in prepubertal children, such as Neisseria gonorrhoeae or Chlamydia trachomatis, are due to abusive contact and should be reported to Child Protective Services. As the modes of transmission of anogenital infections with HPV and HSV are unclear, an evaluation for sexual abuse should be done. Although transmission of HIV after sexual abuse is rare, HIV postexposure prophylaxis must be administered in a timely fashion, and adequate outpatient support provided to facilitate compliance and follow-up.

Partial bowel obstruction in a 2-month-old child. A delayed diagnosis of anal abuse

We present the case of an anal sexual abuse involving a 2-month-old boy, who was admitted to the Pediatric Surgery Unit of the University of Padua for low bowel obstruction. The infant had been already hospitalized for 3 days in a peripheral hospital and treated with daily rectal wash-outs for a fecaloma. Only after a careful interpretation of the plain abdominal radiograph, along with the performance of a rectoscopy and a laparotomy, a vegetable foreign body (about 3 cm in diameter and 7 cm in length) was discovered in the sigma. The morphology and dimensions of the foreign body, as well as its location, left no doubt about the etiology of the partial bowel obstruction, proving that it was clearly related to an anal sexual abuse.

Vulvovaginitis in childhood

Symptoms related to vulvitis and vulvovaginitis are a frequent complaint in the paediatric age. Knowledge of the risk factors and the pathogenetic mechanisms, combined with thorough clinical examination, helps to distinguish between dermatological diseases, non-specific vulvitis and vulvovaginitis proper. On the basis of microbiological data, the most common pathogens prove to be Streptococcus pyogenes, Haemophilus influenzae and Enterobius vermicularis; fungal and viral infections are less frequent. The possibility of isolating opportunistic pathogens should also be considered. In rare situations, the isolation of a micro-organism normally transmitted by sexual contact should prompt a careful evaluation of possible sexual abuse. Current treatments for specific and non-specific forms are outlined, together with pointers for the evaluation of recurrence.

Vaginal laceration as a result of blunt vehicular trauma

BACKGROUND

Sexual abuse often is the primary diagnosis considered when prepubertal girls present with vaginal trauma. Although sexual abuse is very concerning and should remain high in the differential diagnosis, a variety of accidental injuries also can cause genital injury.

CASE

A 5-year-old girl presented to the emergency department with genital bleeding after a vehicle rolled over her pelvis. She had isolated vaginal lacerations on exam.

SUMMARY AND CONCLUSION

Extreme pelvic compression is an adequate mechanism of injury in a child presenting with vaginal laceration.

Update on child maltreatment

PURPOSE OF REVIEW

The authors explore the literature published in the past year addressing child maltreatment issues, including sexual abuse, physical child abuse, inflicted head trauma, and child abuse prevention.

RECENT FINDINGS

The body of knowledge about child abuse and its mimics continues to expand. Evident in this year's literature is the challenge which the diagnosis of child abuse creates for clinicians. Although further strides are being made toward universal education of providers, it is clear that there is still a reluctance to report abuse to child welfare agencies. The legal repercussions of diagnosing abuse can be extensive, and there has been a proliferation of medical defense experts who disagree with the commonly accepted tenets of abusive injury and who are vocal in the literature.

SUMMARY

It remains the responsibility of pediatric providers to consider child maltreatment in the differential diagnosis of any unexplained injury or medical problem. Several studies document the high rate of spanking, slapping or shaking children, and primary care clinicians may be the first professionals in a position to begin the evaluation for possible child maltreatment. Despite the natural hesitancy to diagnose abuse, clinicians have an ethical and moral obligation to address this issue both in their practice and in their communities. The short-term and long-term costs to individuals who experience family violence have been well demonstrated and include not only emotional repercussions, but also chronic health conditions, which result in significant cost to society.