Sexual abuse of children. Current concepts

Acts of pedophilia, rape, and incest are uncomfortable subjects that are underdiagnosed and underreported. Effective management involves a multidisciplinary approach that is difficult to achieve without a special program for sexually abused children. These children deserve all the time, skill, and research that are applied to any other serious and common medical problem. They are now beginning to get this attention.     

Sexual abuse of children. An epidemiologic study.

An epidemiologic study of sexual abuse of children was made by reviewing Minneapolis Police Department records. Children were involved in 33% of all cases reported. Eighty-five percent of cases involved exposure or indecent liberties. Half of the cases occurred in the summer; half of the cases occurred from 2 to 6 PM. The mean age of victims was 10.7 years, and 88% were girls. All reported offenders were men; their "mean estimated age" was 28 years. The method of study did not allow determination of social relationships between victims and the offenders. Little information regarding the magnitude of the problems of medical, psychological, and social sequelae of sexual abuse of children is available in the literature.     

Sexual abuse of battered young children

Four cases of battered children, in whom concurrent sexual abuse was present in the patient or siblings, are presented. The occurrence of both physical and sexual abuse in the same child has not received adequate attention in the literature, yet diagnostic and intervention procedures change drastically when both are present. The possibility of sexual abuse must be considered early in the course of caring for a physically abused infant or young child.     

Lack of transmission of human immunodeficiency virus from infected children to their household contacts

The possibility of transmission of the human immunodeficiency virus (HIV) from infected children to their contacts has been confronted in households, schools, day-care centers, and other child care settings. Cases reported to the Centers for Disease Control and several studies of close contacts of HIV-infected patients suggested that the risk of transmission in these settings is extremely low. However, most of these studies involved infected adults or older children. Younger children, who drool, bite, mouth toys, and are incontinent, may be more likely to transmit HIV in these settings. To assess this possibility, the authors tested 89 members of households in which 25 children with HIV infection, most of whom were preschool-aged, resided. Household members had close personal contact with the infected children. They shared many items likely to be soiled with blood and body fluids, such as toys, toothbrushes, eating utensils, toilets, and bathtubs. Hugging, kissing, sharing a bed, and bathing together were common. Household members were tested no sooner than 4 months after initial contact with the infected child, to allow adequate time for sero-conversion. All 89 participating household members were anti-HIV seronegative, and 78 who were tested were serum p24 antigen negative. It was concluded from this study and other evidence that the risk of transmission from children to their contacts is extremely low and has not been clearly documented in the household setting.     

Loss of hepatitis B antibody in human immunodeficiency virus-positive hemophilia patients

The presence of human immunodeficiency virus (HIV) antibody in hemophilia patients was correlated with the loss of existing antibody to hepatitis B surface antigen (HBsAb) or the inability to develop an antibody to hepatitis B after receiving commercially available hepatitis B vaccine. Of the 137 patients studied 66 were HIV-positive and 71 were HIV-negative. Evidence of HBsAb (n = 44) or exposure to hepatitis vaccine (n = 12) was found in 85% of HIV positive patients at some time during their care in our clinic. However, 20% demonstrated subsequent antibody loss and/or did not respond to hepatitis vaccine. Loss of HBsAb or vaccine nonresponse was restricted to patients less than 21 years of age (72% of all patients). This result contrasted to only a 3% loss of HBsAb or vaccine nonresponse in the HIV-negative patients who had acquired the HBsAb (n = 23) or were given the hepatitis vaccine (n = 29). This result suggests that loss or alterations of hepatitis B immunity occur in association with HIV infection or exposure.     

Cognitive assessment of human immunodeficiency virus-exposed children.

