Evaluating Pediatric Sexual Abuse in the Emergency Department

Authors: Pamela A. Ross, MD, Director, Pediatric Emergency Medicine, University of Virginia Health System, Charlottesville; William J. Brady, MD, FACEP, FAAEM, Associate Professor and Program Director, Emergency Medicine Residency, Department of Emergency Medicine, University of Virginia School of Medicine, Charlottesville.

Peer Reviewers: Allan R. De Jong, MD, Director, Children at Risk Evaluation (CARE) Program, Alfred I. duPont Hospital for Children, Wilmington, DE; Marc S. Leder, MD, Assistant Professor of Clinical Pediatrics, Attending Physician, Pediatric Emergency Medicine, Children’s Hospital, Columbus, OH.

Sexual abuse affects children irrespective of age, sex, socioeconomic class, or geographic location.1,2,3 In 1999, there were approximately 1.07 million substantiated cases of child maltreatment. Of the substantiated cases, 46% were due to neglect, 18% to physical abuse, and 9% to sexual abuse.4 In 1998, more than half of sexually abused children were abused by males.5 Heterosexual males who are known to their victims continue to constitute the majority of pediatric sexual abuse perpetrators.6,7

Although fewer than 1% of victims die as a result of sexual abuse, the long-term effects of sexual abuse are far-reaching.5,8 The investigation of the association between childhood sexual abuse and adult health risk behaviors has been examined in the primary care setting. Increased numbers of childhood exposures to abuse have been correlated with multiple risk factors for the leading causes of death in adults.9 Moreover, abused children become adults who often die prematurely because of disproportionate health risk behaviors.9,10 (See Figure 1.) Among conditions linked to childhood sexual abuse, such common disorders as adulthood depression, morbid obesity, ischemic heart disease, cancer, and chronic lung disease have been shown to have a graded relationship with childhood maltreatment exposures.10

The emergency department (ED) evaluation of a child for sexual abuse can be extremely anxiety-provoking and intimidating for the victim, the child’s family, and the ED staff. The consequences of misdiagnosis of sexual abuse can be damaging from two perspectives: over-diagnosis and failure to diagnose. Over-diagnosis of sexual abuse has been correlated with the inexperience of the practitioner performing the evaluation and can be devastating to everyone involved.11,12 On the other hand, failure to recognize signs and symptoms of sexual abuse can result in increased risk for further abuse and injury to the child.12,13

As a result, knowledge and awareness of the behavioral and physical signs and symptoms of sexual abuse is critical to the detection of sexual abuse in the emergency setting. Accordingly, emergency physicians should be familiar with techniques for pediatric forensic evidence collection as well as basic principles of pediatric genital evaluation. Knowledge of prophylaxis and treatment recommendations for sexually transmitted disease (STD) in children also is mandatory.

With these issues in focus, the purpose of this review is to provide a systematic approach to the diagnosis, evaluation, and management of children suspected of having been victims of sexual abuse. The objective is to outline strategies for assessment and intervention that make it possible for emergency physicians to provide compassionate and comprehensive care to a sexually abused child.— The Editor


Definition of the Problem

C. Henry Kempe is credited with the astute recognition of child sexual abuse as a significant hidden pediatric problem.14 Sexual abuse was originally defined as the involvement of dependent, developmentally immature children and adolescents in sexual activities that they do not fully comprehend, to which they are unable to give informed consent, or that violate the social taboos of family roles.1 Current definitions of child sexual abuse remain inclusive of the original definition. In the past, criminal statutes have defined and classified sexual abuse as misdemeanors or felonies, depending on the degree of penetration of body orifices or whether physical or psychological force was used.15

Environmental risk factors for child abuse include economic deprivation, poor housing, unemployment, and illness. These risk factors correlate closely with those patients likely to seek care in an ED.13 A working knowledge of child sexual abuse enables the emergency physician to provide valuable assistance in a child’s recovery from a traumatic, devastating event. It is critical that the emergency physician remain cognizant that sexual abuse affects patients of all socioeconomic levels. When available, organized response teams consisting of nursing, social work, and law enforcement professionals who have knowledge and expertise in pediatric sexual abuse may be utilized. Pediatric Forensic Assessment Teams (FACT) or Sexual Assault Nurse Examiners (SANE) help to maximize the efficiency of a busy ED and contribute to expanded, effective management of these very sensitive cases.16,17 Though the short-term benefit of such programs in the ED is evident, outcome data is needed to define the actual long-term success of these programs.18

