The impact of adverse childhood experiences on the lifespan
Among the many possible symptoms we mention: growth disorder, cognitive disorder, sleep and food-related disorder, psychosomatic disorder, anxiety and depression, alcohol and substance abuse, smoking, post-traumatic stress disorder, psychiatric disorder, self-injuring behaviors, suicide, cardiovascular pathologies, and cancer [10–12].
Not less important is the trans-generational transmission: from a 2005 study has been found especially in poly-victimization cases, abused children tend to become abusers in adulthood .
The most suitable approach consists of four fundamental steps:
It’s extremely important to identify the phenomena extension, in order to define and apply customized and efficient strategies to face the problem. Face means being able to detect, have the medical competences to assist the victim, and provide the most adequate treatments, but also implement prevention strategies .
The exact child abuse prevalence is unknown. This is due to several factors: absence of unified and shared protocols, victim’s difficulties in disclosing due to the own nature and dynamics of the sexual abuse, low conviction rate in judiciary paths [19, 20].
Many times sexual abuse histories are revealed in adulthood. The NSPCC (National Society for the Prevention of Cruelty to Children) performed many studies, and from one of them, conducted on 2869 adults from 18 to 24-years-old, and the 11% of them reported to have been abused in childhood. Furthermore, comes out that 16.5% of the people from 11 to 17-years-old and the 24.1% of the people from 18 to 24-years-old, experienced sexual acts during childhood .
It’s important, for the detection, to know the risk factors, in particular the environment around the child and his relationships. A recent research on child abuse in Malaysia shows that a low socioeconomic status, dis-harmonies or familiar conflicts, and substance abuse of parents psych disorders can be related to an increase in sexual abuse risk for little girls [22, 23].
Prevention programs have been applied by several world organizations (WHO, UNICEF) involving health, social, educational and justice services, summarized with the acronyms THRIVES (Training in parenting—Household economic strengthening—Reduced violence through legislative protection—Improved services—Values and norms that protect children—Education and life skills—Surveillance and evaluation) that have the potential to reach and sustain the efforts to prevent violence against children [2, 3].
13.3 Medical Examination
Victims usually can’t give a name to what had happened to them and they can’t explain the feelings in words, but their body can tell their stories even if children can’t. Victims do not always receive the type of help they really need and each and every therapy is going to be relatively inefficient if the underlying traumatic experience is not detected and faced.
The medical examination usefulness is undisputed for the identification of the clinical situation and/or the various injuries of nature and a treatment program launch.
It’s vital to detect the sexual abuse as soon as possible to prevent consequences. At this point, clinicians have a key role in the identification, management and report of suspected sexual abuse, and many health organizations promote training programs for clinicians in order to support sexual abuse detection and improve the victim taken in charge.
Clinicians must be able to identify abuse signs and symptoms, diagnose, and provide medical treatments in case of injuries, infections, or other pathological conditions related or not related to the abuse. It’s important that they perform a complete and accurate medical evaluation, examining the little girl from the head to the toes, reassuring her when it’s possible, on her health status [24–26].
The minor victim of sexual abuse can in fact perceive her own body as “damaged,” thus the psychological reassurance related to her body’s status and her integrity represents a fundamental moment along the recovery path in order to avoid the victim to keep saying “I still feel like I am not normal” [27, 28].
During the medical examination, the clinician has to accurately collect the documentation, also photographs, that could be helpful in court site, where he could be asked to give testimony .
The testimony in court needs competences that are not always obtained in clinical practice. Guidelines are available in literature and essential indications for a correct and adequate testimony for the doctors that are usually asked to explain why the physical examination alone does not prove or disprove that sexual abuse occurred [30, 31].
It is the clinicians’ duty to report to the court the child prejudice status according to the state legislation and he must activate, if needed, protection measures to avoid further abuses, also, if necessary, with hospitalization or urgent admission foster care homes.
Even though the importance of specific timing is widely documented in literature, often clinicians don’t have adequate knowledge and technical and emotional skills to deal with a suspected sexually abused girl. Therefore, to limit diagnostic errors (false positive/false negative) and further traumas for the child, it’s important that medical examination is performed by professionals with specific skills [21, 30, 32, 33].
It is not always possible to schedule the first medical examination for a little girl suspected of sexual abuse, thus usually the first examination can’t be performed in the best context.
