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The Child Sexual Abuse Examination

January 2, 2015

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The Child Sexual Abuse Examination

Authors: Maria D. McColgan, MD, Assistant Professor of Emergency Medicine and Pediatrics, Drexel College of Medicine; Urgent Care Physician, St. Christopher’s Hospital for Children, Philadelphia; and Angelo P. Giardino, MD, PhD, Medical Director, Texas Children’s Health Plan, Inc.; Clinical Associate Professor of Pediatrics, Baylor College of Medicine, Houston

Peer Reviewer: Meta Carroll, MD, Pediatric Emergency Physician, Northwest Acute Care Specialists, PC; Emanuel Children's Hospital, Portland, Oregon and Salmon Creek Hospital, Vancouver, Washington, Legacy Health System

One of the most challenging evaluations that an emergency department (ED) physician is asked to perform is the examination of a child with potential child abuse. The majority of ED physicians feel overwhelmed, and although they would like to perform the "ideal" history and physical examination, they find themselves feeling inadequate in these situations. The authors comprehensively review the important aspects of the evaluation of a child with potential sexual abuse and highlight aspects that facilitate appropriate ED management. The Editor

Introduction

Child abuse and neglect is a major public health problem in the United States. In 2002, approximately 896,000 children were victims of child abuse. Of those, about 10%or almost 90,000 were cases of child sexual abuse (CSA) that were substantiated by child protective services.1

The importance of the ED to the evaluation of sexual maltreatment is addressed in the Institute of Medicine’s landmark report, Emergency Medical Services for Children:2

"Child abuse and sexual assault also should receive attention in the ED protocols. These cases require careful and systematic response to ensure that the child receives proper medical and psychosocial care and that appropriate legal and administrative steps are taken. The ED staff…must be alert to those cases in which the true nature of the problem is not reported to medical personnel, as may happen if a family member is the abuser."

The number of cases of CSA seen by a particular ED may vary depending upon available community resources such as a regional child abuse center or availability of local child abuse experts. In addition, families often come to the ED prior to contacting their primary care physician. In one study, 46% of children were first evaluated in the ED.3 Also, a higher percentage of victims of CSA are uninsured or insured by publicly funded insurance than for other pediatric complaints presenting to the ED.4,5

The emergency physician needs to be prepared to conduct a thorough examination in a sensitive and nonthreatening manner to prevent further victimization of the patient. Several studies have indicated a need for continued training in the area of CSA. In a four-year study of ED patients, 46 children were diagnosed with nonacute genital trauma indicative of sexual abuse.6 However, when these patients were re-examined within 2 weeks by physicians with training in child abuse, only eight (17%) had clear evidence of abuse on examination, and four had nonspecific changes; normal findings were found in 32 children (70%).6 In a statewide survey of physicians in Arizona, emergency physicians estimated that physical examinations of victims of CSA would yield physical findings 34% of the time (answers ranged from 2% to 95%).7 However, as will be discussed below, recent studies indicate that positive findings occur less than 10% of the time.8

Epidemiology

Of the 896,000 children who were determined to be victims of child abuse in 2002, more than 60% were neglected, about 20% were physically abused, and 10% were sexually abused.1 Child sexual abuse is defined as involvement of a child or adolescent in sexual activity by a dominant or more powerful person for the purpose of sexual stimulation, or for the gratification of other persons (e.g., child pornography or prostitution). The sexual activities include exhibitionism, inappropriate viewing of the child, allowing the child to view inappropriate sexual material, taking sexually related photographs of the child, sexualized kissing, fondling, masturbation, digital or object penetration of the vagina or anus, and oral-genital, genital-genital, and anal-genital contact. These sexual activities are imposed on the child victim, who is unable to provide consent because of age or developmental stage.9,10

Health Care Evaluation vs Investigation

In the ED, the multidisciplinary team that handles cases of sexual abuse is often composed of the physician, nurse, and social worker, who then relay information to law enforcement and child protective services workers. The evaluation completed by the ED team is contributory, but distinct from the police and child protective services investigation.11 The information obtained during the ED evaluation is critical to the investigation process and focuses on the initial disclosure or symptoms that prompted the visit, the child’s health status and need for treatment, important medical and psychological follow-up, and development of a safety plan. The ED evaluation of suspected CSA includes a history, physical examination, and observations of the interaction between the patient and his/her caretaker. Laboratory studies (e.g., culture testing for sexually transmitted diseases [STDs]) and forensic evidence collection also may be indicated in the ED. By contrast, personnel in child protective services and law enforcement investigate allegations of CSA under legal mandate. The police determine whether a crime has been committed and begin appropriate legal action.12 Child protective services work with the police to ensure the safety of the victim, evaluating a caretaker’s ability to protect the child, and provide support services required by families that may include alternative living arrangements for children deemed unsafe in their homes.13

Emergency Department Evaluation

The health care environment can be a source of stress for children who may fear painful procedures and feel uncomfortable in the technical, adult-oriented environment.14 The child who has been sexually abused may be distressed and/or embarrassed about having painful injuries examined.15-17 Studies of the response to the genital examination in prepubertal children and adolescents show that fear associated with the CSA examination is greater than that associated with a routine doctor visit, but that the examination is less traumatic when performed in a controlled setting by experienced and psychologically supportive clinicians.18,19 The emergency physician can use a variety of strategies to reduce patient anxiety (See Table 1).20

History

Recent studies have shown that the diagnosis of sexual abuse typically relies upon the history given by the child and parent, and that the rates of physical evidence and trauma in sexual abuse are low.8,21 In fact, the history from the child typically provides the most valuable component of the medical evaluation and may be the only diagnostic information uncovered. In 1992, U.S. Supreme Court Chief Justice Rehnquist ruled that excited utterances and statements made in the course of procuring a medical examination might carry more weight than statements made in court.22

In contrast to the interview done by law enforcement, the history should be geared toward information that will help to guide the clinician in diagnosis and treatment of potential medical issues. A medical history, in other words, is not a forensic interview. The history should be viewed as a multistep process: 1) introduction, 2) interview of caretaker, 3) interview of child (if medically necessary), and 4) wrap-up of the history and preparation for the examination.