Presentation

Families often present to the ED immediately following a child’s disclosure of sexual abuse or immediately following direct parental observation or discovery of abuse.19 Sometimes a parent or caretaker simply will bring a child to the ED because of "suspicious" behavior and/or concern that someone has sexually abused their child. Regardless of the presentation, it is critical for the emergency physician to involve the appropriate social service, child protective, or law enforcement agency. A sexual abuse evaluation rarely is overlooked in the child who directly discloses abuse. In these cases, reports are made to appropriate agencies, a physical evaluation is performed, and forensic evidence is collected when indicated. It is important, however, that the emergency physician be familiar with non-specific complaints and other presentations of sexual abuse that may not involve any form of disclosure by the child.20,21 In the sexual abuse assessment, there are a number of behavioral, complaint, and exam indicators that may suggest sexual abuse.11,21-24 (See Tables 1 and 2.) Though the behavioral indicators occasionally are correlated with sexual abuse, none independently are diagnostic of sexual abuse. A great number of physical exam findings have been correlated with sexual abuse; however, only a small number of physical exam findings independently are diagnostic of sexual abuse.19 Child sexual abuse often occurs in the context of other family problems such as substance abuse and family violence.13

Often, the parental, social service, or law enforcement expectation is that the emergency physician definitively confirms or rules out sexual abuse. Emergency physicians should not give in to this demand for an immediate, definitive diagnosis. It is more appropriate to emphasize that there are very few findings that definitively diagnose sexual abuse; that normal or nonspecific findings do not exclude a diagnosis of abuse; and that suspicious findings may have other causes in addition to sexual abuse.12,13,21

History and Interview

The history of sexual abuse may be very difficult to obtain from a child. An understanding of the child’s developmental and emotional state is critical. A full medical history and detailed review of systems should be obtained. If sexual abuse is the leading diagnostic consideration, it is recommended that the child be interviewed as few times as possible. A forensic specialist trained to interview children is most desirable. Anyone not trained in forensic interviewing should limit detailed questioning of the child.

For the purpose of the medical evaluation, it is appropriate for the emergency physician to ask open-ended, non-leading questions and to make reassuring, supportive statements. Generally, questions that begin with the words "Is, Are, Were, Do, Did" have the potential for being considered leading questions. It is important to quote the child directly when recording responses.25,26 (See Table 3.)

Nods and other gestures of reassurance should be provided for the child. Express to the child that what he/she says is believed to be true. Avoid showing disgust, shock, or disbelief regarding details of the child’s disclosure. Children are more likely to change statements and give incorrect information with repeated questioning or other negatively interpreted gestures from the interviewer. The child who has been interviewed multiple times may interpret this as disbelief and start to embellish facts in an attempt to please interviewers.27,28 Whenever possible, the child should be interviewed alone and never in the presence of the alleged perpetrator. It is important that caregivers not be interviewed regarding sexual abuse events in the presence of the child to avoid influencing changes in the child’s disclosure.27,28 Caregivers also should be questioned privately regarding family history of sexual abuse and prior incidences of abuse in the child.28

Sexual Abuse Examination

Many children who present to the ED with a disclosure of sexual abuse present several days or weeks after the event. In these cases, it is most appropriate to make a report to the appropriate child protection agency, establish that it is safe for the child to go home, and refer the child to a regional center specializing in child sexual abuse. In cases of disclosures or presentations as the result of an acute event, the emergency physician should be knowledgeable and prepared to perform a sexual abuse examination. A general physical examination of the child always should be performed prior to examination of the perineum, genitalia, and anus. It is important to convey to the child that all aspects of the physical examination are of interest to the examiner.

The examination of the genitalia should be done as gently as possible. A person not suspected as the perpetrator and trusted by the child represents an acceptable additional presence with the child during the examination. The examination area should be comfortable and child-friendly. It is important that the physical examination of a child not result in additional trauma.29 Proceed in a slow, calm manner and allow time for the child to ask questions and understand what is happening. Conscious sedation or general anesthesia should be considered in the excessively uncooperative, traumatized patient, particularly if there is a high suspicion for physical evidence, anogenital trauma, or persistent bleeding. Skilled examiners who take the time to talk the child through the examination, however, rarely need to use conscious sedation. If the presentation is non-acute (disclosed events occurred prior to the previous 72 hours), then re-scheduling the exam for another time is acceptable.19

The physical assessment should start with simple observation. Note the child’s general appearance and stage of development.13 (See Table 4.)

Examination of the perineum, hymen, and vagina in females and the penis, scrotum, and perineum in males should be followed by an anal examination in both. The majority of abused children have normal or non-specific physical examinations.30,31 It is imperative to recognize that a normal genital and/or anal examination does not exclude sexual abuse. Because the examination of the abused child rarely differs from that of the nonabused child, it has been recommended that legal experts focus on the child’s history as the primary evidence of abuse.31 The physician’s observation of the child’s behavior, the history/disclosure, the review of systems for behavioral indicators of sexual abuse, and the physical exam indicators of sexual abuse become the critical aspects for identifying sexual abuse in the absence of conclusive physical exam findings.