It is fundamental to try to ensure a quiet and discreet environment, not to traumatize the little girl further, ensuring a second clinician’s presence to support both the clinician and the child.
It is important to perform the examination at the presence of a trusted adult—unless the girl prefers he/she doesn’t stay—who remains with her during the clinical evaluation and assists her while she gets undressed and dressed. It is fundamental to have time to be able to obtain the girl’s trust and agreement, providing explanations on examination modalities and reasons, and using a proper language suitable for her age. It is important to ensure privacy, not to use strength or deceits during the exam. In particular, it’s recommend to reschedule the visit if the child is not calm while examining the genital area and she doesn’t cooperate [25, 34–36].
It is also recommended not to touch the genital area and breast, unless if needed for the clinical evaluation: in this case, the little girl must be informed and her agreement obtained. It is important to observe and report the behavior and the emotional state during the examination .
Sedation is performed very rarely, when the benefits are doubtfully higher than potential risks, for example, in case of vaginal and/or anal injuries that need surgical treatment, in case of foreign vaginal and/or ano-rectal bodies, and in case of important bleeding or of nature to be diagnosed.
13.5 Medical History
The medical history data collection and the reported child story are the base for the medical evaluation.
It is important that professionals are competent, empathic, not judging and objective. Often the sexual abuse diagnosis is exclusively based on the medical history so the data collection accuracy is fundamental. Inductive questions should never be asked; instead, the spontaneous story should be reported paying attention to transcribe the girl’s sentences integrally and to avoid making her repeat the story many times. Congruence check is necessary between the dynamic facts, timing and observed clinical status, scheduling possible further investigations (blood exams, pharynx/vaginal/rectal swabs, instrumental exams) .
13.6 Objective Examination
During the medical examination, the little girl must be examined “from the head to the toes” analyzing each single part of her body and paying attention to cover the different areas as the examination proceeds. During the objective examination, the genital area evaluation has to be done. It’s good practice to examine also the oro-pharynx because oro-genital contacts are recurring in sexual abuse. It is fundamental to report any careless signs, paying special attention to the body, hair, and oral hygiene. Weight and height have to be measured as well as the pubertal stage according to Tanner’s stages. It is important to perform a complete evaluation giving back to the little girl, if possible, the “body integrity” concept that could be precluded if the examination is limited to the anal-genital area only [38–41].
13.7 Ano-genital Area Examination
To examine the ano-genital area, the three positions shown in the figure are used (Fig. 13.2):
(a, b) Supine position, (c–e) genupectoral position, (f) left lateral decubitus position
In Figure 13.2 the supine position, usually well accepted, gives a good visualization of the vulvar area, the vaginal orifice (a). It’s possible to examine the youngest little girls kept in this position by a trusted adult on his arm. To visualize clearly the hymenal ring, the little and big lips pull technique is used (b). In the genupectoral position, the little girl leans on her hands and knees (c). This position is sometimes less appreciated because the clinician stands behind her, out of her sight, but it’s fundamental to confirm signs identified in the supine position . To visualize clearly the anus, a light traction is applied to the gluteus (d); the little and big lips pull technique is used for the hymenal ring visualization even in the genu-pectoral position (e).
It is important to know very accurately the ano-genital area anatomy of the prepubertal girl, its anatomic variants, and the typical pubertal age estrogenization. The vaginal orifice is surrounded by a tissue ring called hymen. The hymen and the anus are described using the comparison with the clock quadrants (12 o’clock corresponds to the suburethral zone and 6 o’clock to the rectum medial line in supine position (Fig. 13.3a, b)).
In prepubertal girls, hymenal tissue can be completely absent in the suburethral area approximately from 10–11 o’clock to 1–2 o’ clock. The posterior tissue portion can be more or less represented thus the posterior edge can be more or less high, configuring crescentic hymen, a frequent configuration. In another common hymen configuration, the tissue completely surrounds the vaginal orifice (annular hymen).
The hymen, like the other genital organs, is under the sexual hormones influence. The estrogens, for example during neonatal (due to mother hormones’ presence) and puberal period, make hymen tissues more redundant, in a way that often fold on themselves making edges wavy and frequently covering vaginal orifice.