Begin with a private interview of the adult accompanying the child. If there is more than one adult, each should be interviewed separately to identify corroborationand inconsistenciesin their histories. All caretaker interviews should be conducted without the child present.23 Often the adult can provide enough pertinent information for the clinician to decide upon medical treatment and the need for emergency evaluation versus deferral to a subspecialty setting. In many cases, it is unnecessaryand discouraged by law enforcement and child advocates to obtain a history of the abuse from the child.

When interviewing the adult caretaker in a quiet, private room, answers to the following questions will assist medical decision making:24, 25

  • Why is sexual abuse suspected?
  • Did the child disclose the abuse?
  • If so, to whom did he/she disclose and under what circumstances?
  • If the abuse was witnessed, what did adults or other household occupants see?
  • Who lives with the child?
  • Who provides day-to-day care for the child?
  • What words are used to identify the child’s genitals and other body parts?
  • If the primary caretaker is not a parent, what role do the parents play in the child’s life?
  • Are the parents aware of the CSA concerns?
  • Who is the suspected perpetrator, and what is his/her relationship to the child?
  • When was the last known contact between child and suspected perpetrator?
  • Is there a history of domestic violence, substance abuse, or police or child protective services involvement in the household?

Next, proceed with a thorough review of systems, staying alert to symptoms associated with abuse (e.g., painful urination or defecation, pelvic or abdominal pain, constipation, bleeding, discharge, changes in sleep or dietary habits, and developmental regression).26 In addition to the child’s account of events, the parents’ account of the behavioral history can reveal behaviors inappropriate for the child’s developmental level.27 These include excessive masturbation, acting-out, temper tantrums, school problems, abdominal pain, bedwetting, anger, depression, and new risk-taking behaviors (especially in adolescents).26

Taking a History from the Child

The investigation and successful prosecution in a CSA case may hinge upon the child’s disclosure of abuse.28 When taking a history from a child about the abuse, the clinician should strive to maximize the accuracy of the information and minimize the stress to the child by providing a safe, nonthreatening environment.

Interviewing a CSA victim remains a challenging task, even with the older and more verbal child. Areas of controversy and research include the effects of multiple interviews on the integrity of a child victim’s disclosure, the suggestibility of young children, the effect of trauma on a child’s memory, and linguistic differences between child and interviewer all of which reinforce the importance of adherence to excellent technique and deferring the interview to forensic specialists when appropriate.

Before taking a history about the abuse event(s) from the child, the clinician should first ask if the information obtained will influence decisions regarding evaluation and treatment. If the answer is "no," then the evaluation should proceed without a child interview (which is then deferred to the appropriate forensic setting.) However, if the child’s history is deemed necessary and he/she is ready to disclose, it is important to accurately document the disclosure, with great care employed in the interview technique.29

Begin with an open-ended question, such as, "Do you know why you’re here today?" Proceed slowly and allow adequate periods of silence when questioning a child so that he or she can process the question and formulate an answer.

Follow the child’s lead and continue with open-ended questions that ask about the who, what, when, and where of the abuse. Examples include: "Can you talk with me about it?" "Can you tell me what happened?" Follow up with open-ended questions, such as, "Tell me more," or "Then what happened?" until the child exhausts his/her information. With the child’s answers as your guide, proceed with more specific follow-up questions like, "Who was there?" and "Where did this happen?" Avoid questions using the word "why," such as, "Why did you go in the bedroom with him?" because this connotes blame. Use yes/no questions as infrequently as possible. And whenever possible, return to open-ended questions, such as, "Can you tell me more about that?"

Multiple-choice questions are particularly difficult for children. The child may think that he or she must choose an option. If a multiple-choice question is unavoidable, always give an open-ended choice. For example, the question "Were you in the bedroom or the bathroom?" forces the child to choose between what may be two wrong answers. A question phrased, "Were you in your bedroom, in the bathroom, or somewhere else?" is a better option. Better still is, "Where were you?"

Do not use leading questions or questions with a tag line. Examples of this poor technique include "Didn’t you go in the house with him?" or "You went into the house with him, didn’t you?" Questions with negatives also should be avoided. In one study, children of all ages provided correct answers only 50% of the time when asked questions with negatives (e.g., "Did you not see the woman in the video?").30 When asked the question without the negative, the correct responses increased to 70-100%.30

Use age-appropriate language. Children have a large vocabulary before they fully understand the meaning of the words.31 Between the ages of 1 and 6 years, children acquire five to eight new words per dayoften from a single exposure to a word.32-34

Also, employ short, simple questions and ask only one question at a time. In one study, more than 60% of children’s responses to multipart questions were inaccurate.31 For example, the follow-up question, "Where did he touch you?" is preferable to "Where did he touch you, and what did he touch you with?" This multipart question can be confusing and difficult for young children to answer.

