Sexual abuse

Child sexual abuse is a common pediatric problem that concerns all pediatric health care providers. Management of child sexual abuse is multifaceted and multidisciplinary. Specialized health providers can provide consultation, but this availability does not minimize the role of the referring physician who often has ongoing contact with the family. Physicians are mandated to report cases of suspected or confirmed sexual abuse. In the majority of cases, a child’s statement about sexual abuse is the strongest evidence that abuse has occurred. Physical examination is normal in the majority of sexual abuse victims. Accurate, evidence-based interpretation of physical and laboratory findings is essential. Normal examinations, normal variants, and findings indicative of sexual contact must be differentiated. Forensic evidence collection and prophylactic treatments may be indicated when patients present within 72 hours of an abusive episode, and patients should be triaged accordingly. Potentially negative psychosocial outcomes should be addressed for patients and their families on initial evaluation and follow-up.     

Is it sexual abuse? Confusion caused by a congenital anomaly of the genitalia

Because of the increasing number of reports of sexual abuse of children, pediatricians should become more familiar with the examination of the genitalia of prepubertal children and learn to recognize physical indicators of abuse. Although some physicians may not recognize abnormal findings on examination, in other cases, unusual physical findings may be reported erroneously as possible abuse. The authors report a case of an unusual genital finding in a child which was suspected initially as being caused by sexual abuse but was subsequently determined to be a congenital anomaly. An external examination using a colposcope was useful in delineating the normal appearance of the tissues in question.     

Suicide risk following child sexual abuse.

OBJECTIVE: To determine the suicide rate and prevalence of suicide attempts and suicidal ideation in 183 young people who had experienced child sexual abuse and to examine variables related to the abuse, which may correlate with suicide attempts or suicidal ideation. METHODS: Adolescents and young adults who had experienced child sexual abuse and individuals from a nonabused comparison group were asked about suicide attempts and suicidal ideation 5 and 9 years after intake to the study. Nine years after the abuse, a national death search was carried out to ascertain the number and causes of death in the 2 groups. Logistic regression was used to assess information on demographic and family functioning variables, the sexual abuse, notifications for other child abuse, criminal convictions, and out-of-home placements that were related to the outcome variables. RESULTS: Young people who had experienced child sexual abuse had a suicide rate that was 10.7 to 13.0 times the national Australian rates. There were no suicides in the control group. Thirty-two percent of the abused children had attempted suicide, and 43% had thought about suicide since they were sexually abused. CONCLUSIONS: Little information seems to be available to clinicians at the time of investigations for child sexual abuse in children that may identify those who are at increased risk of suicide. Abuse by an acquaintance, parental denial, or being angry with the child and not the abuser may predispose to suicide attempts but not necessarily to a completed suicide.     

Experiences of special gynaecological services for children and adolescents: a descriptive study

Gynaecological examination of girls during childhood is undertaken somewhat infrequently. These genital examinations should not be taboo or a frightening experience for the girl, for her parents or for the physician. Studies of children suspected of sexual abuse have paid attention to the wide variety of gynaecological conditions already present in childhood. In 1988 we founded a special gynaecological outpatient clinic for girls under 16 y of age at a university hospital to develop the special knowledge and skills needed in children's gynaecology. In this gynaecological clinic for children and adolescents we were able to gain and offer expert knowledge of the problems of this age group. In this special clinic for children, gynaecological examination by special techniques and sonography led to a diagnosis in 71% of the patients without any instrumentation. Children and adolescent girls in need of special gynaecological care should be recognized specifically. Particular attention should be paid to the gynaecological care of victims of child sexual abuse and mentally or physically handicapped girls. In good co-operation with the girl, a gynaecological examination can become a positive experience during the development of female identity.     

Do no more harm: The psychological stress of the medical examination for alleged child sexual abuse

Aim:   Currently, there is some controversy that the medical examination following allegations of child sexual abuse may further traumatise the child. Access for children to appropriate care may be hindered if decisions about referral are influenced by personal beliefs, rather than by recognition of the potential health and psychological benefits of the assessment. We aimed to study the expectations and emotional responses of children and their parents to the medical examination.
Methods:   We conducted a prospective quantitative and qualitative study at the Children's Hospital at Westmead. Participants completed questionnaires pre-examination and post-examination, including Children's Anxiety and Pain Scales. Clinicians recorded a Genital Examination Distress Scale and a questionnaire about potentially prognostic variables.
Results:   Parents found the medical examination significantly less stressful than they had anticipated. They highlighted the importance of being involved in the process, the child's reaction, staff attitudes and the doctor's explanations. Although most parents expected that the medical would be stressful for their child, this did not correlate with the children's reports of feeling scared beforehand. Increased parental and child distress were significantly associated with the child being 12 years or older. The type of abuse was not significantly linked to any of the parent or child self-reports.
Conclusion:   Our findings indicate that the medical examination is not as stressful as expected and support the recommendation that timely medical assessment by appropriately trained professionals should be offered for all children following allegations of sexual abuse.     

