Emergency Department Evaluation and Management of the Sexually Abused Child or Adolescent
Emergency Department Evaluation and Management of the Sexually Abused Child or Adolescent
Authors: Mary Ranee Leder, MD, Assistant Professor of Clinical Pediatrics, Division of Behavioral-Developmental Pediatrics, Child Abuse Program, Children’s Hospital, The Ohio State University, Columbus, OH; and Marc Scott Leder, MD, Assistant Professor of Clinical Pediatrics, Division of Emergency Medicine, Children’s Hospital, The Ohio State University, Columbus, OH.
Peer Reviewer: Marianne Gausche-Hill, MD, FACEP, FAAP, Associate Professor of Medicine, UCLA School of Medicine; Director, Emergency Medical Services, Harbor-UCLA Department of Emergency Medicine, Torrance, CA.
Cases of suspected child sexual abuse are complicated. The evaluation is time consuming and emotionally draining for the physician, child, and family. However, these cases are similar to others seen in the emergency department (ED) since they, too, require a complete history, physical examination, diagnostic evaluation, a clinical impression, and appropriate follow-up. One major difference in these cases is that they often involve a multi-disciplinary approach, utilizing professionals in social work, nursing, child protective services, and law enforcement.
ED physicians need to know the definition of sexual abuse and the epidemiology of the problem. They should focus on the key elements of the history and recognize that professionals of other disciplines can be very helpful in assisting with obtaining information. A complete physical examination, with emphasis on the anal and genital examinations and the significance of findings in these areas, is essential. Testing for sexually transmitted diseases and pregnancy as well as prophylaxis for these conditions is also important. Finally, disposition of the case, including detailed documentation and medical and mental health follow-up, must be carefully considered.
This article reviews how to appropriately triage cases of suspected sexual abuse, become comfortable with the crucial elements of the evaluation, and successfully collaborate with other professionals so that these difficult cases can be more effectively and efficiently managed within the ED.
— The Editor
Definition of the Problem
Sexual abuse is defined as the involvement of developmentally immature children or adolescents in sexual activities that they do not fully comprehend, to which they are unable to give informed consent, or that violate taboos of family relationships.1 It may include exhibitionism, fondling, genital viewing, oral-genital contact, insertion of objects, vaginal or rectal penetration, and pornography. Such contact may occur once with an unfamiliar individual or may involve a long-standing sexual relationship with a family member or a person known to the child. The perpetrator is known to the victim in 70-90% of cases, and 50% of cases involve a relative.2 Sexual assault is generally defined as any sexual act performed by one person on another without that person’s consent. This may involve a threat or the actual use of force. The victim may not be able to give consent due to age, mental or physical impairment, or the use of drugs or alcohol.1
Epidemiology
The actual incidence of child and adolescent sexual abuse is unknown. In 1996, there were an estimated 90,000 substantiated reports of sexual abuse made to child protective service agencies across the United States.3 In our pediatric tertiary care center ED, where approximately 75,000 children and adolescents are seen annually, nearly 400 are seen each year because of concerns about possible sexual abuse.
Sexual abuse is not an uncommon experience in childhood.4 It is believed to occur within all social and economic classes. Among the risk factors for sexual abuse are lack of protective behavior on the part of parents, drug and alcohol abuse within the family, and social isolation.
Data are also available for adolescent sexual assault. It has been estimated that 700,000 females are raped each year and that in 61% of these cases, the victims are younger than 18.5 These statistics do not include rape against males. The age of consent for sexual activity varies from 14-18 years of age, depending on the state. There is a common belief that rape is usually perpetrated by strangers; however, about half of adolescent sexual assaults are committed by acquaintances.6 Male victims are estimated to represent about 5% of the sexual assault cases reported,7 although this may be an underestimate because of the high incidence of underreporting by males.
Cases involving sexual abuse and assault are challenging to manage, as they require significant time, emotional energy, and resources. The subject of child sexual abuse does not receive adequate emphasis during medical training.8 As a result, many medical providers feel inadequately prepared to address this problem.
The Role of the ED
Children and adolescents who have been sexually abused may disclose this to a trusted individual, such as a parent, teacher, therapist, or school counselor. Such disclosures frequently trigger a family crisis, even if significant time has elapsed since the incident(s), the child or adolescent no longer has contact with the alleged perpetrator, and there are no physical complaints. Under these circumstances, families may present to the ED seeking a medical examination and assistance with contacting representatives of child protective services and law enforcement. In other cases, child protective services or law enforcement personnel may already be involved with the family. Such personnel may bring a child or adolescent who has reported a history of sexual abuse to the ED for a medical evaluation. Sometimes, a child or adolescent has not made any disclosures of sexual abuse but a parent or other family member has concerns based on behavioral or physical symptoms. (See Table 1.)
| Table 1. Behavioral Indicators of Possible Sexual Abuse9 |
| • Appetite disturbances (anorexia, bulimia) |
| • Conduct (oppositional-defiant disorder) |
| • Conversion reactions |
| • Depression |
| • Excessive masturbation |
| • Statements about sexual activity |
| • Guilt |
| • Phobias |
| • Promiscuity/prostitution |
| • Sexual activity toward other children or adults |
| • Sexualized play |
| • Sleep disturbances |
| • Substance abuse |
| • Suicidal behavior |
| • Temper tantrums, aggressive behavior |
The ED is not the most appropriate place to evaluate all cases of possible sexual abuse. Patients who report sexual contact within the preceding 72 hours, who complain of physical symptoms (i.e., ano-genital pain, bleeding, or discharge), or who may not be protected from the alleged perpetrator should be seen urgently.10 It may be possible to delay the evaluation of all other patients until an appointment can be arranged in a tertiary care center’s child abuse clinic or a child advocacy center, if such services are available.