During the physical examination, a child may spontaneously disclose details of the abuse. Although these spontaneous disclosures may catch you off guard, avoid strong emotions such as disbelief or surprise. If a child makes a spontaneous disclosure, continue to elicit further details with open-ended questions (e.g., "Then what happened?"). These spontaneous utterances should be documented carefully; they may be particularly helpful to the investigation and criminal prosecution.27

During the interview, you may want to have the child participating in a familiar or stress-reducing activity (e.g., coloring), however, refrain from the use of drawings or anatomical dolls. These tools should be left to professionals trained in their use.27

Because your medical history may be used in legal proceedings, it is important to document the history and the integrity of the interview process in detail. Use quotations to document both the examiner’s question and the child’s response, using exact words when possible.35

Physical Examination

The physical examination in cases of CSA is completed in a head-to-toe manner, and is performed to identify physical injuries, sites for potential forensic evidence collection, and diagnosis of medical conditions causing symptoms that may be unrelated to abuse. The goals of the examination in CSA cases include the following:36

  • Identify physical injuries and/or conditions that require treatment.
  • Document physical findings via written notes, drawn pictures, and photographs.
  • Obtain laboratory specimens and diagnostic studies when indicated.
  • Collect and preserve forensic evidence. This includes the material that may have been transferred from the perpetrator’s body to the child victim (e.g., semen, saliva, sweat, or hair) and materials that place the child at a crime scene (e.g., carpet fibers, grass, dirt.).
  • Determine the appropriate ED and follow-up care for the child’s medical and psychological needs.
  • Provide reassurance to the child and family regarding future health and well-being of child.

The examination of a child who has been sexually abused requires knowledge of genital and anal anatomy. It is important to identify normal anatomic variants versus abnormal findings, as well as to accurately document using specific terminology.37

The following terms are specific to pediatric anogenital anatomy:37

vulva – all of the components of the external genitalia (including, mons pubis, labia majora and minora, clitoris, and vaginal orifice);

perineum – region between the thighs that is bounded by the vulva anteriorly and anus posteriorly in girls, and that lies between the scrotum and the anus in boys;

vestibule – region within the labia minora, bounded by the clitoris anteriorly and the posterior fourchette to the back;

posterior fourchette – formed by the posterior joining of the labia minora;

hymen or hymenal membrane – tissue at the vaginal opening, recessed in the vestibule. (The internal surface of the hymenal membrane marks the most distal portion of the vagina.); and

fossa navicularis – the posterior attachment of the hymen to the posterior fourchette.

Children have been shown to respond well to the genital examination when the clinician talks to the child about the purpose of the examination, what the examination entails, and what they should expect from the examiner.38 In addition, children are not generally retraumatized by a colposcopic examination of the genital area that is performed by a skilled clinician. One study demonstrated the atraumatic nature of a colposcopic examination and the reduction in the child’s anxiety upon completion of the evaluation.18 In the ED setting, however, it is not always possible or necessary to use colposcopy to identify significant injuries or normal findings.

More than two decades of clinical studies have shown that genital examination of CSA victims most often reveals either normal or nonspecific findings.8,21,39-41 A lack of physical findings, therefore, does not exclude sexual abuse. In a study of 36 adolescents who were pregnant at the time of, or shortly before, a sexual abuse examination, 82% had normal findings; 11% were suggestive, and 7% were definitive for penetrating trauma.42 Another study of 2384 girls evaluated for suspected CSA in a regional referral center, found that only 4% had abnormal findings.8 Finally, a case-controlled study comparing 192 abused girls to 200 nonabused girls concluded that the examination of the abuse victim rarely differs from that of the nonabused child.43

The postulated reasons for the relative paucity of definitive physical findings in CSA include the following: 1) the type(s) of sexual contact (e.g., fondling) unlikely to leave a lasting physical injury or scar; 2) the delay in disclosure of abuse and/or presentation to a clinician for examination; and 3) the rapid healing observed in the mucous membranes of the pediatric anogenital area.8,21,44,45 Despite the emergency physician’s expectation of few diagnostic physical findings, a complete examination remains necessary for the symptomatic or recently traumatized child. Also, the child and/or caretaker often have significant concerns about possible injury, and a normal examination may provide great reassurance. Be sure to communicate to the caretaker that a reassuring or normal examinationas well as absence of sexually transmitted infections and forensic evidence does not preclude sexual abuse or acute assault. The caretaker must continue to support the child and seek appropriate follow-up care and counseling for him or her. Finally, examination findings may lead to a treatable medical diagnosis completely unrelated to sexual abuse.

Positioning During the Physical Examination

For the genital examination, place the child in a comfortable position that allows you to view the genitalia under a good light source.53 Children can be examined on a caretaker’s lap or on an examination table. Be mindful that the examination or the position that the child assumes may mimic the specifics of the abuse event. Again, let the child provide the lead in choosing an alternative position. If the child is too distressed to proceed with the examination, consider deferring the evaluation to a subspecialty setting. If an emergency examination is deemed medically necessary for the child too distressed to cooperate, consider an examination under sedation or assembling a team for an examination under general anesthesia. In prepubertal and pubertal girls, the most common examination positions include the frog-leg supine, frog-leg while sitting in the caretaker’s lap, and the prone knee-chest position. The lithotomy position is acceptable for pubertal girls. For boys, the genital examination may be performed in the sitting, standing, supine, or lateral decubitus position. Be sure to document the position(s) used for the examination.

While the supine frog-leg position is most often employed and well tolerated by prepubertal girls, it is important to view the hymen in a second position if a concerning physical finding is seen. Placing the child in the prone knee-chest position allows anterior elements within the vestibule to fall forward and dilatation of the vaginal orifice due to the effects of gravity, and often allows better visualization of the hymen, the fossa navicularis, and the posterior fourchette. Be sensitive to the child’s comfort when employing the prone knee-chest technique, as it places the child in a particularly vulnerable position.29,46 Lateral positions are commonly used for male examinations and allow for anal examinations for both boys and girls. An alternative and well-tolerated position for anal inspection is the supine knee-chest position, achieved by asking the child to hug his/her knees.47

Acute Sexual Assault and Forensic Evidence Collection

The American Academy of Pediatrics (AAP) recommends forensic evidence collection if the medical evaluation of a CSA victim occurs within 72 hours of the assault.27 Because DNA testing of biologic materials has increased in sophistication and sensitivity, obtain swabs of any body area that came in contact with the perpetrator. Specific indications for an urgent genital examination and forensic evidence collection include the following conditions: 47

  • acute anogenital trauma, including pain, bleeding, laceration, and/or bruising noted by the patient or caretaker;
  • child’s disclosure of digital-genital, oral-genital or genital-genital contact with the perpetrator within the preceding 72 hours; or
  • acute vaginal or penile discharge (i.e., suspicion of presence of semen or sexually transmitted infection).

