Introduction
What was initially described as a “hidden pediatric problem” in 1977 has become an increasingly recognized phenomenon in subsequent decades. Sexual abuse occurs when a child or adolescent is engaged in sexual activities that they cannot comprehend, for which they are developmentally unprepared and unable to give informed consent, and/or when there is violation of the legal or social taboos of society. Sexual abuse includes a full spectrum of activities ranging from oral, genital, or anal contact, and fondling by or to the child, to noncontact abuses, such as exhibitionism, voyeurism, or various forms of child exploitation, such as pornography or prostitution. Child sexual abuse may involve one type of activity, or evolve over time into several other activities.
Medical Evaluation
When sexual abuse is suspected, the medical evaluation of the child serves a dual purpose: (1) to ensure the health of the child after an alleged abusive abuse; and (2) to document any injuries or other evidence that may support the allegation of child sexual abuse (CSA). Children from abusive households are at greater risk for undiscovered and inadequately treated health problems. In a retrospective study, Girardet et al found a medical or psychological condition requiring intervention in 123 (26%) of 473 children referred for sexual abuse evaluations. In 39 (8%) of those children, the diagnosis had the potential to result in significant patient morbidity if not immediately addressed.
Time should be taken in establishing a relationship and rapport with the child. Proper introductions and spending a few minutes in nonthreatening social conversation builds the patient’s rapport and trust, and increases his or her comfort with the medical evaluation.
The interview of the child and caretaker begins the evaluation process (see chapters 7 and 8 ). The medical and psychological reviews of systems often reveal behavioral, emotional, and/or physical symptoms in the child. Information can be gathered from the child, the parent, or through standardized instruments such as the Trauma Symptom Checklist for Children. In addition, information can also be gathered by a team of professionals, including the clinician, a mental health professional, a nurse, child life specialist, and/or a social worker. Medical and behavioral assessments often reveal symptoms important to the recovery and treatment of the child, but are usually not specific to the diagnosis of sexual abuse; most physical symptoms, for example, can be seen in other medical illnesses as well. , Table 9-1 lists common physical signs and symptoms commonly identified in sexually abused children.
| Early Warnings |
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| Psychosomatic and Behavioral Changes |
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| Physical Symptoms |
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| Other Problems |
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Approach to the Physical Examination
Timing of the Examination
The anogenital examination serves to identify and treat possible trauma and other sequelae of abuse and to gather physical evidence of sexual abuse. Additionally, the anogenital examination provides reassurance for the child. The physical examination in the majority of sexual abuse cases is normal.
The date and time of the last incident should be obtained on initial presentation of a child for alleged sexual abuse. When and where the medical examination is conducted is crucial. Acute injuries and/or other physical findings must be appropriately documented, and evidence must be preserved. If the most recent assault of a child has occurred less than 72 hours before the child presents, and/or the history reveals the likelihood of transfer of biological evidence from the perpetrator (i.e., semen, saliva, or blood), forensic evidence collection should be done (see Chapter 13 ). The patient should immediately be assessed for potential life-threatening physical trauma in addition to evaluation of the sexual assault. When more than 72 hours has passed and no acute injuries are present, an emergency examination usually is not necessary. In these cases, if the parents and child agree, an evaluation should be scheduled at the earliest convenient time in a more appropriate setting such as an advocacy center or clinic. Clinicians should be familiar with regional protocols providing recommendations for forensic evidence collection timing and procedures.
An emergent medical evaluation should be done if the child complains of pain in the genital or anal area or if there is anal or genital bleeding or injury. Genital and anal injuries in children heal quickly and may not persist if the examination is delayed. In some cases, the child will have emergent health issues (mental or physical) requiring immediate attention. In others, the child’s disclosure might put them in imminent danger. The person triaging the child for examination must determine if the child should be examined immediately or whether the child’s examination can be deferred.
Preparing the Child for Examination
Taking time to explain the importance of the examination helps gain the child’s confidence and trust. The child should have a feeling of control over what happens next to her body. Allowing her to have choices such as who should chaperone the examination helps give the child some control and demonstrates respect for her feelings. Propping up the head of the examining table so the child can see the physician during the examination will usually decrease the child’s anxiety. The equipment used during the examination can appear intimidating and technical to the family and child. All procedures and equipment should be explained, including the colposcope. Distraction techniques, such as singing, counting, reciting nursery rhymes, or blowing bubbles will encourage the child to relax. Because abuse usually involves authority and control over the child, children should not be subjected to force during a medical examination. If an emergent evaluation is essential for the child’s medical health and the child is unable to cooperate with the examination, use of anesthesia or conscious sedation is a reasonable alternative. ,
The Medical Examination
The medical examination of the child should include a thorough “head-to-toe physical examination, leaving the anogenital examination until the end of the examination. In addition to evaluating for possible physical injuries or unmet health care needs of the child, the inclusion of the entire physical examination of the body relays to the child that all parts of his or her body are important. The examination should be unhurried and thorough, looking for physical abuse injuries such as defensive wounds ( Figure 9-1 ), strangulation or choking injuries ( Figure 9-2 ), ligature marks, or bruising. Photo-document, sketch, and measure any cutaneous injuries noted on the child’s body. Bitemarks, if acute, should be swabbed for forensic evidence. Photographs of bitemarks should include a size standard and color bar (see Chapter 27 ). Self-inflicted injuries should be assessed and documented. Self-mutilation injuries such as “picking” ( Figure 9-3 ) or “cutting” of the skin can be a sign of covert abuse or psychiatric disorders.