OBJECTIVE--To determine (1) the level of impairment in cognitive and motor functioning in human immunodeficiency virus (HIV)-exposed and HIV-infected preschool and school-age children; (2) cognitive strengths and weaknesses that characterize HIV-infected children; and (3) potential contributions of serostatus, neurologic impairment, and prenatal drug-exposure to cognitive functioning. DESIGN--Cross-sectional, single-blind study. SETTING--Pediatric neurology clinic at a large metropolitan hospital in New York, NY. PARTICIPANTS--Forty-one HIV-infected and eight seroreverter school-age children. INTERVENTIONS--The McCarthy Scales of Children's Abilities were administered to all children, as was the Neurologic Examination for Children. MEASUREMENTS/MAIN RESULTS--The obtained mean of the sample on the McCarthy Scales' General Cognitive Index was in the Borderline range, with 44% of the subjects scoring in the Mentally Retarded range. The most severe cognitive deficits were found on the Quantitative, Verbal, and Memory scales (Borderline range). Children infected with HIV with neurologic impairment performed significantly worse than did seroverters and neurologically normal HIV-infected children. There were no significant differences in cognitive functioning due to gender, ethnicity, and prenatal drug exposure. CONCLUSIONS--Cognitive deficits were detected in HIV-infected and seroreverted children. The presence of neurologic dysfunction in HIV-infected children markedly intensified these deficits.     

Sexual abuse in children: prevention of sexually transmitted diseases

When a child suffers from sexual abuse clinical guidelines must be established. There is a risk of infection from the following agents responsible for sexually transmitted diseases: the hepatitis B, hepatitis C and human immunodeficiency viruses, Neisseria gonorrhoeae, Chlamydia trachomatis, syphilis, herpes simplex virus, bacterial vaginosis, papillomavirus, Trichomonas vaginalis and Pediculus pubis. Therefore, a follow-up with periodic serological monitoring for 1year and immunoprophylaxis or chemoprophylaxis for some of these diseases should be started. Postpuberal girls should receive emergency contraception.     

Sexual abuse of street children brought to an observation home

This study was conducted to assess the magnitude and pattern of sexual abuse among male inmates of an observation home in Delhi. A total of 189 boys aged 6 to 18 years were assessed for sexual abuse using Finkelhors scale and Child Maltreatment History Self-Report followed by clinical examination using American Medical Associations guidelines. Majority of boys were runaways and 38.1 percent had suffered sexual abuse. On clinical examination, 61.1 percent showed physical signs and 40.2 percent showed behavioral signs of sexual abuse. Forcible sex was reported by 44.4 percent of victims and 25 percent had signs suggestive of sexually transmitted diseases. Strangers were the most common perpetrators of sexual abuse.     

The evaluation of sexual abuse in children

This clinical report serves to update the statement titled "Guidelines for the Evaluation of Sexual Abuse of Children," which was first published in 1991 and revised in 1999. The medical assessment of suspected sexual abuse is outlined with respect to obtaining a history, physical examination, and appropriate laboratory data. The role of the physician may include determining the need to report sexual abuse; assessment of the physical, emotional, and behavioral consequences of sexual abuse; and coordination with other professionals to provide comprehensive treatment and follow-up of victims.     

Thrombocytopenia and human immunodeficiency virus in children

Thrombocytopenia occurs in 13% of children with symptomatic human immunodeficiency virus (HIV) infection. The clinical and laboratory course of 19 children infected with HIV with thrombocytopenia is described. Bone marrow aspirates showed normal to increased numbers of megakaryocytes. Levels of antiplatelet antibodies were increased in 80% of the children and circulating immune complexes were found in 74%. Clinically significant hemorrhage leading to anemia occurred in five patients, and CNS bleeding led to a fatal outcome in an additional three children. Spontaneous remission of thrombocytopenia occurred in three of the 19 subjects. High-dose IV gamma-globulin was effective in increasing the platelet counts of six of 15 patients (40%) but resulted in a sustained remission in only one subject. Oral prednisone was effective in increasing the platelet count of two thirds of those whose platelet counts could not be controlled by IV gamma-globulin. Bleeding manifestations were eliminated in all patients whose platelet counts increased significantly. Of the 11 children whose counts increased either spontaneously or as a result of therapy, eight remain alive (72%). In contrast, all of the eight patients whose platelet counts did not improve have died. Thrombocytopenia in children with HIV disease is engendered by immune mechanisms and is a major cause of morbidity and mortality. High-dose IV gamma-globulin and/or corticosteroids are temporarily effective in increasing the platelet count and reducing bleeding in about half of thrombocytopenic patients and are recommended for use. The ability to respond to therapy correlates with improved survival.