Physical Examination Techniques

It is acceptable for pubertal adolescent females who have achieved menarche to receive speculum examinations. In circumstances of sexual abuse, however, it may not be well-tolerated by the adolescent who has never undergone a speculum examination. Speculum examinations are not indicated in prepubertal females. Techniques for examination of children without a speculum provide adequate visualization of many structures. These techniques also can be used in pubertal females who cannot tolerate a speculum exam.6,29

Supine Frog Leg Position. This positioning can be performed with the child lying on an examination table or sitting comfortably in a caretaker’s lap. The plantar surfaces of the feet can be placed together while the hips are abducted and externally rotated. A child facing the examiner in a caretaker’s lap can tolerate abduction of the legs so the child’s feet rest on the outer aspect of the caretaker’s legs. The supine frog leg position and its variations allow adequate visualization of the perineum in females and males.6,29

Labial Separation. As the child relaxes in the supine frog leg position, gently separate the labia. (See Figure 2.) This does not require significant traction or tension on the perineum. Gentle separation provides visualization of the hymenal orifice.29,32

Labial Traction. With the child in the supine frog leg position, gently grasp the labia majora and apply gentle traction outward and downward. (See Figure 3.) This will help relax the pelvic musculature, allowing maximal visualization of the hymenal orifice. The internal vaginal canal also may be visualized with this technique.6,29

Supine Knee-Chest. This position can be accomplished by having the child pull his or her knees to the chest. This position allows visualization of anal structures without significantly moving the child.6,29

Prone Knee-Chest. The child lies on the table with the anterior chest and shoulders touching the table, the knees apart, and the buttocks in the air. The back should assume a significant lordosis. The hymen is then examined by using the thumbs to separate the labia in an upward and outward motion. (See Figure 4.) This alternative position can be used for better visualization of the hymen and vagina. This position facilitates visualization of posterior hymenal injuries in both prepubertal and pubertal females. This position also facilitates visualization of the vaginal canal. Vaginal foreign bodies and/or the cervix also can be visualized when a child is in this position. The prone knee-chest position is important for clarifying findings noted in the supine position.6,29 Findings identified with the child in the supine position often disappear when the child is placed in the prone knee-chest position.32 This simple maneuver potentially decreases the rate of false positive findings for sexual abuse.33

Saline, Swab, and Foley Catheter Techniques. In the prepubertal female, saline can be squirted gently over the hymen to facilitate movement so that the edges can be visualized. In contrast to the prepubertal hymen, the adolescent hymen is estrogenized, thickened, redundant, and elastic. Viewing the edges of an estrogenized hymen can be challenging. A moistened saline swab can be used to visualize the edges of the thick, elastic adolescent hymen without discomfort. If a moistened saline swab does not adequately reveal the edges of the adolescent estrogenized hymen, the Foley catheter technique can be used. The Foley catheter technique allows improved visualization of the adolescent estrogenized hymen, but it is not indicated in the prepubertal female. A 12- to 14-gauge Foley catheter can be inserted gently just past the vaginal opening, and the balloon can be inflated using normal saline or air. Following inflation of the balloon, the catheter is pulled gently to expose the estrogenized hymenal edges.34 This technique generally is well-tolerated in adolescent females as well as in adult women.

Other Specialized Forensic Exam Techniques

Many techniques have been utilized to facilitate the anogenital examination of sexually abused children. Some are controversial and have been studied minimally in children.35 Colposcopy is commonplace in centers where frequent sexual abuse examinations of children occur. Colposcopy can increase the accuracy of descriptions and facilitate consultation between examiners.36 A colposcope provides superior light and magnification. When attached to a camera or video recorder, it can be used for photography or videography of the examination. Most forensically significant examination findings, however, are visible without colposcopy.35 A hand-held otoscope can be used to provide a small field of light and magnification, and is readily available in most exam rooms.29 The lens of an otoscope provides a reasonable degree of magnification of suspicious areas; however, it is important not to contaminate the instrument. Wood’s lamp illumination has been recommended for identifying seminal fluid, but substantial shortcomings of this method have been identified. Numerous substances other than seminal fluid illuminate with use of the Wood’s lamp. Therefore, Wood’s lamp illumination should be used only to identify suspicious areas or specimens for more definitive forensic testing.35 Toluidine blue dye can be used to aid in the detection of perineal lacerations. The dye is absorbed only by the nuclei of damaged epithelial cells and can be useful for the identification of small lacerations that otherwise may be difficult to detect. This technique cannot distinguish accidental injury from intentional injury.37