Components of the Evaluation
The evaluation for possible sexual abuse includes the collection of historical information, a medical evaluation, a report made to child protective services if abuse is suspected, clear documentation of historical and medical information, feedback to the patient and family, and follow-up of medical and mental health issues. Depending on available resources, the ED physician does not need to be directly involved with each component. Utilizing the expertise of other ED personnel, such as professionals in nursing and social work, is critical in managing these cases efficiently and effectively.
Obtaining the History
The medical history is usually obtained by the ED nurse or physician. Psychosocial information may be obtained by the ED social worker. Only professionals who have been specifically trained should interview the child. Such professionals should have expertise in conducting a developmentally appropriate interview using nonleading, open-ended questions.11 In the case of an adolescent sexual assault victim, nonjudgmental, open-ended questions by a social worker, nurse, or physician can be used to gather accurate information.6
When obtaining the medical history, record the date and time of the hospital visit; sources of any information; and the date, time, and place of the alleged assault.1 Questions should focus on what happened and specifically whether genital, rectal, or oral contact occurred. Use language that is easily understood by the patient and consider repeating certain questions during the physical exam when the patient may be more familiar with the correct anatomic terms. In acute situations, find out whether the patient has bathed, douched, urinated, or defecated since the assault. With adolescent victims, obtain a menstrual and contraceptive history as well as any history of consensual sexual activity. Avoid the temptation to decide whether or not an assault actually took place based on the child’s or adolescent’s emotional response. Many patients are tearful and visibly upset, whereas others are calmer and more controlled.
Performing the Physical Examination
After the history is completed, inform the patient and family of the need for a complete physical exam. Explain each step of the exam and offer the patient and family an opportunity to ask questions. Remember that victims of sexual abuse have had control taken away from them by the perpetrator; therefore, it is important for them to be able to set the pace of the exam and to trust that the physician will stop at any point if requested.
Allow the pre-pubertal child to remain with the parent or other trusted adult during the physical exam, provided that this adult is not the alleged perpetrator. Permit adolescent patients to choose whom they would like present for the medical examinations. Members of child protective services or law enforcement should not be present for the physical examination unless their presence is requested by the patient.
Start with an assessment of general appearance. By performing a complete physical exam, the patient hopefully will become more comfortable with the examiner and pace of the exam so that the evaluation of the ano-genital area is less threatening. During the assessment of general appearance, look for evidence of any other injuries (i.e., bruises, abrasions, and lacerations) and clearly document them in the medical record.
Examination of the Pre-Pubertal Female. After assessing the pre-pubertal girl’s general appearance, perform an external examination of the anal and genital areas.12,13 Do not use a speculum on a pre-pubertal girl, as it is painful and can be emotionally traumatic. Use an otoscope or a hand-held lens with a bright light source to adequately visualize the hymen. A colposcope examination is not essential. However, if used, the child should be given the opportunity to familiarize herself with its function by visualizing her fingers or jewelry through it. Reassure both the parent and child that the instruments will be used to look "on the outside" of the ano-genital area.
In some institutional sexual abuse clinics and EDs, a parent or caretaker is permitted in the room with the child for support and to assist with the exam. Many children tolerate the exam better when the parent stands close to them or holds their hand. Children, who sometimes are afraid of lying on the exam table, can be examined in the parent’s lap with legs straddled while the parent sits in a chair or is in a semi-reclined position with his or her feet in the stirrups of the exam table. Do not use a rushed approach during the ano-genital exam as this may increase the child’s anxiety and resistance. Sometimes, leaving the room and giving the child a few minutes to prepare can be helpful when the child is reluctant to be examined.1 If a child is having vaginal bleeding or there is trauma to the ano-genital area, an urgent examination is needed. If cooperation by the child cannot be obtained, then an exam under anesthesia may be required.
Familiarize yourself with the normal pre-pubertal female genital anatomy in the supine position. (See Figure 1.) The hymen can be readily visualized by gently grasping the labia majora and providing gentle separation or traction (pulling forward). (See Figure 2.) The knee-chest position can be useful to more clearly visualizing the hymen if difficulties with that part of the exam occur in the supine position. (See Figure 3.) In the knee-chest position, the vaginal walls and cervix may be seen.
More than two-thirds of victims of sexual abuse have normal anal and genital examinations.14 Note that there are several normal hymenal variations, including the annular, redundant, and crescentic hymen. (See Figure 4.) Carefully examine the edges of the hymen, looking for transections (tears) or scars in the inferior portion. A redundant hymen can be more readily assessed by using a drop of saline on the hymen, which causes the edges to float. Alternatively, examining the child in the knee-chest position will sometimes allow the edges of a redundant hymen to be more clearly visualized.
Hymenal findings have been categorized into normal, nonspecific or normal variants, concerning for abuse, suggestive of penetration, and clear evidence of penetrating trauma. (See Table 2). Imagine the hymen as the face of a clock with the urethra at the 12 o’clock position. (See Figure 2.) Focus your attention on the lower half of the hymen between the 3 and 9 o’clock positions. Abnormalities due to sexual abuse are generally located in this area. Look for irregularities of the edge of the hymen between the 3 and 9 o’clock positions. Any abnormalities noted in the supine position should be confirmed in the knee-chest position. Carefully document in the medical record any abnormalities seen during the ano-genital exam. Anatomical diagrams can be useful.