The myth the hymen “breaks up” during the first sexual intercourse leads to the preconception that it’s possible to determine whether there has been sexual activity at least ones with the medical examination; actually, it is evident that health professionals without specific experience often expect that penetrative acts always leave clear physical signs and believe that a doctor can determine through the medical examination if an adolescent is “virgin” or not [43, 44].
In this regard, Kellogg’s review on 36 pregnant adolescents is very interesting: only 2 of the 36 girls presented hymenal complete transection1 of the posterior half. The scientific explanation is that penetration doesn’t always cause visible tissue damages and/or that acute injuries can heal without leaving any sign.
13.8 Medical Examination Timing
Sexual abuse often doesn’t produce evident signs and many of the injuries are superficial. For this reason, it is fundamental to perform the medical examination as soon as possible. Literature recommends to carry out the examination within 72 h from the sexual abuse or anyway as soon as the minor protection safety measures have been applied.
Latest studies indicate the need to perform the medical examination in prepubertal girls within 24 h from the event and within 72 h in adolescents. Furthermore, still for prepubertals, it has been confirmed that DNA research provide positive results especially when the medical examination is executed within 24 h .
The early medical examination objectives are numerous [25, 27, 33]:
Identify ano-genital injuries and sexually transmitted diseases
Prevent pregnancies through emergency contraception in pubescents
Collect evidences for forensic medicine purpose
Safeguard victim’s physical integrity and psychological wellness reassuring on her health state
Medical examination should be postponed only in case the girl is not cooperative and she doesn’t agree with the exam execution despite the reassurances. We restate that the doctor who is going to perform the clinical examination must have specific competences. In case a competent professional isn’t available, it’s recommended to send the child to the closest specialized hospital or territorial center [30, 34, 45].
13.9 Injures Recovery Time
Traumatic ano-genital injuries heal rapidly, often leaving no trace .
The more often damaged structures during a penetrative sexual abuse are the hymenal membrane, the fossa navicularis, and the fork .
The healing process of these injuries is not different from the recovery of any other injuries of the same nature in other body regions. The healing stages consist of:
Thrombosis and inflammation cells activation
Damaged cells regeneration
New cells multiplication
New epithelium differentiation
The healing process of the more superficial injuries proceeds with formation of new epithelium at a rate of 1 mm in 24 h. For deeper injuries, the damaged cells regeneration process is fully active between 48 and 72 h, and the multiplication and differentiation processes begin from the fifth and seventh day. The complete tissue recovery takes from 4 to 6 weeks; the scarring tissue maturation might need at least 60–180 days [33, 47, 48].
These healing processes explain the usual absence of genital injuries in little girl victims of sexual abuse if the medical examination is performed too far in time from the last suspected violence episode.
13.10 Physical Signs
The evaluation of possible signs of sexual abuse can be accomplished during the medical examination performed for other reasons or asked by a parent reporting a suspect. In this case, it is the doctor’s duty to activate the services and/or report to the Court according to the state legislation in the different countries.
Physical signs in case of sexual abuse are caused by traumas, mechanical actions characterized by rubbing, stretching, and compressing. The sexual trauma effects, and thus physical signs, can be: bruises, hematomas, abrasions, grazes, injuries.
Generally speaking, this signs vary depending on several factors [21, 46, 47, 49]:
Abusive action type
Girl’s age and pubertal status
Abusive events frequency
Elapsed time from last abusive episode
It is fundamental to reaffirm that in the majority of cases, anal and genital injuries become undetectable in a short time period from when they have been produced and consequently it’s very recurring that injuries are not detectable anymore, not because the episode didn’t happen but because the healing process leaves no cues. Thus, conclusions that exclude with absolute certainty that the event happened must be avoided [50–52].
The doctor can rarely formulate a definitive diagnostic hypothesis based on the objective examination alone; therefore, the diagnosis of sexual abuse must be multidisciplinary to avoid, due to a wrong medical valuation, a not-guilty adult is unfairly accused or a minor victim of abuse isn’t safeguarded by the abuser [53–56].
The observed signs have more or less probative consistency through the integration with other acquired evidence findings [25, 57].
Many studies demonstrate that 90–95% of children who declared in believable way they have been abused have normal clinical finds or not specific physical signs. In fact, the answer to the question “Has the girl been abused?” it is not usually on the body [27, 33, 58].
Related to the physical signs only, several indications are provided by scientific literature and the classifications proposed can lead to the correct interpretation of what is observed during the medical examination [21, 30].