CHAPTER 145

Sexual Abuse

Sara T. Stewart, MD, MPH, FAAP

Child sexual abuse is the involvement of children and adolescents in sexual activity that they cannot consent to because of their age and developmental level. An age disparity exists between the targets, who are younger, and the perpetrators, who are older. The intent of the abuse is the sexual gratification of the older individuals, and the abusive incident(s) may or may not include physical contact. Sexual abuse may include acts of oral, genital, or anal contact by or to a child and may involve acts such as exhibitionism or involvement in pornography. It is differentiated from “sexual play” by the difference in the developmental levels of the participants and the coerciveness of the behavior.

Sexual abuse has been recognized with increasing frequency since the 1980s, in part because medical knowledge about the anogenital anatomy in molested and nonmolested prepubescent children has expanded. Technical advances have altered the manner in which these children are evaluated. In particular, the colposcope, with its potential for magnification and photographic or video recorded documentation, has been valuable. Parental awareness and school-based programs have resulted in increased disclosures about abuse as well as a greater willingness on the part of adults to believe these disclosures.

Patient interviews are another key component of the assessment process that has been shaped by continued research in the field. Non-leading, open-ended questions are asked by interviewers as few times as possible, and when available, specialized forensic interviewers ask these questions.

Epidemiology

In 2015, an estimated 676,000 children were targets of child maltreatment in the United States, and just under 10% of these were targets of sexual abuse. Exact figures on the prevalence of child sexual abuse are not readily available because they depend on reports of a condition that may not come to medical attention for many years. Anonymous surveys indicate that approximately 20% to 25% of women and 10% to 15% of men have been sexually abused before reaching adulthood.

Targets of sexual abuse come from all socioeconomic and ethnic groups. Girls experience sexual abuse at a rate 5 times that of boys. Some investigators believe that the statistics for boys are falsely low because boys are generally reluctant to disclose their abuse. Men are more commonly the perpetrators than women, and at least 20% of perpetrators are adolescents. Frequently, the sexual abuse has been occurring for several years. Perpetrators are usually known by the targets, and recent national data showed that 37% of perpetrators were biological parents, 23% were nonbiological parents, and 40% were other individuals. The mean time from onset of abuse to disclosure is 3 years. Sometimes children are not ready to disclose but the abuse is discovered incidentally because the targets develop symptoms, such as vaginal discharge or functional symptoms.

Clinical Presentation

Most cases of child sexual abuse come to the attention of authorities after the child discloses the abuse. Associated physical or behavioral symptoms may or may not be present. Physical symptoms in the anogenital area may include bleeding, pain, swelling, dysuria, vaginal discharge, or difficulty passing stool. More often, however, children have no specific anogenital symptoms. Instead, they have nonspecific symptoms, such as headache or abdominal pain, or vague systemic symptoms, such as fatigue (Box 145.1).

Behavioral changes may also be noted as these children respond to the stress of being targeted and of their environments. These changes may include sleep disturbances, hyperactivity, enuresis, encopresis, decreased appetite, and depression. The sexually abused adolescent may manifest school failure, delinquency, and suicide attempts. A child may also respond with sexual behavior or sexual knowledge that is considered inappropriate or excessive for age.

Psychophysiology

Children are subjected to sexual abuse after becoming entrapped. They may be enticed with promises of rewards or presents or may be made to feel special or grown up by being allowed to engage in adult behavior. Some children do not regard the sexual experiences as threatening but rather as a means by which they can obtain the love they crave. Only when they grow older do they realize that these sexual relationships were not normal or appropriate.

Other children are coerced into sexual activity with threats of physical harm. Once they have acquiesced, they are maintained in the relationship with threats of reprisal if they disclose the abuse. Children feel guilty and responsible for what has happened. This sense of responsibility for family disruption is often perpetuated by the legal system, which may remove the children from their families or place the offending family member in custody.

Finally, some children enter into sexual relationships out of curiosity. They too become entrapped, particularly because they were initially willing to participate.

As a child reacts to an abusive experience, it is common to feel a need for secrecy. As a result, disclosures of abuse are often delayed, and when they do occur, the child often provides the information incrementally over time. A child may also recant disclosures about abuse; such recantations are not considered to reliably indicate that the abuse did not occur.