| Table 2. Interpretation of Ano-Genital Findings15 |
| Normal |
| Periurethral bands; longitudinal intravaginal ridges, hymenal tags, hymenal bump, linea vestibularis, hymenal cleft/notch above 3 and 9 o'clock line, estrogen effects. |
| Normal variants or nonspecific findings |
| Septate hymen, failure of midline fusion, diastasis ani, perianal skin tag, increased perianal skin pigmentation, erythema of vestibule or perineal tissues, labial adhesion, vaginal discharge, lesions of condyloma in a child younger than 2 years, anal fissures, anal dilation with stool present. |
| Concerning for sexual abuse |
| Immediate anal dilation of at least 20 mm with stool not visible or palpable in vault, hymenal notch/cleft in inferior portion of hymenal rim, condyloma in child older than 2 years, acute abrasions, lacerations or bruising of labia or perihymenal tissues (history crucial in determining significance). |
| Suggestive of abuse/penetration |
| Scar or laceration of posterior fourchette, not involving hymen, perianal scar. |
| Clear evidence of blunt force or penetrating trauma |
| Laceration of hymen, bruising on hymen, perianal lacerations extending deep to external anal sphincter, hymenal transection (healed), wide areas of posterior half of hymen with absence of hymenal tissue extending to base of hymen (confirmed in knee-chest and supine positions). |
A remarkable healing process takes place in cases of sexual abuse and assault. One study, which followed victims of sexual abuse, found that signs of acute injury disappeared within a few days. The most persistent findings were irregular hymenal edges and narrow hymenal tissue at the point of injury. Most injuries with jagged edges tended to smooth off. Injuries to the posterior fourchette also healed with minimal scar tissue.16
Next, examine the child’s anus, looking for signs of trauma. Keep in mind that the normal elasticity of this area usually prevents injury from sexual abuse; therefore, children who have experienced anal penetration usually have a normal exam. When injuries are present in victims of anal assault, healing may take place within days.17 In one study, superficial lacerations healed within 1-11 days, deeper injuries healed within 1-5 weeks, and by 12-14 months, all signs of injury had disappeared.18
The interpretation of ano-genital findings is a rapidly changing field. It is therefore imperative that the practitioner read updated literature for the latest guidelines and refer to a child abuse expert for a second-opinion exam if abnormal findings exist or if the physician is uncertain about whether the ano-genital exam is normal.
Examination of the Adolescent Female. The examination of the adolescent female includes all of the steps taken for the pre-pubertal female. Additionally, all adolescents who have achieved menarche should have a speculum exam.6 Prior to performing a speculum exam, use a saline moistened swab to examine the edge of the hymen, looking for transections or tears in the inferior region. In contrast to the pre-pubertal hymen, the adolescent hymen is thickened, elastic, and redundant due to the effects of estrogen, and it can be examined with a moist swab without causing the adolescent any discomfort. Alternatively, a Foley catheter can be used to visualize the edge of the adolescent hymen (see section on Specialized Techniques).
Explain the pelvic exam step by step and answer the adolescent’s questions prior to beginning the exam. The use of drawings or a plastic model can be helpful in accomplishing this. Prior to using the speculum, insert one, then, if possible, two gloved fingers through the hymenal ring in order to gauge the elasticity of the hymen. A hymen that can comfortably accommodate two examining fingers should be able to accommodate a speculum. For the pelvic exam, use a small Huffman speculum on adolescents who have never had consensual sexual activity, otherwise, a standard speculum is appropriate. A wet mount should be made of any vaginal discharge to look for white blood cells, clue cells, or trichomonas. A pap smear is also important, especially if the alleged sexual contact occurred several weeks to months ago, to look for evidence of cervical dysplasia due to human papilloma virus (HPV).
Ano-genital findings in adolescents are classified in the same way as they are for pre-pubertal girls. (See Table 2.) Again, focus your examination on the inferior half of the hymen between the 3 and 9 o’clock positions where hymenal trauma from sexual abuse or assault is most likely to occur. Keep in mind that the absence of physical examination findings is common in cases of adolescent sexual assault even if penetration is reported by the victim or perpetrator. This is because of the high degree of elasticity of the tissue in these areas. If you have any questions about the significance of a specific finding, referral for a second opinion at a child abuse clinic is appropriate.
Examination of the Male Patient of any Age. After completing the general assessment, carefully examine the male patient’s penis, scrotum, and anus. Clearly document any signs of injury such as bruises, lacerations, abrasions, or other lesions. Any penile discharge should be examined for the presence of white blood cells and organisms such as trichomonas. The anal area also should be carefully examined for signs of trauma.
Remember that the majority of male victims of sexual abuse or assault have normal physical exams because certain types of sexual contact leave no physical findings (i.e., fondling and oral-genital contact). Victims of anal penetration may not have abnormal physical findings because of the high degree of elasticity of the tissues in that area.
Specialized Exam Techniques
Many centers utilize specialized techniques to facilitate the ano-genital examination. The following section describes several of these techniques and discusses the indications for each.
Toluidine Blue. Toluidine blue can be used to aid in the detection of perineal lacerations in pediatric and adolescent sexual abuse victims. This technique involves the application of 1% toluidine stain to the perineum, specifically the posterior fourchette, with a piece of gauze. After a few seconds, the dye is removed with lubricating jelly. This technique helps the examiner visualize lacerations of the perineum because with these injuries, the deeper dermis is exposed and allows uptake of the dye. A positive test is defined as the presence of a discrete area of dye uptake.
The usefulness of this technique recently has been the subject of much discussion. Proponents of toluidine blue note that use of the dye increases the detection of posterior fourchette lacerations, which may be suggestive of sexual assault.19 For this reason, toluidine blue is viewed by many as a useful tool in the evaluation of the sexually abused patient. Others are less enthusiastic about the use of the dye and find that it is messy. They also argue that it does not help discern areas of trauma from those of superficial irritation (which can have many causes) or from the normal texture of the tissue in the perineal area. Be aware that if this technique is used in the adolescent patient, it cannot distinguish trauma from consensual vs. nonconsensual sexual contact.