In addition, a pubertal child with a suspected pregnancy as a result of sexual abuse should prompt an urgent genital examination, with forensic evidence collected only in cases of recent (i.e., less than 72 hours) contact.

If sexual contact occurred more than 72 hours prior to the ED visit, and there are no immediate physical complaints such as pain, discharge, or bleeding, a detailed genital examination can be delayed. Beyond 72 hours, forensic evidence usually has disappeared from the child’s person. However, trace evidence may be identified by forensic scientists on clothing and bed linens, and the family should be encouraged to provide these materials to the police.48

To proceed with forensic evidence collection, the child and caretaker should be brought to a private room as quickly as possible. A clean hospital bed sheet is placed on the floor; then, the paper sheet provided in the forensic kit is placed on top. The child stands in the middle of the sheet and disrobes, allowing the loose materials on the clothing to be caught on the paper sheet. It is critical to collect the clothing that was worn during the abuse or put on immediately after the abuse. (If this clothing is in the child’s home, instruct the caretaker not to wash the clothes, and to place them in a clean paper bag for the police.) Each article of clothing (especially the underwear) should be packaged in its own paper bag, when practical. The examiner or assistant collecting any specimen, (including clothing) should be gowned and gloved at all times. (Also consider wearing surgical caps and masks to keep the hair and respiratory secretions of health care personnel out of the kit.)

The child’s body is then inspected for stains that may represent the presence of blood, semen, and/or saliva. This can be done using the fluorescent lighting common in hospital units, or with the help of an ultraviolet (UV) light source. While the use of UV lighting had been standard protocol for most assault examinations, recent evidence suggests a flaw in relying upon this technique to guide specimen collection. Santucci and colleagues recently showed that of 41 emergency physicians using the Wood’s lamp, not one was able to differentiate semen from other products.49 Furthermore, of the 29 known semen samples used in the study, not one fluoresced under a Wood’s lamp.49 Any suspicious areas under UV or ambient lighting should be swabbed with four cotton-tipped swabs moistened with water, and the swabs air-dried, labeled, and packaged.

Allow the child to put on a hospital gown, and proceed with hair collection from his or her head. Run the comb provided in the kit through the child’s hair, collecting foreign material or debris. Crime laboratory protocols regarding plucked specimens vary; they typically request a sample of plucked hairs to permit identification of the child’s hair versus the hair of other people, potentially the perpetrator. These plucked hairs should be collected and submitted in appropriately labeled envelopes. Because of the potential trauma of having hair plucked, some laboratories will defer the request for the child’s plucked hair until a later date if it deems that examination essential to the investigation. Confirming the practice of the specific crime laboratory serving a given ED regarding hair collection (and pubic hair collection) is advised.

Next, obtain oral specimens by placing the swabs between the buccal mucosa and gum line. This area, where semen may pool in the child’s mouth after an oral assault, requires at least four swabs. Again, proceed with the air-drying, packaging, and labeling of the swabs. It is highly useful to have additional personnel available to immediately label and package a specimen.

Pay particular attention to certain body areas in the search for injury and trace evidence from the perpetrator (e.g., the mouth, neck, chest, or breasts, lower abdomen and upper/inner thighs, and the anogenital area). The neck, wrists, and ankles should be examined for ligature marks, and all skin should be inspected for bite marks. Any site of bruising, bites, or injury should be described carefully in the medical record, photographed, and swabbed for evidence collection.

The last site of examination and evidence collection is the anogenital area. Examiners may be quick to proceed with identification of the hymen and swabs of the vaginal orifice, but fail to identify evidence of blunt force trauma to the labia majora or more external structures. Inspect the inner thighs, mons pubis, and labia majora, swabbing any areas that appear traumatized or have foreign material (i.e., blood, semen, saliva). Again, collect four swabs per anatomic site, if possible. Then, proceed with an examination of the more protected vestibular structures. When obtaining vaginal material, collect pooled secretions with swabs. It is unnecessary to aspirate or irrigate the vagina. In the male, swab the periurethral portion of the penis, as well as any bitemarks, petechiae, or bruises on the shaft. Perianal swabs in boys and girls also should be obtained. For the adolescent victim of sexual assault, proceed with speculum examination if tolerated, obtaining any material pooled in the vaginal vault, as well as swabbing the cervix. While the examiner can use dry swabs for collection of cervical and vaginal material in the adolescent, swabs of other anogenital sites, especially in the prepubertal child, will require moistening with water.

For the adolescent assault victim, if a speculum examination is performed, do not throw away the speculum. The speculum may be the first item placed in the vagina after the assault and therefore, may contain critical trace evidence. Place the speculum in a plastic bag, and do not seal the bag. Next, place the plastic bag in a large paper envelope, then label and seal the envelope. If a tampon is extracted at the time of the ED examination, it may contain valuable evidence as well and should be placed in an unsealed plastic bag, then sealed in a labeled paper envelope.