Aberrant genital practices: an unrecognized form of child sexual abuse.

The sexual abuse of children in the United States is a problem of epidemic proportions. Sexual abuse is defined as any activity with a child that is conducted for the sexual gratification of the perpetrator. Common examples of sexual abuse include vaginal intercourse; oral-genital contact; anal-genital contact; fondling; finger manipulation; and stimulation of the offender. Sexual abuse may also occur in less typical patterns in which children are subjected to aberrant genital care practices, typically by their parents. Three case studies illustrate examples of aberrant genital practices. This type of abuse can be identified in primary care settings by asking specific questions of parents and children. Examples of such questions are provided.     

Forms of child abuse with regard to its forensic aspects

Civil legislation (Bürgerliches Gesetzbuch = BGB) as well as the penal code (Strafgesetzbuch = StGB) contain a broad spectrum of laws to protect children against physical abuse, physical neglect, sexual abuse, emotional abuse and neglect: i.e. section 1666 BGB (failure to provide the necessities of life for the child); section 170d StGB (neglect of care and education); section 176 StGB (sexual abuse of children); section 223b StGB (physical as well as emotional abuse and neglect). From the forensic point of view statistical data and different mechanisms of child abuse and neglect are reported. The basic differential diagnosis concerns an accidental injury of a child and parental right to punish (so called "Züchtigungsrecht" according to section 1631 BGB) in bona fide disciplinary effort. Emotional abuse and neglect are next to impossible to define and to be proved at court. The attending physician must carefully weigh the characteristics and presentation of any child injury or illness to determine the presence of child abuse or neglect. In the final analysis, the safety of children should be of greater concern than parental rights to privacy and protection from defamation or even criminal punishment.     

Vulvovaginitis: clinical features, aetiology, and microbiology of the genital tract.

AIM: To clarify the contribution of clinical and environmental factors and infection to the aetiology of vulvovaginitis in premenarchal girls, and to determine clinical indicators of an infectious cause. DESIGN: It was necessary first to define normal vaginal flora. Cases were 50 premenarchal girls > 2 years old with symptoms of vulvovaginitis; 50 controls were recruited from girls in the same age group undergoing minor or elective surgery. RESULTS: Interview questionnaire showed no difference between cases and controls in regards to hygiene practices, exposure to specific irritants, or history of possible sexual abuse. Normal vaginal flora was similar to that described in previous studies, with the exception of organisms likely to be associated with sexual activity. 80% of cases had no evidence of an infectious cause. In the 10 cases in whom an infectious cause was found, there was significantly more visible discharge and distinct redness of the genital area on examination compared with other cases. CONCLUSIONS: The findings suggest that vulvovaginitis in this age group is not usually infectious or necessarily related to poor hygiene, specific irritants or sexual abuse, although any of these can present with genital irritation. The possibility of sexual abuse should always be considered when a child presents with genital symptoms, but our data indicate it is not a common contributing factor. Infection is generally associated with vaginal discharge and moderate or severe inflammation.     

Prepubertal female genitalia: examination for evidence of sexual abuse

Experience with more than 375 cases of possible sexual abuse has taught us that much work still needs to be done in understanding normal prepubertal female anatomy and interpreting findings in sexual abuse cases. Because pediatric clinicians are often called upon to assess possible sexual abuse victims, knowledge of what is known and how best to examine the genitalia of a young girl is essential. Two cases are discussed that involve normal and abnormal anatomy. Examination techniques for adequate visualization include proper tension and timing with the spreading of the labia in the supine position, the knee-chest position, and lateral traction on the buttocks while lying flat on the abdomen to look for anal relaxation. The hymen, contrary to common notion, is often a slack, thick, folded, stretchable tissue which may persist after digital or penile penetration. Findings secondary to sexual abuse are often subtle. Acute tears or bruising are rare because force is seldom a part of the sexual acts committed against a child. A vaginal opening of greater than 5 mm is not common and may indicate vaginal penetration with a finger, object, or penis. An "intact" hymen does not necessarily preclude vaginal penetration. Lack of physical evidence never rules out abuse because many sexual acts leave no physical findings.     