Foley Catheter Technique. Within the past 10 years, some experts in the field of adolescent sexual assault have advocated inserting a 12- to 14-gauge Foley catheter into the vagina of adolescent females and inflating the catheter bulb with 10 cc of air in order to spread out the redundant tissue of the estrogenized hymen. Proponents of this technique feel that it facilitates a complete examination of the hymenal edge in pubertal females.20 Success has been reported with this technique. In a study of 17 postpubertal patients, none complained of pain or refused the examination.21 The authors concluded that this technique may be useful in the identification of forensically significant physical findings in sexually abused and assaulted adolescent girls. Note that this technique should only be performed on postpubertal girls, as it would be painful and potentially emotionally traumatic for a prepubertal girl.
Wood’s Lamp. The Wood’s lamp has been used to detect the presence of seminal fluid on victims of sexual abuse. Recent studies have found that the Wood’s lamp is unreliable in detecting the presence of semen and that substances such as urine, Surgilube, Balmex, and Desitin can be mistaken for semen using Wood’s lamp florescence.22,23 Most experts believe that if the Wood’s lamp is employed, it should be used to identify suspicious areas and specimens from such sites should be collected for more definitive forensic testing.
Colposcopy. Colposcopy has been used in sexual abuse evaluations since the 1980s. Two studies have been done that compared colposcopy to direct inspection of the hymen with the unaided eye. Abnormal findings were identified by colposcopy alone (and not by inspection) in only four of 130 (3%) prepubertal girls.24 This study concluded that unaided examination of the hymen is sufficient in most cases. In another study of 88 patients, colposcopy revealed additional findings (as compared to the unaided examination) in 12% of cases.25 The authors found that direct inspection was more accurate in identifying certain anal findings (i.e., gaping).
While colposcopy can increase identification of ano-genital abnormalities, another study found that less than 20% of physicians who examine children’s genitalia use colposcopy.26 Since most forensically important examination findings are visible using unaided inspection, colposcopy is believed to be a useful adjunct but not an absolutely necessary procedure in the evaluation of sexually abused children and adolescents. Colposcope photographs provide a record and are useful for teaching and consultation between colleagues. Magnification with an otoscope light is generally felt to be sufficient in most cases.
Sedation/Surgical Consultation. In situations where there is excessive bleeding, a vaginal laceration, or when a foreign body is suspected, a surgical consult and possible examination under anesthesia is indicated. However, most cases do not require sedation. If a child without serious physical symptoms (i.e., no bleeding or discharge) cannot tolerate the examination in the ED, then follow-up with the primary care provider or child abuse clinic of a tertiary care center should be considered. An excellent review of these specialized examination techniques has recently been published and is a recommended reference for the ED physician.27
Evaluation for Sexually Transmitted Disease and Pregnancy. A positive gonorrhea culture from the vagina/urethra or anus has been reported in 2-3% of sexually abused children.28 The risk of acquiring chlamydia during sexual assault has been estimated to be between 4-17%.29 Both gonorrhea and chlamydia can be acquired congenitally from mother to infant and can persist for many months after birth. However, antibiotics used to treat common childhood infections within the first 3 years of life make the issue of persistence beyond this age less likely and the concern for sexual transmission becomes greater. The Centers for Disease Control and Prevention (CDC) estimates the rate of syphilis infection to be 0.5-3%, although patients with other sexually transmitted diseases are at increased risk.30 The risk of acquiring HPV is unknown; however, development of this infection has been documented from a single case of rape.1 The risk of acquiring HIV in one study was 0.25 per 1000 assessments for child sexual abuse. However, the children who were tested in this study were not randomly selected.31
Testing for sexually transmitted diseases in cases of acute sexual assault (less than 72 hours) is controversial.32 In most acute cases, the results of cultures will be negative. When results are positive, they may not indicate a new infection. One option is to culture patients in whom there are obvious signs of a sexually transmitted disease. Other indications for cultures may include the presence of ano-genital injury and cases where the perpetrator has a known sexually transmitted disease or when there are multiple perpetrators.27 Some have suggested culturing all adolescent victims due to the high rate of sexually transmitted diseases from consensual sexual activity.1
Once the decision to test for sexually transmitted diseases is made, obtain oral, genital, and anal cultures for gonorrhea as well as genital and anal cultures for chlamydia. Swabs should be taken from these areas and plated on standard culture media. Nonculture tests for the detection of chlamydia (i.e., DNA probes) are insufficiently specific for use in genital and rectal sites in children and adolescents since false-positive tests are frequent. For this reason, only approved culture methods should be used in children and adolescents who are victims of sexual abuse or assault.33 When cultures are performed, baseline serologic testing, including a RPR and hepatitis B surface antigen are also recommended. Testing for HIV is controversial. The CDC does not state that HIV testing is required, although the American Academy of Pediatrics (AAP) recommends testing for victims of sexual assault.6,34 Lesions suspicious for herpes simplex virus should be swabbed and sent for culture.
After obtaining the appropriate cultures, give antibiotic prophylaxis to those in whom a sexually transmitted disease is suspected based on the physical examination, for whom follow-up is uncertain, or if requested by the parent or patient (see Table 3 for recommended antibiotic doses). Patients who have not been immunized against hepatitis B should receive prophylaxis with the first hepatitis B immunization. (See Table 3.) The issue of providing HIV prophylaxis is a controversial one and consensus has not yet been achieved. Many institutions are working on protocols to address this issue. Consultation with a pediatric infectious disease expert may be useful.