Terminology and Anatomy

The diagnosis of pediatric sexual abuse is difficult for a number of reasons. The literature has produced evidence to suggest that many physicians are unable to recognize normal and abnormal female prepubertal anatomy.38 In addition to a potential lack of physician awareness of age-adjusted genital anatomy, there are a number of conditions that can be confused with sexual abuse.11,39 The ability to describe and accurately document abnormalities is dependent upon the use of correct terminology.40 It is standard nomenclature to refer to location on the hymen, anus, or perineum using positions on the face of a clock.39 The 12 o’clock position is anatomically the most superior, and the 6 o’clock position is the most inferior. Clock-face nomenclature designation is completely useless, however, if the position of the patient is not clearly indicated. For example, 6 o’clock in the supine position becomes 12 o’clock when the same patient is placed prone. The emergency physician performing abuse evaluations on females should be familiar with the following anatomy and descriptive terminology for accuracy and consistency: • Clitoris—a small, cylindric, erectile body, situated in the anterior, superior portion of the vulva, covered by a sheath of skin (clitoral hood); • Labia majora—rounded folds of skin forming the lateral boundaries of the vulva (external genitalia of the female); • Labia minora—longitudinal, thin folds of tissue within the labia majora. In prepubertal children, the labia minora are not completely developed and do not connect inferiorly until puberty. This area is referred to as the posterior commissure in the prepubertal female and posterior fourchette in the pubertal or postpubertal female; • Fossa navicularis—concavity of the lower part of the vestibule situated posterior (inferior) to the vaginal orifice and extending to the posterior commissure; • Hymen—a membrane located at the junction of the vestibular floor and the vaginal canal that partially or completely (rare finding) covers the external vaginal orifice; • Vaginal vestibule—the area external to the hymen that is bordered laterally by the labia minora, superiorly by the clitoris, and posteriorly by the posterior commissure or posterior fourchette. It encompasses the fossa navicularis; • Vagina—internal structure extending from the uterine cervix to the inner aspect of the hymen. It has two components, the vaginal vestibule and the vaginal canal; and • Urethral meatus—external opening of the urethra from the bladder.40

Physical Examination Findings and Classification

Multiple research studies have been published describing the appearance of the genitalia of abused and nonabused children.41-47 Many findings that previously were believed to be associated with sexual abuse subsequently have been determined to be present in a significant number of nonabused children.39,46 Various classification systems for sexual abuse have been proposed.28,33,48 Currently there is no single, agreed-upon, uniform system for classification of sexual abuse findings among child abuse specialists.36 A simplified classification system for use by the emergency physician places findings into four categories. Normal findings represent findings commonly identified in children who never have been abused sexually.28,33,48 (See Table 5.) Nonspecific findings represent findings occasionally seen in children who have been abused sexually but that also are seen in children who never have been abused sexually.28,33,48 (See Table 6.) Specific or highly suspicious findings represent findings that commonly are seen in children who have been abused sexually but that occasionally are found in children who never have been abused sexually. Data related to highly suspicious findings are not sufficient to implicate sexual abuse as the only explanation.28,33,48 (See Table 7.) Conclusive findings are those that have expert consensus on the definitive diagnosis of sexual abuse and constitute medical certainty for sexual abuse.19,28,33,48 (See Table 8.) Unfortunately, no findings in the conclusive category can be identified by physical examination alone. When these findings are present, however, they make the diagnosis of sexual abuse a medical certainty, even in the absence of a positive history or disclosure of sexual abuse.

 

 

 

It has been proposed that clear evidence for penetrating trauma also be included as a category in diagnosing sexual abuse.32 This category consists of injuries or conditions that have no explanation other than trauma to the anogenital tissues. They include acute laceration to the hymen; ecchymosis on the hymen; perianal lacerations extending (deep to) beyond the external anal sphincter; healed hymenal transections (which represent areas where the hymen has been torn through to the base so there is no hymenal tissue remaining between the vaginal wall and the fossa or vestibular wall); and absence of hymenal tissue (wide areas in the posterior/inferior half of the hymenal rim with an absence of hymenal tissue, extending to the base of the hymen). All findings must be confirmed in the knee-chest position.33

Evidence Collection

It generally is recommended that evidence collection on children be performed in the ED if the alleged abuse has occurred within the previous 72 hours or if there is bleeding or other evidence of acute injury. Protocols for evidence collection in pediatric sexual abuse should be established and followed. In these cases, a chain of evidence must be maintained. Collection methods and procedures vary by jurisdiction, but there are a few general principles that should be followed. Specialized evidence recovery kits are available from law enforcement agencies. The kits usually contain necessary supplies and instructions for performing evidence recovery.13 Recommendations for evidence collection in children if the abuse has occurred fewer than 72 hours previously is extrapolated from adult literature. In the only large study of evidence recovery kits in prepubertal children, it was concluded that general guidelines are not well suited for forensic evidence collection in prepubertal children and that swabbing the child’s body for evidence is unnecessary after 24 hours. The study indicated that clothing and linens yield the majority of evidence in cases of prepubertal sexual abuse.49