Unexpected vaginal sperm in two sexual abuse victims

A careful forensic examination of the sexually abused child may reveal evidence of male ejaculation if this had occurred in the recent past. Two cases of the unexpected presence of vaginal sperm in prepubertal children are presented. The techniques of sperm and acid phosphatase collection are discussed. Sperm and/or other seminal products should be sought in victims of recent assault, in preverbal or nonverbal children, in victims with signs or symptoms of recent penetration, or in any case where the recency of sexual contact is unknown or uncertain.     

Child maltreatment 2002: Recognition, reporting and risk

BACKGROUND: Child abuse is a major cause of morbidity and mortality in the USA and in all other countries which have studied its incidence. It is the second leading cause of death of children in the USA. To decrease the incidence of child abuse and improve the welfare of children there must be international efforts to recognize, and report child abuse and to decrease those risk factors, which place children in jeopardy. In the USA, reports of child maltreatment have decreased each year since 1994 after nearly two decades of increase. The increase was associated with the passage of laws that mandated reporting child maltreatment and increased recognition of maltreatment. RESULTS: Several theories have been proposed to explain the decrease. These include: improved economy with decreased caretaker stress and more vulnerable children in day-care, imprisonment of offenders, treatment of victims to prevent reactive abuse, decreased use of corporal punishment, earlier recognition and reporting, prevention programs including home visitors and less corporal punishment in schools. If early recognition is to occur there must be clearly defined and uniform laws that define abuse and the significant consequences to mandated reporters for failure to report. The laws must be concise, understandable and contain medically based definitions of abuse. A bruise should be considered a significant injury. The use of an instrument on a child, for any reason should be reportable as abusive. Society must be taught that a child's head and its contents are particularly susceptible to trauma. Heads should not be slapped, shaken, or struck. The purpose of a report of suspect maltreatment should be to obtain services for families. Without proper services, abuse will reoccur and victims will become victimizers. Any sexual act, including pornography, involving a child who is unable to give consent constitutes reportable sexual abuse. Recognition of what constitutes abuse would be simplified if all countries adopted laws that forbid corporal punishment in schools and homes. Parenting education, which offers alternatives to the use of corporal punishment and anger and stress management skills, should be universal and begun in preschool. In the older child, topics would include conflict management tactics, mate selection, child development, child health, and pregnancy planning. DISCUSSION: Professional knowledge of child maltreatment is inadequate. This multidisciplinary topic must be incorporated into the undergraduate and graduate curricula in medicine and other professions dealing with children. Child victims are unable to represent themselves. In most other childhood diseases the parents rise up in arms to lobby for their children's rights and raise money for research, professional education and clinical services. In child maltreatment, government and private organizations must take on this task. The valuable resources of Federal Public Health Services become available when child maltreatment is declared to be a disease. Other countries should emulate countries that have eliminated corporal punishment of children. Countries that do not protect children from maltreatment including the ravages of war must be seen as perpetrators of child maltreatment and answerable to the international community. One may adhere to the adage that one is not one's brother's keeper. This should never be applied to children. As the world's most precious resource, we must be the keepers of all children.     

The diagnosis of child sexual abuse.

OBJECTIVE--To examine how the history, psychological evaluation, medical examination, and child's response to the examination contributed to a diagnosis of child sexual abuse by an interdisciplinary team. DESIGN--Patient series. SETTING--Subspecialty clinic for evaluating prepubertal children alleged to have been sexually abused. PARTICIPANTS--One hundred thirty-two children alleged to have been sexually abused and their parents or guardian, evaluated consecutively in a subspecialty clinic between September 1989 and June 1990. MEASUREMENTS/MAIN RESULTS--A social worker interviewed the parents, a psychologist interviewed the child, and a pediatrician obtained a medical history and examined the child. Parents completed a Child Behavior Check list and the child's response to the physical examination was noted. Both a disclosure by the child and abnormal physical findings were significantly and independently associated with the team's diagnosis of sexual abuse, whereas the presence of sexualized behavior, somatic problems, and the child's response to the examination did not make an additional contribution to the diagnosis. CONCLUSIONS--The findings support the need for a skilled psychological interview and a medical examination of a child alleged to have been sexually abused to make the diagnosis of sexual abuse. An interdisciplinary team appears to be a valuable approach for evaluating these children and their families.     