| Table 3. Prophylaxis and Treatment for Sexually Transmitted Disease33,34 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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The overall risk of conception following rape of an adolescent is 2-4%.6 It is recommended that female rape victims be offered post-coital contraception. A baseline urine or serum pregnancy test should be performed to detect a pre-existing pregnancy. Current pregnancy prophylaxis includes Ovral (2 tablets immediately, followed by 2 tablets 12 hours later) or LoOvral (4 tablets immediately and 4 tablets 12 hours later) within 72 hours of the assault.36 Additional regimens can be given. (See Table 4.) If nausea and vomiting occur after the first dose, an anti-emetic, such as promethazine (Phenergan), can be given. A follow-up urine pregnancy test should be done 2-3 weeks later to detect treatment failures.
| Table 4. Pregnancy Prophylaxis35 | |
| Two tablets of Ovral within 72 hours of unprotected intercourse followed by two tablets 12 hours later. | |
Collaboration with Child Protective Services and Law Enforcement
The Rape Kit. Not every case of sexual abuse requires a rape kit. The rape kit is probably of little value for patients who give a clear history of exhibitionism, fondling, or genital viewing. Consider doing a rape kit in children and adolescents who give history of penetration of oral, vaginal, or rectal areas within the last 72 hours. You should also consider doing a rape kit on patients who present within 72 hours of an assault who have an abnormal ano-genital exam regardless of the type of contact they disclose. State guidelines dictate the content of the legal forensic evaluation and rape kits contain the materials for collection of forensic evidence that may be needed in a criminal investigation.6
The rape kit is used for collection of semen, vaginal cells, saliva, blood, hair, and other debris from the victim’s body, which are used to help identify the perpetrator. Though kits may vary from one jurisdiction to another, they generally contain swabs and slides for vaginal, oral, and rectal areas, which can be used to look for semen. Envelopes are used to collect foreign hairs and debris. There is usually paperwork to document the patient’s medical history, details of the assault, observations of any injuries, and any recent consensual sexual contact as well as the steps taken to collect such forensic evidence. It is very important that the forensic examination include careful documentation and an unbroken chain of evidence of specimens. Forensic lab technicians are able to use the swabs and slides to perform presumptive tests for semen (i.e., acid phosphatase catalyzed color reaction) and confirmatory semen tests (i.e., microscopic observation of spermatozoa and P3 reaction with antibodies). Blood, saliva, or semen DNA can be extracted, typed, and compared to standards from the victim and suspect.
Patients are asked to disrobe over a large paper sheet, which is subsequently folded and placed into a bag included in the kit. Each item of clothing is collected and placed in the bags provided. The examiner should not touch this clothing unless gloves are worn. Swabs of the oral, rectal, and genital areas are collected. Saline or distilled water moistened swabs of the perineum may be as useful and less traumatic than those from the vagina, especially in pre-pubertal females. Any secretions (wet or dry) on the victim’s skin should be swabbed and sent in the kit for forensic (DNA) testing, even if it does not fluoresce with the Wood’s lamp. The victim’s pubic hair is combed and he or she may be asked to help pull a few scalp and pubic hairs as standards. It is better to omit collection of hair standards if this is painful for the victim rather than to re-traumatize the victim or jeopardize consent to collect the kit. Photographs, with the patient’s name, a ruler, and color standard may be taken of any bite marks on the skin. These photographs may later be used in consultation with a forensic dentist to identify the perpetrator. Saline-moistened swabs should be applied to the bite mark to collect any dried saliva.
Keep in mind that collecting material for a rape kit can be uncomfortable or traumatic for the victim. The need to collect forensic evidence for law enforcement must therefore be balanced with the emotional needs of the patient. A victim of sexual abuse or assault should not be further traumatized to obtain evidence for the rape kit.
Documentation
Clearly document each component of the evaluation for suspected sexual abuse or assault in legible handwriting, preferably in black ink. Centers with child abuse programs have developed specific forms for such cases to assure that all necessary information is recorded. (See Figure 6.) Document the results of the complete physical examination, including a description of any other injuries. Include the findings on ano-genital examination. If the examination is normal, clearly state this. If not, document any abnormalities. Diagrams can be useful in describing the type or location of any abnormal or unusual ano-genital findings. It is important to include a statement about the implications of either a normal or nonspecific ano-genital examination. (See Table 5.)
| Table 5. Documentation of Significance of a Normal Ano-Genital Examination |
| Normal pre-pubertal girl: |
| "__ has a normal/nonspecific anal and genital exam. Two-thirds of girls with substantiated cases of sexual abuse have normal or nonspecific findings on examination. Therefore, today's findings do not exclude the possibility of sexual abuse." |
| Normal boy: |
| "__ has a normal/nonspecific anal and genital exam. Only a small minority of boys who are sexually abused have abnormal physical exam findings, so today's normal/nonspecific findings do not exclude the possibility of sexual abuse." |
| Normal pubertal girl: |
| "__ has a normal/nonspecific anal and genital exam. The hymen in pubertal girls becomes thickened and elastic under the influence of hormones. For this reason, it is less prone to injury with intercourse. Therefore, today's findings do not exclude the possibility of sexual abuse/assault." |
Parents, child protective services workers, and members of law enforcement may mistakenly believe that the absence of physical findings negates a child or adolescent’s clear, consistent disclosure that sexual abuse or assault has occurred. It is important to state that a normal or nonspecific physical examination is common in cases of sexual abuse and assault. On the other hand, if abnormal findings are consistent with a child or adolescent’s disclosure of penetrating injury to the anus or hymen, then this should be clearly documented.