Some centers have chosen to maintain a 72-hour rule, while others use 24 or 48 hours. Furthermore, some centers have a time rule that incorporates multiple modifiers, including the type of contact described, suspected material on exam to be sampled, and physical findings that suggest a recent act. Emergency physicians potentially could help collect more evidence for cases involving prepubertal children simply by reminding the police to search the crime scene for clothing, sheets, and towels. Pediatric FACT, SANE, or other established pediatric forensic response teams greatly assist the emergency physician and help the general flow of a busy ED when they are involved with these highly specialized cases.16,17 The physician should establish that the child physically is safe from the alleged perpetrator if discharged home. If this is not the case, protective custody should be arranged for the child, or the child can be admitted to the hospital. In all other cases of alleged pediatric sexual abuse, it is acceptable for the emergency physician to refer the child to his or her primary care physician, a child abuse specialist, or a child advocacy center that performs these specialized exams on a regular basis.15

STD Testing and Prophylaxis

The yield of positive cultures is very low in asymptomatic, prepubertal, sexually abused children.50,51 In most instances, cultures will be negative, and if positive, may not indicate new infection.11 It is important that only "gold standard" culture techniques be used in children. Tests commonly used for adult screenings of STD (i.e., DNA probe) should not be used in children, due to reports of high false-positive rates.11,52 Both historical and physical factors should be considered when deciding whether to obtain cultures and perform serologic tests for STDs in children. Historical criteria include the possibility of oral, genital, or rectal contact; a perpetrator known to have an STD; a sibling of the patient known to have an STD; abuse by multiple perpetrators; prior consensual sexual contact; or a history of genital discharge. Physical criteria include Tanner Stage 3 or greater; genital discharge or injury; or the presence of specific STD lesions.11,35,50,51,53 (Editor's note: Table 9 has been removed from this article.) Prophylaxis and treatment of pediatric STDs can be found in Table 10 (click here).52,54

Differential Diagnosis for Sexual Abuse

Most children with anogenital symptoms have some cause for their symptoms other than sexual abuse.55 A variety of dermatologic, traumatic, infectious, gastrointestinal, urologic, and congenital conditions may be mistaken for physical findings caused by sexual abuse. A pediatric presentation of anogenital erythema and/or edema frequently brings about the consideration of sexual abuse. Explanations or other causes for findings of anogenital erythema or edema include: excoriation, pruritis, fecal contamination, retained urine, restrictive clothing (such as tights), chemical irritants (such as bubble bath soaps), atopic dermatitis, diaper dermatitis, lichen sclerosus, scabies, nonspecific vaginitis, pinworms, perianal streptococcal cellulitis, inflammatory bowel disease, Kawasaki syndrome, and Candida albicans infection.39,56-60

The most common dermatologic syndrome mistaken for sexual abuse is lichen sclerosus. Lichen sclerosus manifests as subepidermal hemorrhage of the genital tissues, usually caused by minimal trauma to the area, such as wiping after using the toilet. Children occasionally may present with vesicular, blistering, or bullous lesions. The characteristic hourglass configuration of atrophic, hypopigmented skin around the genitalia and/or anus is consistent with the diagnosis, which is confirmed by biopsy.39,57,58

Anogenital bruising from accidental injury may be mistaken for sexual abuse. In general, these injuries result from straddle mechanisms, producing damage to external structures in a unilateral distribution, anterior or lateral to the hymen. The hymen usually is not traumatized in these instances, but periurethral or labial bruising is common. Hymenal and vaginal lacerations have been noted in young females who fall astride sharp objects. Although hymenal lacerations have been reported by accidental mechanisms, they occur infrequently. Therefore, hymenal damage should alert the clinician to an increased probability of sexual abuse.61-63 Trauma that occurs in motor vehicle crashes has been reported to cause genital injury. In one report, an improperly placed lap belt was responsible for perineal tears and labial abrasions sustained in an automobile accident, but the hymen appeared uninjured.64 Other conditions that can present with the complaint of anogenital bruising include lichen sclerosus, phytodermatitis, bleeding disorders, vascular nevi, and Mongolian spots.39 The custom of female circumcision in African and Middle Eastern cultures may result in adhesions and scarring of the genitals.63

Infectious disorders from non-STD organisms also may produce findings similar to child abuse. Pinworms and Candida albicans cause erythema, edema, and excoriations. Perineal streptococcal cellulitis presents with bleeding, anal fissures, painful bowel movements, and profuse erythema.39,65 Acute varicella (chicken pox) infection initially may appear in the genital area, prompting the physician to make the diagnosis of H. simplex infection. Only after the typical exanthem pattern is noted and/or viral culture results are available is the correct diagnosis made.66

Gastrointestinal and urologic conditions also have been misdiagnosed as sexual abuse. Crohn’s disease may manifest with fistulas, rectal tumors, chronic constipation with anal fissuring, rectal prolapse, and megacolon.67-71 Urologic conditions that may be mistaken for sexual abuse include urethral prolapse, urethral caruncle, and urethral hemangiomas. These conditions may present with complaints of pain and vaginal bleeding in children.39,72,73 In the event of rectal or urethral prolapse, a number of etiologies other than sexual abuse have been reported. A thorough investigation of the history will aid in making the diagnosis.74

