Has a child been sexually abused?

Pediatric sexual abuse cases are severely underreported, says Marianne Gausche, MD, FACEP, FAAP, director of emergency medical services at Harbor-UCLA Medical Center in Torrance, CA. "The CDC recorded 126,000 cases in 1996, and they estimate there are over 300,000 potential cases," she reports. "Sexual abuse is criminal and a social taboo. People are extremely uncomfortable with this situation, so there may be a tendency to want to minimize that feeling."

Nurses are key to increasing detection of sexual abuse, Gausche says. "Awareness by nurses is extremely important, because they are the initial contact and spend a lot of time with patients," she notes.

Here are some ways to detect sexual abuse in your emergency department (ED):

Get a thorough history. "Any child who comes in with urinary symptoms or abdominal pain should be evaluated for sexual abuse," says Gausche. "Ask them, Has anybody touched you in a way you didn’t like?’ The child should be examined for obvious signs of sexual abuse."

Allow experts to conduct interviews, gather evidence. "We work with local law enforcement to provide forensic evidence," says Michael Altieri, MD, FACEP, an ED physician at Fairfax Hospital in Falls Church, VA. "If a child is suspected of being abused sexually, we leave the questioning to the police department. We don’t want non-professional interviewers to contaminate the process, which has occurred in several big cases at day care centers."

At Fairfax, if a child presents to the ED and sexual abuse is alleged or suspected, the triage nurse notifies a social worker and the patient is seen by SANEs. "Law enforcement comes to the ED and does a preliminary interview. They determine if they want a forensic exam done, which is a high-tech evidence gathering exam. The ED physicians and nurses are not involved at all," Altieri explains.

At Fairfax, 20-30 alleged pediatric sexual assaults are seen per month. "Our system is based on the use of a protocol, to ensure that evidence is collected properly by individuals who have special expertise," says Altieri. (See protocol in this issue.) "An ED physician may not know what a 2-year-old vagina looks like, let alone one that has been sexually assaulted."

Make the child comfortable. "Ask some non-threatening questions first, and move into the more threatening realm," says Gausche. "This helps develop the child’s ability to be truthful."

Ask simple and direct questions. Complaints that can seem unrelated may turn out to be the tip of the iceberg, says Altieri. "A 6-year-old girl came in complaining of pain when she voided, but it turned out to be vaginal pain," he recalls. "We asked a simple question, Did somebody touch you where it hurts? She told us, yes, that happened two days ago, it was [her] uncle. The mother was trying to tell her not to say anything, but it turned out the uncle who lived in the house had been abusing the child sexually for months."

Collaborate with physicians. If you have any concerns about abuse, communicate that with the physician caring for patient, stresses Gausche. "The nurse may notice something the physician hasn’t even thought of," she says. "Good communication is important because patients sometimes say more to the nurse than the doctor, or vice versa."

Suspect abuse when children display sexual behavior. "When a child is beginning to be examined, they may exhibit behaviors with a sexual connotation," says Gausche. "One toddler took off her diaper, lay down and spread her legs open, which is not typical behavior for a toddler. Children may look at these behaviors as playful, because their defense mechanisms do not like to say they are doing something wrong, especially if the abuser is someone they love."

On another occasion, a male resident went in to examine a child, who sat on his lap and stroked his face. "It struck us as clearly crossing the line as inappropriate behavior, and was very concerning," says Gausche. "It’s important to realize that a lot of children who are sexually abused don’t exhibit any of these behaviors. In fact, that is generally the rule."

Watch for excessive clinging. "Excessive clinging, especially to a female caregiver, can be cause for concern, especially with older children," says Gausche. "However, we see that a lot in children, so you need to put it in the context of the history and chief complaint."

Don’t ignore gut feelings. "Don’t hesitate to mention a gut level feeling. People in medicine understand that," says Gausche. "Even if you can’t quantify it, don’t hesitate to bring it up as another piece of information to put into the clinical picture."

Know signs and symptoms (See chart on behavioral and physical complaints associated with abuse.) Nurses must be familiar with all signs and symptoms of sexual abuse, ranging from subtle to obvious, Gausche stresses. "There is a huge range of things to look for, which should increase your level of concern," she says.

"Subtle signs and symptoms would include abdominal pain, dysuria, scratching, and vaginal irritation," says Gausche. "They may not want to use the restroom if they have been sodomized, or they may have nightmares, school phobias or constipation."

Sources

For more information about detection or the reporting of child abuse, contact the following:

• Michael Altieri, MD, FACEP, FAAP, Fairfax Hospital, Department of Emergency Medicine, 3300 Gallows Road, Falls Church, VA 22046. Telephone: (703) 698-3195. Fax: (703) 698-2893.

• Brenda Barton, RN, BSN, St. Luke’s Regional Medical Center, 190 E. Bannock, Boise, ID 83712.

• Julie Ann Cantlon, BSN, CARES, St. Luke’s Regional Medical Center, 190 E. Bannock, Boise, ID 83712. Telephone: (208) 381-3063. Fax: (208) 381-3222.

• Marianne Gausche, MD, FACEP, FAAP, Harbor-UCLA Medical Center, Department of Emergency Medicine, 1000 W. Carson Street, Box 21, Torrance, CA 90509-2910. Telephone: (310) 222-3500. Fax: (310) 212-6101. E-mail: mgausche@emedharbor.edu

• Marti Monk, CARES, St. Luke’s Regional Medical Center, 190 E. Bannock, Boise, ID 83712. Telephone: (208) 381-3063. Fax: (208) 381-3222.

Elizabeth Nicholson, MS, SW, LISW, Care House, Children’s Medical Center, 1 Children’s Plaza, Dayton, OH 45404. Telephone: (937) 463-5006. E-mail: lnicholson@cmc-dayton.org

Categories of child maltreatment

Physical abuse: Any act committed by an adult or person in authority over a child that results in intentional physical injury to the child

Sexual abuse: Any sexual contact or exposure to

sexual stimuli rendered to a child by an adult or older person.

Emotional or Psychologic Abuse: Patterns of behaviors manifested by a person of authority over a child which result in degradation, humiliation, rejection, or terror to the child.

Neglect: Failure to provide a child with the basic

necessities of life, such as food, clothing, shelter, medical care, and a safe environment.

Source: Marianne Gausche, MD, FACEP, FAAP


Behavioral/Physical complaints which may be associated with sexual abuse

Behavioral Physical

aggressive behavior abdominal pain

clinging behavior anorexia

insomnia constipation

excessive masturbation painful defecation

sudden change of behavior encopresis

phobias, fears pregnancy

sexualization of play rectal bleeding

attempted suicide sexually transmitted

disease

urethral discharge

urinary symptoms

vaginal symptoms

Source: Marianne Gausche, MD, FACEP, FAAP