A number of guidelines have been developed by the AAP to help physicians determine when they should be suspicious for sexual abuse and when a report to child protective services is in order. (See Table 6.) Familiarize yourself with these guidelines. The implications and suggested plan when sexually transmitted diseases are diagnosed in infants and pre-pubertal children have also been clarified by the AAP. (See Table 7.) Refer to this information when you have cases involving a positive culture for a sexually transmitted disease in this age group. Keep in mind that physicians are mandated by law to report cases of suspected child abuse. Failure to make a report when abuse is suspected may result in loss of one’s medical license and may place a child’s safety in jeopardy. Medical providers cannot be held liable for making a report of suspected sexual abuse that is subsequently unsubstantiated, provided that the report was made in good faith. If you are unsure about the significance of a medical finding and the child has not disclosed any history of sexual abuse, then it is appropriate to defer reporting to child protective services and to refer the case for further assessment by a child abuse expert at a tertiary care center.
| Table 6. Guidelines for Making the Decision to Report Sexual Abuse of Children10 | ||||
| History | Physical Exam | Lab | Level of concern | Report? |
| None | Normal | None | None | No report |
| Behavioral changes | Normal | None | Variable | Possible report, possible mental health referral |
| None | Nonspecific findings | None | Low | Possible report |
| Nonspecific history by child or history by parent | Nonspecific findings | None | Immediate | Possible report |
| None | Specific findings | None | High | Report |
| Clear statement | Normal | None | High | Report |
| Clear statement | Specific findings | None | High | Report |
| None | Normal/nonspecific finding | + Cx for GC | Very High | Report |
| + HIV | ||||
| Presence of semen | ||||
| Sperm acid phosphatase | ||||
| Behavioral changes | Nonspecific | STD | High | Report finding |
| Table 7. Implications of STDs in Infants and Pre-Pubertal Children10 | ||
| STD | Implication | Suggested Plan |
| Gonorrhea | Diagnostic of abuse (if not perinatal) | Report |
| Syphilis | Diagnostic (if not perinatal) | Report |
| HIV | Diagnostic (if not perinatal or transfusion acquired) | Report |
| Chlamydia | Diagnostic (use culture) (if not perinatal) | Report |
| Trichomonas | Highly suspicious | Report |
| Condyloma acuminata | Suspicious (if not perinatal) | Report |
| Herpes (genital) | Suspicious | Report (unless clear history of auto-innoculation) |
| Bacterial vaginosis | Inconclusive | Medical follow-up |
Providing Feedback to the Child and Family
Provide feedback regarding the physical examination to the patient and family, including the significance of the presence or absence of abnormal ano-genital findings. Use diagrams to augment your explanation if possible, as many parents are unfamiliar with pre-pubertal female anatomy and mistakenly believe that the hymen covers the vaginal opening completely. In most cases of sexual abuse, the ano-genital examination is normal. It should be clearly explained to patients that a normal examination is common in such cases and that the normal findings do not discount a child or adolescent’s clear, consistent statement that sexual contact has occurred.
Many children and adolescents who have been sexually abused feel as though they are "damaged goods" or that they are responsible for their abuse. It is a tremendous relief for them to know that their bodies are normal and that nobody can tell that sexual abuse has occurred just by looking at them. Explain to older children and adolescents there is no reason, based on their history of sexual abuse, that they would not be able to successfully have children in the future. Many victims of sexual abuse have unprotected consensual intercourse later in life because they believe that they are infertile as a result of prior sexual abuse. Boys may worry about their sexual orientation after experiencing sexual abuse.
In cases where physical findings are present, explain to patients and families that a remarkable healing process allows such injuries to resolve with few physical scars. A follow-up appointment at a sexual abuse clinic at a tertiary care center to document progress of such healing may be reassuring to patients and families.
Disposition
Medical Issues. Patients whose ano-genital cultures are positive need treatment for their infection and repeat cultures in approximately two weeks. It is also recommended that patients who develop ano-genital symptoms be seen for follow-up cultures even if the initial cultures were negative. Patients who receive baseline serologic testing should have follow-up blood work (RPR and HIV testing) in six months. Adolescents who receive pregnancy prophylaxis need a repeat pregnancy test in 2-3 weeks.
Mental Health Issues. Victims of rape may have a difficult adjustment to the assault. They may blame themselves and the assault may diminish their self-esteem or interfere with their trust in future relationships.37 A variety of mental and physical consequences may result from sexual abuse. Referral of the patient to a rape crisis team if available may be helpful in the early stages of the victim’s psychological treatment. Up to 80% of adolescent rape victims may experience a form of post-traumatic stress disorder characterized by the following symptoms: re-experiencing the traumatic event by intrusive thoughts, dreams, or flashbacks; avoidance of previously pleasurable activities; avoidance of the place or circumstances in which the rape occurred; and an increased state of psychomotor arousal leading to difficulties with sleep and memory.38 Information about psychological counseling should be provided to patients and families where sexual abuse or assault is suspected. Initially, the family and patient may not feel that counseling is necessary. However, they may reconsider this option if they have information about available resources.
Protective Issues. A report will need to be made to child protective services when sexual abuse is suspected. (See Table 6.) After a report is made, a member of child protective services may determine that a child can remain in the home, especially in cases where the alleged perpetrator is a stranger or non-custodial adult. However, the child sometimes must be placed into foster or substitute care if the alleged perpetrator is a custodial adult or if the child’s safety cannot be assured. Close collaboration with child protective services is necessary in such cases to ensure that the child’s safety remains a priority.
Law Enforcement Issues. Depending on the state, a report of suspected sexual abuse, which is filed with child protective services, may be forwarded to a representative of law enforcement. For this reason, clear, complete, legible documentation is of the utmost importance. Check whether your state also requires a report to law enforcement whenever an alleged rape occurs.
Preparing for and Going to Court. Physicians who diagnose and treat abused children may be asked to testify in several different types of court proceedings. These may include criminal prosecutions, proceedings to protect abused children, child custody and visitation litigation, and proceedings to terminate parental rights.10
Sexual abuse or assault cases usually do not go to court for months, therefore, accurate documentation within the medical record is essential. The more detailed the documentation, the more the ED physician will remember about the case if testimony is requested. It is possible that complete documentation in legible writing may eliminate the need for court testimony in some cases.