When obtaining specimens for STD testing simultaneous to forensic evidence collection, be sure to obtain the forensic kit swabs first, then the swabs for the hospital microbiology laboratory. Keep the specimens clearly labeled and separate. The forensic kit should not include any culture or DNA probe swabs or any urine samples for STD screening or identification. However, in the case of suspected drug-facilitated sexual assault, proceed with local law enforcement protocols to obtain consent from the patient and blood and/or urine samples for forensic toxicology testing.

To summarize, proper forensic evidence collection includes the following techniques:50

  • Never use a rape kit that is not fully sealed; a partially opened kit must be considered contaminated.
  • Change gloves after completing each stage (i.e., anatomic site) of the exam to prevent cross contamination of specimens.
  • If specimens require moistened swabs, use one drop of water per swab (preferably distilled water) and not saline.
  • Allow samples to air dry. Do not use heat.
  • Use paper or glass in which to store specimens, not plastic.
  • Use paper bags for storage of clothing or linens, not plastic.
  • Never lick envelopes to seal them; your DNA would then be a part of the kit. If the envelopes do not have self-sealing adhesive, use tap water.
  • Seal and label all evidence. The integrity of the evidence and its admissibility in criminal court hinges upon strict adherence to proper technique.
  • Document the person who sealed the box and to whom the box was passed. Maintaining a record of the chain of custody of the evidence again protects its integrity and utility in criminal proceedings.
  • Refrigerate specimens (preferably in a locked/secured refrigerator) if not immediately handed to law enforcement personnel.

In a recent study of forensic evidence examination of prepubertal sexual assault victims, Christian and colleagues evaluated the yield of forensic kits.48 Forensic evidence was found in 25% of the children, all of whom were evaluated within 44 hours of assault. Sixty-four percent of evidence identified was located on clothing and bed linens. However, in only 35% of cases was clothing collected from the patient for forensic analysis. No swabs from a child’s body were positive for blood after 13 hours or for semen after 9 hours. This study reasserts the need for prompt evidence collection from the child’s body and the items critical to forensic analysis, including clothing and bedding. While the emergency physician has no access to the crime scene, encouraging the caretaker to carefully preserve items for the police may prove highly useful.

Genital Examination

The genital examination of the child begins with inspection of the external genitalia.53 Determine the child’s Tanner stage and document this in the medical record. As previously discussed, diagnostic anogenital injuries are uncommon. Most injuries to this area due to CSA are superficial and heal quickly.44,45,51 Injuries in sexual abuse may be visible to the examiner if the examination is done near to the time of the contact, typically within hours of the assault. However, because disclosures in CSA often are delayed, visualization of fresh injuries is uncommon.

Examine the genital area for scarring, tears, abrasions, bruising, and decreased amount/thickness or absence of hymenal tissue. Note the contour of the hymenal opening, paying particular attention to its free edge. Start with the child in a supine frog-leg position. If abnormalities are seen or if the vestibular structures are difficult to visualize, have the child assume the prone knee-chest position. Use downward lateral traction of the labia majora to visualize the hymen and other structures within the vestibule. The colposcope or a hand-held magnifying lens may assist with this inspection.46,52 The location of visible injuries are noted in relationship to the face of a clock placed over the child in the anatomic position, with anterior-superior being 12 o’clock.

Document the examination simply describing what you see, noting pertinent positives and negatives.53 Avoid use of vague language (e.g., hymen intact). Instead, describe the hymen and provide pertinent negatives (e.g., crescentic hymen, without notches, tears, bleeding, or bruising). Avoid qualitative phrases (e.g., hymen with clear evidence of penetration) in the physical examination description. Describe the injuries that lead to this conclusion, and save such a statement for your assessment. For example, fresh blunt force trauma may described as "annular-shaped hymen with a fresh tear at 7 o’clock (child supine), abrasions at the fossa navicularis, and blue bruising of the posterior fourchette." Do the same for the anal examination. A normal examination, for example, may be described as "normal perianal folds, normal tone; no skin tags, tears, fissures, bruising, or bleeding."

It is often difficult for a child to describe specific sexual acts, including touch versus penetration of the vaginal orifice. A common abusive act, described as "vulvar coitus," occurs when the perpetrator’s penis passes between the labia but does not enter the vaginal canal.52 Vulvar coitus can produce abrasions and bruising but does not usually disturb the hymen because of this structure’s recessed position.52 If the child is examined immediately after the abuse, minor trauma may be seen (e.g., erythema or swelling of the labia.)

For the male patient, the examiner again documents Tanner stage and circumcision status. The clinician should inspect the penis, scrotum, testicles, perineum, and perianal area for signs of trauma (e.g., bite marks, bruising, petechiae, or abrasions). In the uncircumcised boy, retract the foreskin and inspect the glans, not forgetting to pull the foreskin back to its original position.47

Vaginal Examination

The appearance of the normal hymen in both prepubertal and pubertal children is variable. The prepubertal hymen has a variety of orifice configurations that can be described as annular, crescentic, fimbriated, cribriform, or septate.36,52 The most common shapes are crescentic and annular. Estrogen affects the hymen as it does all periurethral tissue. Maternal estrogen affects the appearance of the newborn hymen by causing a thick and redundant appearance. This affect changes after two to three months and then reappears again as the child approaches puberty. Estrogen results in a thicker and paler appearance to the hymen. The prepubertal, unestrogenized hymen appears thin and highly vascular.36,52

The prepubertal child’s hymen and other vestibular structures may be visualized with supine or seated frog-leg positioning and gentle traction only. Traction is applied by grasping the labia majora between the examiner’s thumb and forefinger and gently applying traction downward and lateral.47,52 The hymenal membrane of the prepubertal child is innervated and highly sensitive to touch.36,52 Applying too much traction or touching the hymen with items such as a cotton-tipped swab will be uncomfortable for the child, especially in the presence of recent trauma.

