Sexual Abuse
Deborah Madansky
Christine E. Barron
Carole Jenny
I. Description of the problem.
Sexual abuse is defined as the engagement of a child in sexual contact or activities that the child cannot comprehend, for which the child is developmentally unprepared and cannot give informed consent, and/or that violate societal, legal, and social taboos. The activity occurs for the gratification of the older individual and can include forms of anal, genital, and oral contact to or by the child, exhibitionism, voyeurism, or using the child for the production of pornography. Force is not always involved, but coercion or threats are commonly used by the perpetrator.
A. Epidemiology.
The true prevalence of sexual abuse is unknown since many cases go unreported. In retrospective surveys of adults, about 25% of women and 15% of men report sexual contact with an adult during childhood or adolescence.
1. 7.6% of reported cases of child abuse and neglect involve sexual abuse.
2. 75% of reported victims are female, but there is evidence that male victims are less likely to report.
3. Men are more commonly perpetrators.
4. The vast majority of perpetrators are known to the child.
5. Sexual abuse crosses all socioeconomic, ethnic, and racial lines.
B. Contributing factors.
Children at higher risk are those with a diminished capacity to resist or disclose, such as preverbal, developmentally delayed, or physically handicapped children, and children in dysfunctional or reconstituted families.
II. Making the diagnosis.
A. Presentations of child sexual abuse.
1. Acute assault. A child presenting within 72 hours of an assault should be referred to an emergency room, or to child protection programs when available, where forensic specimens may be collected.
2. In the pediatric office.
a. The child is referred by protective services or law enforcement for a medical evaluation as part of an investigation.
b. The child is referred by a family member who is aware of or suspects sexual abuse.
c. The child is seen for a routine examination or medical and behavioral complaint where the differential diagnosis includes sexual abuse.
B. Signs and symptoms.
1. Specific indicators.
a. Genital or rectal pain, bleeding, trauma, or infection
b. Sexually transmitted diseases (Table 73-1)
c. Developmentally inappropriate sexual behavior in young children, such as engagement in intercourse, oral sex, or sexual coercion.
2. Behavioral indicators are nonspecific and similar to symptoms due to other stressors. They are not indicative of specifically sexual abuse:
a. Fears and phobias, especially of circumstances similar to the abuse
b. Nightmares and other sleep disturbances
c. Appetite disturbance or eating disorders
d. Enuresis or encopresis
e. Change in behavior, attitude, or school performance
f. Depression, withdrawal, or suicidality
g. Excessive anger, aggression, or running away
h. Promiscuous behavior or substance abuse
Table 73-1. Implications of commonly encountered sexually transmitted diseases for the diagnosis and reporting of sexual abuse of prepubertal infants and children
Likelihood of sexual abuse
Suggested action
Gonorrheaa
Certain
Reportb
Syphilisa
Certain
Report
Chlamydiaa
Probable
Report
Condylomata acuminatuma
Possible
Evaluate. Report if sexual abuse is suspected based on history and physical exam
Trichomonas vaginalisc
Probable
Report
Herpes simplex type 1 (genital)
Possible
Evaluate. Report if sexual abuse is suspected based on history and physical exam.
Herpes simplex type 2
Probable
Evaluate. Report if sexual abuse is suspected based on history and physical exam.
Bacterial vaginosis
Uncertain
Medical follow-up
Candida albicans
Unlikely
Medical follow-up
aIf not perinatally acquired.
bTo agency mandated in community to receive reports of suspected sexual abuse.
cDifferentiate from Trichomonas hominis.
C. History.
1. The parent or guardian should be interviewed alone regarding his or her concerns, the child’s disclosures or complaints, and a review of the child’s medical, developmental, emotional, and behavioral status. The clinician should ask specifically about the following:
a. The child’s disclosures
b. Content of sexual play with peers, adults, or dolls
c. Masturbation or genital fondling
d. Genital complaints or symptoms
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