If called to court, remember that your role is to educate the judge and/or jury. Contact the attorney requesting your testimony. Review all medical records and laboratory studies pertaining to the case. Have the attorney review the questions that will be asked on direct exam. If possible, arrange to be "on call" so that you can avoid waiting for long periods to testify.
When making a court appearance, be conservatively dressed. Hospital garb is inappropriate in the courtroom. During direct and cross exam, do not hesitate to ask the attorney to explain any unclear questions. Avoid use of medical jargon. If a particular medical term is used, try to define it so that the judge or jury understands what it means. During cross-examination, it is common to encounter hypothetical questions based on hypotheses, which are extremely unlikely, and the physician may need to point out the unlikelihood. When a question is posed in a strictly "yes" or "no" fashion but the correct answer is "maybe," the witness should state, "I cannot accurately answer that question with a yes’ or no’ answer" and attempt to find a way to express the true answer. At the end of a court proceeding, it is helpful to obtain feedback on your performance as a witness from the attorney who requested your testimony. There are a number of references, which the ED physician may find helpful to review prior to giving court testimony.39-41
Summary
Victims of sexual abuse or assault are frequently seen in the ED. Cases which require urgent evaluation, including those in which the alleged event occurred within the last 72 hours, the victim has ano-genital symptoms, or the child is not safe from the alleged perpetrator, require a complete evaluation. Knowing the elements of a complete assessment, becoming familiar with ano-genital anatomy and sexually transmitted diseases, learning to collaborate with multiple disciplines, and understanding when to refer to a tertiary care center can make these complex cases much more comfortable for the physician, child, and family. For additional information about this complex subject, the reader is referred to a consensus-based set of recommendations published by the American College of Emergency Physicians.32
References
1. Emans SJ. Sexual abuse. In: Emans SJ, et al, eds. Pediatric and Adolescent Gynecology. 4th ed. Philadelphia, PA: Lippincott-Raven; 1998:751-794.
2. Finkelhor D. Current information on the scope and nature of child sexual abuse. Future Child 1994;4:31.
3. Alexander R. Statistics of child abuse. In: Jones J, ed. A Guide to References and Resources in Child Abuse and Neglect. Elk Grove Village, IL: American Academy of Pediatrics; 1998:181-185.
4. Koverola C. Psychological effects of child sexual abuse. In: Heger A, et al, eds. Evaluation of the Sexually Abused Child. New York, NY: Oxford University Press; 1992:15-29.
5. National Victim Center and Crime Victims Research and Treatment Center. Rape in America: A Report to the Nation. Arlington, VA: 1992:1-16.
6. American Academy of Pediatrics, Committee on Adolescence. Sexual assault and the adolescent. Pediatrics 1994;94:761-765.
7. Greydanus DE, Shaw RD, Kennedy EL. Examination of sexually abused adolescents. Semin Adolesc Med 1987;3:59-66.
8. Leder M, Emans SJ, Rappaport L, et al. Addressing child sexual abuse in the primary care setting. Pediatrics 1999;104:270-275.
9. Krugman R. Recognition of sexual abuse in children. Pediatr Rev 1986;8:28.
10. American Academy of Pediatrics, Committee on Child Abuse and Neglect. Guidelines for the evaluation of sexual abuse of children: Subject review. Pediatrics 1999;103:186-191.
11. Bourg W, Broderick R, Flagor R, et al. Interviewer training. In: Bourg W, et al, eds. A Child Interviewer’s Guidebook. Thousand Oaks, CA: Sage Publications; 1999:10-18.
12. Emans SJ. Office Evaluation of the child and adolescent. In: Emans SJ, et al, eds. Pediatric and Adolescent Gynecology. 4th ed. Philadelphia, PA: Lippincott-Raven; 1998:1-48.
13. Kahn J, Emans SJ. Gynecologic examination of the pre-pubertal girl. Contemporary Pediatrics 1999;16:148-159.
14. Adams JA, Harper K, Knudson S, Revilla J. Examination findings in legally confirmed child sexual abuse: It’s normal to be normal. Pediatrics 1994;94:310-317.
15. Adams JA, Harper K, Knudson S. A proposed system for the classification of ano-genital findings in children with suspected sexual abuse. Adolesc Pediatr Gynecol 1992;5:73-75.
16. McCann J, Voris J, Simon M. Genital injuries resulting from sexual abuse: A longitudinal study. Pediatrics 1992;89:306-317.
17. Finkel M. Anogenital trauma in sexually abused children. Pediatrics 1989;84:317-322.
18. McCann J, Voris J. Perianal injuries resulting from sexual abuse: A longitudinal study. Pediatrics 1993;91:390.
19. McCauley J, Gorman R, Guzinski G. Toluidine blue in the detection of perineal lacerations in pediatric and adolescent sexual abuse victims. Pediatrics 1986:78:1039-1043.
20. Starling S, Jenny C. Forensic examination of adolescent female genitalia: The foley catheter technique. Arch Pediatr Adolesc Med 1997;151:102-103.
21. Persaud D, Squires J, Rubin-Remer D. Use of Foley catheter to examine estrogenized hymens for evidence of sexual abuse. J Pediatr Adolesc Gynecol 1997;10:83-85.
22. Santucci KA, Kennedy KM, Duffy SJ. Wood’s lamp utilization and the differentiation between semen and commonly applied medicaments. Pediatrics 1998;102:718.
23. Santucci K, Nelson D, McQuillen K, et al. Wood’s lamp utility in the identification of semen. Pediatrics 1999;104:1342-1344.
24. Muram D, Elias S. Child sexual abuse: Genital tract findings in prepubertal girls. II. Comparison of colposcopic and unaided examinations. Am J Obstet Gynecol 1989:160:333-335.