A vaginal speculum is never used in the ED in the awake prepubertal child. If a speculum examination is medically necessary in the young child (e.g., copious vaginal bleeding), proceed with arrangements for an examination under anesthesia.36 A nasal speculum is typically not helpful for the genital examination. Instead, an excellent light source, a slow and gentle manner during the examination, and careful observation will reveal most findings.

Anal Examination

The anal sphincter is covered with epithelium that meets centrally at a point called the anal verge. Within the loose connective tissue surrounding the external orifice is the hemorrhoidal plexus. The external tissue has symmetric radiating folds known as rugae. Just internal to the anal verge is the pectinate line, which demarcates the boundary between skin and the rectal mucous membrane.

The perianal area is carefully inspected for injury using gentle retraction of the gluteal folds during inspection of the tissues. The anus and perianal area are evaluated with the child in frog-leg supine, prone or supine knee-chest, lithotomy with buttocks separation, or lateral decubitus positions.52 A trained examiner may need to perform an anoscopic examination if acute injury of the rectum is suspected. It is typically not necessary to insert a gloved finger into the anus.47 When the buttocks are separated, the perianal muscles typically tighten reflexively. Brushing the examiner’s hand against the medial aspect of the child’s buttock and thigh also may stimulate this tightening. Laxity of anal sphincter tone may be noted in the setting of chronic abuse. It also is seen when stool is present in the rectal vault.52

Abnormal findings that may be indicative of abuse include lacerations, bruising, ulcerations, external and internal scarring, bleeding, or fissures. Inflammation is seen as redness, swelling, or tenderness of perianal tissues.52,53

Another abusive act, termed gluteal coitus, occurs when the perpetrator rubs the dorsal shaft of the penis between the buttocks over the external anal tissues; such activity can cause abrasions, and leave trace evidence of seminal products. Therefore, careful inspection for lacerations and abrasions of the anus and forensic evidence collection are necessary parts of the examination.53

In many states, criminal statutes do not distinguish between vulvar coitus versus vaginal penetration, and gluteal coitus versus sodomy. For example, in some states, any genital contact between perpetrator and child is labeled penetration and prosecuted accordingly (Information about legal aspects of child abuse and neglect available at http://nccanch.acf.hhs.gov/general/legal/index.cfm). From the medical and psychological perspective, any contact is abusive.

Diagnostic Studies-Sexually Transmitted Diseases

The incidence of STDs in CSA is low. In a study of 1538 children, ages 1 to 12 years, evaluated for possible sexual abuse, Neisseria gonorrhoeae was identified in 2.8% of cases (41 of 1469); human papillomavirus presenting as condyloma acuminata in 1.8% of cases; Chlamydia trachomatis in 1.2% of cases (17 of 1473); Treponema pallidum (syphilis) in 0.1% of cases (1 of 1263); and herpes simplex virus in 0.1%.54 Decisions regarding appropriate testing for STDs in cases of suspected CSA must be made on a case-by-case basis. In prepubertal children, asymptomatic vaginal infections are thought to be increasingly uncommon.

Factors that increase the likelihood of an STD in CSA include: 1) the prevalence of the disease in the adult population, 2) the type and frequency of physical contact and the number of perpetrators, 3) the infectivity of the organism, and 4) whether the child has been on antibiotics for other reasons.

The AAP and the Centers for Disease Control and Prevention (CDC) recommend STD testing in the following high-risk scenarios:

  • The child has signs or symptoms of an STD (e.g., vaginal pain, discharge).
  • A household member or close contact has an STD.
  • The suspected perpetrator is known to have an STD or is at high risk for an STD.
  • The patient or family requests testing.
  • Evidence of oral, genital or anal penetration or ejaculation is present.
  • The prevalence of STDs is high in the community.27,55

When these criteria were applied in one study, 80 of 84 patients with vaginal cultures positive for gonorrhea had vaginal discharge. The remaining four patients met historical criteria.56 In another study examining symptomatic versus asymptomatic STDs, 581 children were cultured during evaluation for sexual abuse; 22 grew gonorrhea from vaginal specimens, all of whom had vaginal discharge on examination. However, six patients with Chlamydia (and negative gonorrhea cultures), were asymptomatic.57

As the diagnosis of STDs in children has important legal ramifications, diagnostic tests for STDs in children must be highly specific (Table 2). The low prevalence of STDs in prepubertal children and cross-contamination with local fecal flora increase the likelihood that rapid antigen testing will give false-positive results.58 Therefore, when STD testing is indicated, culture testing is the current recommended method for identification of Chlamydia and gonorrhea. Palusci and Reeves estimated that culture testing alone would miss 4 per 100 cases of gonococcal infections (assuming a baseline prevalence of 10%). Their recommendation is the use of sequential testing using initial nonculture methods, followed by culture testing when nonculture tests are positive.59 However, nonculture tests of childrenwhile presently used in many centers for initial screeningare not FDA-approved.

Endocervical specimens are not necessary in prepubertal girls. Obtain specimens from the vagina in girls and the urethra in boys, as well as from the rectum. See Table 3 for more specific information on obtaining cultures.

Adolescent victims of sexual abuse provide an additional challenge. Siegel and colleagues found the prevalence of STDs in abuse victims was 3.2% in prepubertal girls and 14.6% of pubertal girls.60 Due to the prevalence of STDs in sexually active teens, universal screening for STDs in pubertal patients is recommended by the CDC.55

The CDC recommends the following initial STD testing for the adolescent sexual assault patient:75

  • cultures for N. gonorrhoeae and C. trachomatis from specimens collected from any site of penetration or attempted penetration;
  • FDA-approved nucleic acid amplification tests;
  • wet mount and culture of a vaginal swab specimen for T. vaginalis infection. If vaginal discharge, malodorous discharge, or itching is evident, the wet mount also should be examined for evidence of bacterial vaginosis and candidiasis; and
  • collection of a serum sample for HIV, hepatitis B, and syphilis testing.