Photographing the physically abused child. Principles and practice

Photographic documentation of significant findings is an important part of any child abuse evaluation. High-quality photographs of significant physical findings may be important in helping courts to adjudicate whether child abuse has taken place. The physician evaluating abused children should ensure adequate photographic documentation of visible lesions. Physicians who care for abused children should be familiar with the basic principles and techniques of clinical photography. These include good equipment, adequate lighting, and planned composition. Equally important is a working knowledge of camera equipment, film procedure, and medicolegal implications. This review outlines for the practicing physician the basic concepts and techniques of photographing abused children.     

Vulvovaginitis: clinical features,aetiology, and microbiology of the genital tract

AIM—To clarify the contribution of clinical and environmental factors and infection to the aetiology of vulvovaginitis in premenarchal girls, and to determine clinical indicators of an infectious cause.DESIGN—It was necessary first to define normal vaginal flora. Cases were 50 premenarchal girls > 2 years old with symptoms of vulvovaginitis; 50 controls were recruited from girls in the same age group undergoing minor or elective surgery.RESULTS—Interview questionnaire showed no difference between cases and controls in regards to hygiene practices, exposure to specific irritants, or history of possible sexual abuse. Normal vaginal flora was similar to that described in previous studies, with the exception of organisms likely to be associated with sexual activity. 80% of cases had no evidence of an infectious cause. In the 10 cases in whom an infectious cause was found, there was significantly more visible discharge and distinct redness of the genital area on examination compared with other cases.CONCLUSIONS— The findings suggest that vulvovaginitis in this age group is not usually infectious or necessarily related to poor hygiene, specific irritants or sexual abuse, although any of these can present with genital irritation. The possibility of sexual abuse should always be considered when a child presents with genital symptoms, but our data indicate it is not a common contributing factor. Infection is generally associated with vaginal discharge and moderate or severe inflammation.     

Therapeutic interventions in sexual child abuse

This article describes the steps in a therapeutic crisis intervention in cases of intrafamilial child sexual abuse. It is outlined how the form and organisation of the intervention can in itself be highly therapeutic or very harmful. Taking to children, physical examination, coordination of professionals, the disclosure with parents and a family meeting are described as part of an overall therapeutic approach in the disclosure of the abuse. The described therapeutic crisis intervention attempts to take into account paediatric-medical routine and does not refer to any specialist therapeutic techniques in order to enable any child health professional who dares to face the issue of child sexual abuse to undertake the intervention.     

Uro-genital bleeding in pre-menarcheal girls: dilemmas of child abuse

Uro-genital bleeding in pre-menarcheal girls always raises concerns regarding child abuse. There are serious social issues involved; however, before labeling it as sexual abuse, all efforts must be made to rule out an organic pathology. We recently encountered two young girls of Afro-Caribbean origin who presented with vaginal bleeding with concerns from referring physicians about child/sexual abuse. On examination both had a rare condition of urethral prolapse. One of them underwent four-quadrant excision and the other was treated conservatively with urethral catherization.     

Medical assessment and legal outcome in child sexual abuse

OBJECTIVE: To examine the relationship of behavioral symptoms, interview disclosures, and physical examination findings with changing legal outcomes in child sexual abuse. DESIGN: Retrospective case series. SETTING: Hospital- and community-based multidisciplinary child abuse evaluation teams in the same county in 2 periods. PATIENTS: Children ages 0 to 17 years referred for evaluation of sexual abuse. MAIN OUTCOME MEASURES: Substantiation by child protective services, issuance of a warrant by law enforcement authorities, and criminal penalties were compared with reported changes in behavior, disclosure by the child, and physical evidence on examination. RESULTS: Among 497 children evaluated in 1991-1992 and 1995-1996, those with a positive examination finding were 2.5 times more likely to result in a criminal prosecution with a finding of perpetrator guilt (P<.001). Similar rates of disclosure, positive examination findings, child protective services substantiation, and warrant issuance were noted in the 2 periods. Decreasing rates of guilt determination and increasing criminal penalties were identified in 1995-1996 (P<.002). Disclosure of child sexual abuse during medical assessment was significantly associated with a positive physical examination finding, child protective services substantiation, and issuance of a warrant, but not a finding of guilt or criminal penalty. CONCLUSIONS: Medical assessment plays an important role in the overall community response to child sexual abuse. While behavioral symptoms and disclosure are important in medical treatment and child protective services investigation, positive physical findings are associated with a finding of guilt. There is a trend toward less finding of guilt and more years of criminal penalty that is not explained by case characteristics.