A number of congenital anomalies may masquerade as sexual abuse. A general guideline suggests that abnormalities of midline structures in the genital, perineal, and anal areas may represent congenital abnormality rather than sexual abuse. Failure of midline fusion across the posterior fourchette, congenital cleft superior to the urethra, and anomalies of the anal sphincter all have been diagnosed incorrectly as the sequelae of past sexual abuse.39,75 Hemangiomas of the hymen, the vaginal wall, and the vulva also have been identified incorrectly as being the result of sexual abuse.39,76 Other congenital abnormalities of the genitourinary tract that mimic sexual abuse include ectopic ureter and rectovaginal fistula.74-76

Conditions commonly presenting with anogenital bleeding or vaginal bleeding or discharge include: vaginal foreign bodies, atopic or seborrheic dermatitis, precocious puberty, hormone-producing tumors, vaginal polyps, vulvar hemangioma, and sarcoma botryoides.39,60,65,67 Conditions that can present with non-bloody vaginal discharge include leukorrhea, vulvovaginitis, varicella, measles, scarlet fever, and typhoid.39,66,67

Other conditions confused with sexual abuse include phimosis/paraphimosis, hair tourniquet syndrome, hematocolpos, and mucocolpos. The diagnosis of sexual abuse should be based primarily on the history of an abusive event from the child.31 A thorough history, therefore, is critical.40,67,68 The emergency physician should be mindful that although physical symptoms in the ano-genital region should raise concerns, the history is key to the diagnosis of sexual abuse.

Legal Issues and Reporting

Mandatory reporting of child maltreatment exists in all 50 states. In most states, the emergency physician is considered a mandated reporter. For mandated reporters, the law requires a penalty for failure to report and provides protection from liability if the report of suspected abuse turns out to be unfounded once an investigation is completed. The mechanisms for reporting sexual abuse to appropriate social service, child protection, or law enforcement agencies vary from state to state. It is important for emergency physicians to be familiar with these mechanisms in the scope of their given practice location.

References

1. Kempe CH. Sexual abuse, another hidden pediatric problem: The 1977 C. Anderson Aldrich Lecture. Pediatrics 1978;62:382-389.

2. Muram D. Child sexual abuse: Relationship between sexual acts and genital findings. Child Abuse Negl 1989;13:211-216.

3. Russell DEH. The incidence and prevalence of intrafamilial and extrafamilial sexual abuse of female children. Child Abuse Negl 1983;7:133-146.

4. Peddle N, Wang CT. Current trends in child abuse reporting and fatalities: The results of the 1999 annual fifty-state survey. Chicago: National Committee to Prevent Child Abuse;2001.

5. U.S. Department of Health & Human Services, Administration on Children, Youth and Families. Child Maltreatment 1998; Reports from the States to the National Child Abuse and Neglect Data System. Washington, DC: U.S. Government Printing Office;2000.

6. Finkel MA, De Jong AR. Medical Findings in Child Sexual Abuse. In: Reece RM, Ludwig S (eds). Child Abuse: Medical Diagnosis and Management. 2nd ed. Philadelphia, PA; Lippincott Williams & Wilkins;2001:207-286.

7. Jenny C, Roesler TA, Poyer KL. Are children at risk for sexual abuse by homosexuals? Pediatrics 1994;94:41-44.

8. Olafson E, Boat B. Long-term management of the sexually abused child: Considerations and challenges. In: Reece RM (ed). Treatment of Child Abuse: Common Ground for Mental Health, Medical, and Legal Practitioners. Baltimore, MD; Johns Hopkins University Press;2000:14- 35.

9. Felitti VJ. Long-term medical consequences of incest, rape, and molestation. South Med J 1991;84:328-331.

10. Felitti VJ, Anda RF, Williamson DF, et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. Am J Prev Med 1998;14:245-258.

11. Hymel K, Jenny C. Child sexual abuse. Pediatr Rev 1997;17:236-249.

12. Jenny C. Pediatrics and child sexual abuse: Where we’ve been and where we’re going. Pediatric Annals 1997;26:284-286.

13. Ludwig S. Child Abuse. In: Fleisher GR, Ludwig S (eds). Textbook of Pediatric Emergency Medicine. 4th ed. Philadelphia, PA; Lippincott Williams & Wilkins;2000:1669-1704.

14. Donnelly AC, Oates K. Sexual Abuse. In: Donnelly AC, Oates K (eds). Classic Papers in Child Abuse. Thousand Oaks, CA; Sage Publications 2000:103-114.

15. American Academy of Pediatrics Committee on Child Abuse and Neglect: Guidelines for the evaluation of sexual abuse of children. Pediatrics 1991;87:144-150.