Nucleic acid amplification tests, as recommended for STD screening in teens, offer the advantage of increased sensitivity. If a nucleic acid amplification test is used, a positive test result should be confirmed by a second test. Confirmatory testing consists of a second FDA-licensed nucleic acid amplification test that targets a different DNA sequence. Enzyme immunoassay (EIA), nonamplified probes, and direct fluorescent antibody (DFA) tests are not acceptable alternatives for culture because false-negative test results occur more often with these nonculture tests. In addition, false-positive test results may occur.

The CDC reports that the risk of HIV antibody seroconversion after a single episode of sexual assault or abuse is low, but has occurred in children whose only known risk factor was sexual abuse.55 The risk of HIV transmission depends upon many factors, including 1) type of sexual contact (i.e., oral, vaginal, or anal); 2) presence of oral, vaginal, or anal trauma (including bleeding); 3) site of exposure to ejaculate; 4) viral load in ejaculate; and 5) presence of another STD or genital lesions in the perpetrator or victim. Children may be at higher risk for HIV transmission because child sexual abuse often is associated with multiple episodes of assault and may result in mucosal trauma. The emergency physician may want to consult a local HIV specialist to determine if HIV testing and postexposure prophylaxis is indicated.61

Treatment

Prophylaxis. Prophylaxis for STDs is not recommended for asymptomatic prepubertal children being evaluated for possible CSA.55 According to the CDC, "Presumptive treatment for children who have been sexually assaulted or abused is not recommended because a) the prevalence of most STDs is low following abuse/assault, b) prepubertal girls appear to be at lower risk for ascending infection than adolescent or adult women, and c) regular follow-up of children usually can be ensured."55

In contrast, teen patients and adults should receive antibiotic prophylaxis for STDs.55 However, clinicians should be aware that the efficacy of these regimens in preventing gonorrhea, trichomoniasis, bacterial vaginosis, and Chlamydia trachomatis genitourinary infections after sexual assault has not been studied adequately. The following prophylactic regimen is recommended for the adolescent sexual assault victim:55

  • Postexposure hepatitis B vaccination, without HBIG, should adequately protect against HBV.
  • Hepatitis B vaccine should be administered to a sexual assault victim at the time of the initial examination if he/she has not been previously vaccinated.
  • Follow-up doses of vaccine should be administered 1-2 and 4-6 months after the first dose.

An empiric antimicrobial regimen against Chlamydia, gonorrhea, Trichomonas, and bacterial vaginosis should be provided, as below:

ceftriaxone 125 mg IM in a single dose PLUS

metronidazole 2 g orally in a single dose PLUS

azithromycin 1 g orally in a single dose

OR

doxycycline 100 mg orally twice daily for 7 days.

Data are insufficient concerning the efficacy and safety of postexposure prophylaxis for HIV in children, teens and adults.55,61 When considering HIV postexposure prophylaxis, consult a local HIV specialist to assist in the initial ED decision making and follow-up counseling, testing, and treatment. In addition, pregnancy prophylaxis should be considered in pubertal females. Consider anti-emetic medications when providing pregnancy prophylaxis (especially estrogen-containing products currently on the market).

Differential Diagnosis

A number of nonabuse conditions result in physical findings that mimic CSA. (See Table 4.)

Documentation and Photography

Photography is an important component of documentation and evidence preservation and allows for expert consultation in some cases of CSA.72,73 There are a number of camera systems that meet the evidentiary standards in documenting injuries in CSA.70,73 Photographs require adequate lighting and a planned composition of the anatomical area.29,72,73 Photographs of injuries should include a scale in the frame and key anatomic landmarks. One photograph of the entire child is recommended to mark the beginning of the photographic set. Photography of physical findings does not preclude a detailed description of the injury in the medical record.

Digital photography provides the newest and best technology in obtaining and sharing images with members of the multidisciplinary child abuse team. Images also can be transmitted to CSA medical experts via the Internet or computer-to-computer connections.72,73 In response to the criticism (often made by defense attorneys) that digital images can be easily manipulated, some digital cameras have encrypting devices that demonstrate if the image is in its original form or has been altered.

Preservation of pictures must be discussed within the health care and forensic teams. It is important to maintain the chain of custody, which requires established protocols for the release of photographs to team members. Storage of digital images on a hospital-based computer system should be password protected to ensure limits on access to this highly confidential material. An alternative and recommended method of photo documentation involves eliciting the help of a local police forensic photographer. In this manner, all photographs that are to be used in the course of a criminal trial are secured by law enforcement. Police photography should not inhibit the use of medical photography, which can be critical for consultation and education purposes, after provision of permission by the caretaker.

Use of Colposcopy in the Anogenital Examination

A colposcope is the instrument of choice for the detection and recording of genital injury. It provides a noninvasive method for visualizing the anogenital area, particularly in the female patient, and provides photographic documentation of the clinical findings.11 The child’s ability to observe the examination via the videocolposcope screen may provide significant reassurance to him or her.53 A study of children who underwent videocolposcopy found that children generally watched their evaluation and were highly cooperative throughout the examination.74 Videocolposcopy is most commonly used in the child abuse subspecialty setting and may be impractical or cost-prohibitive for some EDs. However, reliance on standard examination techniques, with the use of a hand-held magnifying glass, when necessary, provides visualization of most traumatic injuries.