25. Adams J, Phillips P, Ahmad M. The usefulness of colposcopic photographs in the evaluation of suspected child sexual abuse. Adolesc Pediatr Gynecol 1990;3:75-82.
26. Paradise J, Finkel M, Beiser A, et al. Assessments of girls’ genital findings and the likelihood of sexual abuse. Arch Pediatr Adolesc Med 1997;151:883-891.
27. Atabaki S, Paradise J. Medical evaluation of the sexually abused child: lessons from a decade of research. Pediatrics.1999;104:178-186. Supplement.
28. Ingram D, Everett V, Lyna P. Epidemiology of adult sexually transmitted disease agents in children being evaluated for sexual abuse. Pediatr Infect Dis J 1992:11:945.
29. Schwarcz S, Wittington W. Sexual assault and sexually transmitted diseases: Detection and management in adults and children. Rev Infect Dis 1990;12(suppl 6):S 682.
30. Rawstron S, Bromberg K, Hammerschlag M. STD in children: Syphilis and gonorrhea. Genitourin Med 1993;69:66.
31. Gellert G. Pediatric acquired immunodeficiency syndrome: Testing as a barrier to recognizing the role of child sexual abuse (editorial). Arch Pediatr Adolesc Med 1994;148:766.
32. American College of Emergency Physicians. Evaluation and Management of the Sexually Assaulted or Sexually Abused Patient. Dallas, TX: ACEP; 1999.
33. Hammerschlag M, Ajl S, Laraque D. Inappropriate use of nonculture tests for the detection of chlamydia trachomatis in suspected victims of child sexual abuse: A continuing problem. Pediatrics 1999;104:1137-1139.
34. Centers for Disease Control, 1998 Guidelines for Treatment of Sexually Transmitted Diseases. MMWR Morbid Mortal Wkly Rep 1998;47:RR-1.
35. American Academy of Pediatrics, Section on Child Abuse and Neglect. Sexually transmitted diseases in child victims of sexual abuse. Newsletter of Section on Child Abuse and Neglect. 1999;11:3-4.
36. Emans SJ. Contraception. In: Emans SJ, et al, eds. Pediatric and Adolescent Gynecology. 4th ed. Philadelphia, PA: Lippincott-Raven; 1998:611-674.
37. Katz BL. The psychological impact of stranger versus nonstranger rape on the victims’ recovery. In: Parrot A, Bechhofer L, ed. Acquaintance Rape: The Hidden Crime. New York: John Wiley and Sons: 1991:251-269.
38. Pynoos RS, Nader K. Post-traumatic stress disorder. In: McAnarney ER, et al, eds. Textbook of Adolescent Medicine. Philadelphia, PA: WB Saunders Co.; 1992;104:1003-1009.
39. Baum E, Grodin M, Alpert J, et al. Child Sexual Abuse, Criminal Justice, and the Pediatrician. Pediatrics 1987;79:437-439.
40. Starling S. Courts and court testimony. In: Jones J, ed. A Guide to References and Resources in Child Abuse and Neglect. Elk Grove Village, IL: American Academy of Pediatrics; 1998:21-23.
41. Chadwick D. Preparation for court testimony in child abuse cases. Pediatr Clin North Am 1990;37:955-970.
Physicians CME Questions
41. Which of the following is true regarding the physical examination in victims of sexual abuse?
A. The physical examination can routinely determine whether a child has been sexually abused.
B. A colposcope examination is mandatory for victims of suspected sexual abuse.
C. Most victims of sexual abuse have normal findings on physical examination.
D. Fluorescence by Wood's lamp is specific for seminal fluid.
E. A rape kit should be completed in all cases of suspected sexual abuse.
42. Which of the following is the best choice for the treatment of chlamydia in an adolescent female?
A. Ciprofloxacin 500 mg po x 1
B. Azithromycin 1 g po x 1 or Doxycycline 100 mg po bid x 7 days
C. Acyclovir 80 mg/kg/d divided qid x 7 days
D. Benzathine Penicillin 50,000 U/kg IM
43. An indication to evaluate a patient urgently in the emergency department for possible sexual abuse is:
A a patient with persistent vaginal bleeding.
B. a patient reporting sexual contact 1 week ago.
C. parental concern about behavioral changes in a child such as sexualized play.
D. all children younger than 10 years of age.
44. Prophylaxis for gonorrhea as recommended by the CDC includes:
A. Acyclovir 400 mg po tid x 7 days.
B. Metronidazole 15 mg/kg/d divided tid.
C. Erythromycin 30 mg/kg/d divided qid x 10 days.
D. Ceftriaxone 125 mg IM x 1.
E. Podophyllin 10% topically.
45. In the sexual assault victim, a physical exam finding strongly indicative of blunt force or penetrating trauma would be:
A. hymenal bump.
B. hymenal tag.
C. hymenal laceration.
D. periurethral bands.
46. In the majority of cases of sexual abuse, the perpetrator is:
A. known to the victim.
B. an unfamiliar individual.
C. the same age at the victim.
D. a known heroin addict.
47. Which of the following is true regarding specialized exam techniques used in the assessment of the sexual assault victim?
A. In the adolescent patient, toluidine blue can distinguish trauma from consensual vs. nonconsensual sexual contact.
B. The Wood's lamp should be used to identify suspicious areas and specimens from such sites should be collected for more definitive forensic testing.
C. Colposcopy is an absolutely necessary procedure in the evaluation of all sexually abused children.
D. The Foley catheter technique is advocated in prepubertal girls.
48. In which cases would cultures for sexually transmitted diseases in a prepubertal child be indicated?
A. All cases of child sexual abuse
B. Children who disclose a history of genital fondling
C. Children with behavioral changes
D. Children with an abnormal ano-genital exam (i.e., discharge or signs of injury)
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