16. Derhammer F, Lucente V, Reed JF 3rd, et al. Using a SANE interdisciplinary approach to care of sexual assault victims. Joint Comm J Qual Improv 2000;26:488-496.

17. Selig C. Sexual assault nurse examiner and sexual assault response team (SANE/SART) program. Nurs Clin North Am 2000;35: 311-319.

18. Ciancone AC, Wilson C, Collett R, et al. Sexual Assault Nurse Examiner programs in the United States. Ann Emerg Med 2000; 35:353-357.

19. American Academy of Pediatrics, Committee on Child Abuse and Neglect. Guidelines for the evaluation of sexual abuse of children: Subject review. Pediatrics 1999;103:186-190.

20. Wells RD, McCann J, Adams J, et al. Emotional, behavioral and physical symptoms reported by parents of sexually abused, nonabused, and allegedly abused prepubescent females. Child Abuse Negl 1995;19:155-163.

21. Bays J, Chadwick D. Medical diagnosis of the sexually abused child. Child Abuse Negl 1993;17:91-110.

22. De Jong AR, Finkel MA. Sexual abuse of children. Curr Probl Pediatr 1990;20:495-567.

23. Hunter RS, Kilstrom N, Loda F. Sexually abused children: Identifying masked presentations in a medical setting. Child Abuse Negl 1985;9:17-25.

24. Sidel JS, Elvik SL, Berkowitz CD, et al. Presentation and evaluation of sexual misuse in the emergency department. Pediatr Emerg Care 1986;2:157-164.

25. Jones DPH, McQuiaton M. Interviewing the Sexually Abused Child. 2nd ed. Denver, CO: C. Henry Kempe National Center for the Prevention and Treatment of Child Abuse and Neglect: 1986.

26. Muram D. Child Sexual Abuse. In: Sanfilippo JS, Muram D, Dewhurst J, Lee PA (eds). Pediatric and Adolescent Gynecology. 2nd ed. Philadelphia, PA; W.B. Saunders Co.:2001:399-214.

27. American Professional Society on the Abuse of Children. Guidelines for Psychosocial Evaluation of Suspected Sexual Abuse in Young Children. Chicago, IL;American Professional Society on the Abuse of Children:1990.

28. Monteleone JA, Glaze S, Bly KM. Sexual Abuse: An overview. In: Monteleone JA, Brodeur AE (eds). Child Maltreatment: A Clinical Guide and Reference. St. Louis, MO; G.W. Medical Publishing: 1998.

29. American Academy of Pediatrics, Section on Child Abuse and Neglect. The Visual Diagnosis of Child Abuse. Elk Grove Village, IL; AAP Department of Marketing and Publications: 1997.

30. Adams JA, Harper K, Knudson S, et al. Examination findings in legally confirmed child sexual abuse: It’s normal to be normal. Pediatrics 1994;94:310-317.

31. Berenson AB, Chacko MR, Wieman CM, et al. A case-control study of anatomic changes resulting from sexual abuse. Am J Obstet Gynecol 2000;182:820-834.

32. McCann J, Voris J, Simon M, et al. Comparison of genital examination techniques in prepubertal girls. Pediatrics 1990;85:182-187.

33. Adams JA. Sexual abuse and adolescents. Pediatr Ann 1997;26: 299-304.

34. Starling SP, Jenny C. Forensic examination of adolescent female genitalia: The Foley catheter technique. Arch Pediatr Adolesc Med 1997;151:102-103.

35. Atabaki S, Paradise JE. The medical evaluation of the sexually abused child: Lessons from a decade of research. Pediatrics 1999; 104:178-186.

36. Adams JA, Wells R. Normal versus abnormal genital findings in children: How well do examiners agree? Child Abuse Negl 1994; 17:663-675.

37. McCauley J, Gorman RL, Guzinski G. Toluiding blue in the detection of perineal lacerations in pediatric and adolescent sexual abuse victims. Pediatrics 1986;78:1039-1043.

38. Ladson S, Johnson CF, Doty RE. Do physicians recognize sexual abuse? Am J Dis Child 1987;141:411-415.

39. Bays J, Jenny C. Genital and anal conditions confused with child sexual abuse trauma. Am J Dis Child 1990;144:1319-1322.

40. American Professional Society on the Abuse of Children. Glossary of Terms and the Interpretations of Findings for Child Sexual Abuse Evidentiary Examinations. Chicago, IL; American Professional Society on the Abuse of Children:1998.

41. Muram D. Child sexual abuse: Relationship between sexual acts and genital findings. Child Abuse Negl 1989;13:211-216.

42. Finkel MA. Anogenital trauma in sexually abused children. Pediatrics 1989;84:317-322.

43. McCann J, Voris J, Simon M. Genital injuries resulting from sexual abuse: A longitudinal study. Pediatrics 1992;89:307-317.