Medical Follow-up

Proper medical follow-up must be ensured for all children and adolescents who are victims of sexual abuse or assault. These follow-up visits provide the clinician an opportunity to 1) detect new infections acquired during or after the assault; 2) complete hepatitis B immunization, if indicated; and 3) complete counseling and treatment for other STDs.55

Follow-up examination should be done within 1-2 weeks of the assault, and is especially important in the patients who did not receive prophylactic treatment. If treatment was provided, retesting should be done in the symptomatic patient. The CDC also recommends that serologic tests for syphilis and HIV infection be repeated 6, 12, and 24 weeks after the assault, and at 12 weeks post-assault for hepatitis B if initial test results were negative and there exists a high index of suspicion for infection in the perpetrator.55

The Impact of Sexual Abuse

There is neither a predictable nor universal response to the psychological trauma of sexual abuse.75-77 Individual differences after childhood sexual abuse have been attributed to the nature of the abuse and individual psychological adaptation. A meta-analysis of published research on the effects of child sexual abuse conducted on 37 studies published between 1981 and 1995 that collectively contained 25,367 people did not find evidence to support a specific CSA syndrome. Rather, a multifaceted model of traumatization after CSA was described, with the potential for significant impairment in both physical well-being and mental health in the victimized child.75

Physical injury or infection in a CSA victim often is limited and readily treated.78 Berkowitz summarized the commonly recognized medical sequelae of CSA using the following organ systems approach:79

Gastrointestinal (GI) disorders, which are secondary to the association between GI symptoms and stressful events (and related to acid secretion and intestinal motility). Disorders associated with sequelae from sexual abuse tend to show no structural, infectious, or metabolic basis and as such are called "functional." Included in these disorders are irritable bowel syndrome, nonulcer dyspepsia, and chronic abdominal pain.

Gynecologic disorders, which are considered related to the inappropriate focus on the child’s genital region that may occur in the context of sexual activity. In general, those with long-term gynecologic symptomology associated with CSA tend to have no organic etiology identified. These disorders include chronic pelvic pain, dysmenorrhea, and menstrual irregularities.

Somatization, which is due to a preoccupation with bodily processes. Conflicting research in this area makes definitive statements difficult but some clinical population studies suggest that somatization may account for the reported increased complaints of chronic headache and backache, as well as other functional neurological complaints, in children and adults who have been abused. The psychological foundation of a child’s normal development and sense of self-worth, are all placed at risk by the perpetrator’s abusive acts. The effect of CSA on the mental health of the victim has been described: 1) in terms of a severity continuum ranging from mild to severe; 2) along a time course ranging from relatively short-term effects to those that are long-term, and in many cases lifelong; and 3) as an internalizing versus externalizing symptom pattern, with victims who respond to the abuse with withdrawal and depression (i.e., internalize), versus those who become aggressive and disruptive (i.e., externalize.)80

The coping behaviors of a CSA victim and his or her unique environmental supports and stressors affect the severity, acuity, and expression of the victim’s psychological response. A number of mental health conditions have been described which include:80

  • behavioral problems;
  • post-traumatic stress disorder (PTSD) symptoms;
  • interpersonal difficulties and limited ability to establish trusting relationships;
  • impaired cognitive functioning and declines in school performance; and
  • impaired emotional function.

Long-Term Effect of Sexual Abuse

Victims of childhood sexual abuse are at risk for a variety of medical and psychological symptoms.81 Children who have been sexually abused may present with enuresis or encopresis, urinary tract or anal pain, chronic abdominal pain, and headaches. They may exhibit a wide variety of complaints resulting from a somatic response to stress and psychological pain.

Kawsar and colleagues found that 81% of female child and adolescent victims of sexual assault reported having current psychological difficulties, with mood changes and sleep disturbances being the most common; 15% attempted self-harm.82 Kendall-Tackett reviewed 45 studies that found CSA victims had more psychological symptoms than nonabused children.76 The severity of symptoms was related to the relationship of the victim to the perpetrator, the duration and frequency of abuse, a history of penetration, and presence/absence of maternal support. In the adult survivor of sexual abuse, researchers have described a link between sexual abuse and emotional and behavioral dysfunctions including depression, low self-esteem, suicide attempts, multiple personality disorder, school failure, regressive behavior, post-traumatic stress disorder, drug and alcohol abuse, running away, sexual promiscuity, prostitution, and delinquent behavior.77 Also, there is a growing body of literature concerning adult survivors of CSA experiencing higher rates of various physical disorders.83,84

Children with Special Needs

In 1995, the National Center on Child Abuse and Neglect reported that children with developmental disabilities were at approximately two times the risk for child maltreatment when compared with the nondisabled pediatric population.25 Using a nationally representative sample of children, this study validated what had long been a clinical observation: Children with disabilities were at increased risk for neglect, physical abuse, and sexual abuse.85-87 The incidence of CSA in the population of children with special needs was 3.5/1000, compared with a rate of 2.0/1000 for children without special needs.87 (See Table 5.)

Table 5. Proposed Reasons for the Vulnerability of Children with Special Needs to Sexual Abuse

Performing the medical evaluation of children with special needs presents a number of unique challenges to the clinician. Great care, compassion, and diligent advocacy for the child with special needs and involvement of the multidisciplinary team are essential for a thorough and timely evaluation of this patient population one that ensures the child’s recovery and safety.88- 93

Summary

CSA involves the betrayal of a child’s trust, misuse of a relationship, and imposition of age-inappropriate sexual activity. Current data from child abuse evaluation centers provide a scientific basis for the interpretation of examination findings in CSA victims. Most important is the low incidence of abnormal findings in this patient population, again emphasizing the need for an effective multidisciplinary approach to these cases. The clinical plan of action must maximize data collection and maintain its integrity, empower the child victim and not the abusive caretaker, promote the patient’s health and psychological recovery, and ensure the future safety of the child.

The emergency physician plays a powerful role in advocating for this vulnerable group of patients by engaging the team and helping each patient take an important first step toward recovery.

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