Differential Diagnosis

Several medical conditions involving the anogenital area may be mistaken for acute or chronic changes resulting from sexual abuse (Box 145.2).

A child may sustain accidental blunt or penetrating injury to the genital area. The most common of these are straddle injuries that occur from falls with impact to the genital area. Pain and bleeding are the most common symptoms with these injuries, and external genital structures, such as the labia majora, labia minora, and peri-urethral areas, are typically affected. The hymen is unaffected.

Genital bleeding is also a frequent symptom in girls with urethral prolapse, a condition that is reported most often in prepubescent black girls between 4 and 8 years of age. These girls have a protuberant mass extruding from the urethra. The condition is of uncertain etiology, but it is not related to abuse.

Lichen sclerosus et atrophicus, which is a less common dermatologic condition that can also be confused with the sequelae of sexual abuse, typically is characterized by atrophic, hypopigmented skin in a figure-of-8 configuration in the anogenital area with associated macules, papules, and hemorrhagic blisters. The skin changes may be misinterpreted as scarring from prior abuse and because the atrophic skin is easily traumatized, findings may also be confused with recent abuse. One factor that may differentiate this condition from injuries related to sexual abuse is that the hymen is unaffected in lichen sclerosus et atrophicus.

Labial adhesions occur most commonly in toddlers and may be confused with scarring from prior sexual abuse. The adhesions occur as the result of inflammation in the genital area of a prepubertal (ie, hypoestrogenic) female. Such inflammation has multiple causes, including poor hygiene, recurrent vulvovaginitis, and trauma. The presence of labial adhesions is not a specific indicator of past sexual abuse.

Congenital malformations may also affect the anogenital area. Failure of midline fusion along the median raphe can have the appearance of denuded skin and may be confused with an abra-sion or superficial laceration of the area. This failure of fusion is a congenital finding, however, and no bleeding is evident, as would occur with a traumatic injury. Other congenital malformations include hemangiomas that may bleed and be mistaken for traumatized tissue. These hemangiomas are most often noted in infants and children younger than 2 to 3 years, and they usually regress with time.

Medical conditions may also affect the perianal area and may be mistaken for abuse. Crohn disease may result in fissures, fistulas, perirectal abscesses, or tags. Generally, Crohn disease affects older children and produces other symptoms, such as fever, weight loss, and problems passing stool, or extraintestinal symptomatology. Perirectal abscesses may occur in patients with neutropenia, sometimes as the presenting symptom of leukemia. Hemorrhoids occur rarely in children, and their presence should raise concern for intra-abdominal venous congestion.

Conditions causing vaginal discharge may be related to sexual abuse, particularly if they are secondary to sexually transmitted infections (STIs), such as gonorrhea or chlamydia infection (Box 145.3). Other agents, including Candida, shigella, and group A β-hemolytic streptococci, may produce similar symptoms, yet not be sexually acquired. The streptococci may produce a painful erythematous rash in the perianal area, which is frequently misdiagnosed as secondary to trauma or sexual abuse.

Evaluation

The extent and urgency of the evaluation is in part dependent on whether the allegations involve an acute abusive episode or an episode that occurred in the past. An acute abusive episode (occurring within the previous 72 hours) warrants an immediate assessment for evidence that may otherwise be lost within hours.

History

When a child presents with a physical finding, statement, or behavior that raises the concern of possible sexual abuse, it is important for the examiner to ask carefully thought out, non-leading questions to determine whether the level of suspicion has been reached such that the examiner is mandated to report the concern to a child protective services agency. Beyond that, an attempt should be made to minimize the number of times the child is questioned about the abuse-related incidents. It is also important to establish sufficient medical history to address any pressing clinical issues. Such a history should include a review of systems, menstrual history, sexual activity history, past incidents of abuse, and any prior genital trauma or medical procedures of the anogenital area. A psychosocial history should also be obtained, because behavioral problems, depression, anxiety, suicidality, homicidality, and other issues requiring mental health expertise are common in children who have been sexually abused (Box 145.4).

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