44. McCann J, Voris J. Perianal injuries resulting from sexual abuse: A longitudinal study. Pediatrics 1993;91:390-397.

45. Berenson A, Heger A, Hayes J, et al. Appearance of the hymen in prepubertal girl. Pediatrics 1992;89:387-394.

46. Berenson AB, Somma-Garcia A, Barnett S. Perianal findings in infants 18 months of age or younger. Pediatrics 1993;91:838-840.

47. Gardner JJ. Descriptive study of genital variation in healthy, nonabused premenarchal girls. J Pediatr 1992;120:251-257.

48. Adams JA, Harper K, Knudson S. A proposed system for the classification of anogenital findings in children with suspected sexual abuse. Adolesc Pediatr Gynecol 1992;5:73-75.

49. Christian CW, Lavelle JM, DeJong AR, et al. Forensic evidence collection in prepubertal victims of sexual assault. Pediatrics 2000; 106:100-104.

50. De Jong AR. Sexually transmitted diseases in sexually abused children. Sex Transm Dis 1986; 13:123-126.

51. Hanson RM. Sexually transmitted diseases and the sexually abused child. Pediatrics 1993;5:41-49.

52. 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.

53. Ingram DL, Everett VD, Flick LAR, et al. Vaginal gonococcal cultures in sexual abuse evaluations: Evaluation of selective criteria for teen-aged girls. Pediatrics 1997;99:E8.

54. Centers for Disease Control. 1998 Guidelines for Treatment of Sexually Transmitted Diseases. MMWR Morb Mortal Wkly Rep 1998; 47:RR1.

55. Kellogg ND, Parra JM, Menad S. Children with anogenital symptoms and signs referred for sexual abuse evaluations. Arch Pediatr Adolesc Med 1998;152:634-641.

56. Socolar RRS, Champion M, Green C. Physicians’ documentation of sexual abuse of children. Arch Pediatr Adolesc Med 1996;150: 191-196.

57. Handfield-Jones SE, Hinde FRJ, Kennedy CTC. Lichen sclerosus et atrophicus in children misdiagnosed as sexual abuse. BMJ 1987; 294:1404-1405.

58. Jenny C, Kirby P, Fuquay D. Genital lichen sclerosus mistaken for child sexual abuse. Pediatrics 1989;83:597-599.

59. Paul DM. The medical examination in sexual offenses against children. Med Sci Law 1977;17:251-258.

60. McCann J, Voris J, Simon M, et al. Perianal findings in prepubertal children selected for non-abuse: A descriptive study. Child Abuse Negl 1989;13:179-193.

61. Muram D. Genital tract injuries in the prepubertal child. Pediatr Ann 1986;15:616-620.

62. Bond GR, Dowd MD, Landsman I, et al. Unintentional perineal injury in prepubescent females: A multicenter, prospective report of 56 girls. Pediatrics 1995;95:628-631.

63. Unuighe JA, Giwa-Osagie AW. Pediatric and gynecological disorders in Benin City, Nigeria. Adolesc Pediatr Gynecol 1988;1: 257-261.

64. Baker R. Seat belt injury masquerading as sexual abuse. Pediatrics 1986;77:435.

65. Spear RM, Rothbaum RJ, Keating JP, et al. Perianal streptococcal cellulitis. J Pediatr 1985;107:557-559.

66. Boyd M, Jordan SW. Unusual presentation of varicella suggestive of child abuse. Am J Dis Child 1987;141:940.

67. Hey F, Buchan PC, Littlewood JM, et al. Differential diagnosis in child sexual abuse. Lancet 1987;1:283.

68. Hobbs CJ, Wynne JM. Sexual abuse of English boys and girls: The importance of the anal examination. Child Abuse Negl 1989;13: 195-210.

69. Lazar LF, Muram D. The prevalence of perianal and anal abnormalities in a pediatric population referred for gastrointestinal complaints. Adolesc Pediatr Gynecol 1989;2:37-39.

70. Clayden GS. Reflex anal dilation associated with severe constipation in children. Am J Dis Child 1988;63:832-836.

71. Zempsky WT, Rosenstein BJ. The cause of rectal prolapse in children. Am J Dis Child 1988;142:338-339.

72. Johnson CF. Prolapse of the urethra: Confusion of clinical and anatomic characteristics with sexual abuse. Pediatrics 1991;87: 722-723.

73. Roberts JW, Devine CJ. Urethral hemangioma: Treatment by total excision and grafting. J Urol 1983;129:1053-1054.

74. Lowe FC, Hill GS, Jeffs RD, et al. Urethral prolpse in children: Insights into etiology and management. J Urol 1986;135:100-103.

75. Adams JA, Horton M. Is it sexual abuse? Clin Pediatr 1986;28: 146-148.

76. Levin AV, Selbst SM. Vulvar hemangioma simulating child abuse. Clin Pediatr 1988;27:213-215.