II. Epidemiology
- Perpetrators are known to child or child's family in 90% of cases
-
Incidence of sexual buse during childhood in U.S.
- One in four girls
- One in thirteen boys
III. Symptoms: Sexual Abuse Indicators
- Behavior change
- Unwilling to participate in activities
- Aggression
- School problems
- Sleep problems
- Eating disturbance
- Regression to Thumb Sucking or security blanket
- Bizarre, sophisticated behavior or knowledge
- Beyond age appropriate behavior
- Sexual acting out
- Child may report sexual abuse (believe them)
- May be most important piece of information
IV. Findings: Sexual Abuse Indicators
- Difficult walking or standing
- Torn, stained or bloody undergarments
- Genital pain or Pruritus
- Genital Bruising or bleeding
- Frequent Urinary Tract Infections
- Encopresis
- Enuresis
- Recurrent Abdominal Pain
- Chronic Headaches
- Pregnancy or Sexually Transmitted Disease
V. History: Medical Interview Technique
- Perform alone with open ended questions
- Use neutral tone
- Avoid leading questions
- Record answers exactly as spoken
VI. Exam: Technique
- Perform full medical exam (including for other signs of injury)
- See Child Abuse
- Forensic evidence with Rape Kit if within 72 hours
- Typically performed by Sexual Assualt Nurse Examiner (SANE)
- Consider adjunctive examination equipment
- Colposcope
- Otoscope
- Examination points
- Examination of mouth for forced oral penetration
- Palatal Ecchymosis or Petechiae
- Trauma to frenulum of Tongue
- Genital exam in Girls
- Pubertal girls
- Speculum Exam in lithotomy position
- Prepubertal girls
- Examine in frog-leg position in caretakers lap
- Prone with knee-chest position exam
- Internal exam is typically performed by specialist in operating room under sedation
- Endoscope
- Speculum exam for unexplained bleeding
- Moistened cotton swab for hymenal exam
- Foley Catheter in vagina behind hymenal ring
- Pubertal girls
- Genital exam in Boys
- Examine penis, Testicles, perineum, and anus
- Examination of mouth for forced oral penetration
VII. Exam: Red Flags
- Findings suggestive of abuse
- Posterior hymenal ring deep notches or clefts
- Condyloma in children over age 2 years
- Significant anal dilatation or scarring
- Findings diagnostic of Penetrating Trauma
- Hymenal Laceration or Ecchymosis
- Posterior hymenal ring tissue defect or cleft
- Anal Laceration
VIII. Management
- Consult Sexual Assualt Nurse Examiner (SANE) for evidence based exam
- Indicated if sexual act within last 72 hours
- See Rape Management
- Includes testing and empiric treatment for Sexually Transmitted Infection
- Consult Child Abuse specialists
- Evaluate safety of home environment
- Report all cases of suspected abuse
- Evaluate patient's physical and mental health
- Anticipatory guidance for non-perpetrator parents
- Support and believe your children
- Respond in a protective and calm manner
- Reassure children that this is not their fault
- Ensure close medical and mental health follow-up
IX. References
- Claudius and Willner in Herbert (2019) EM:Rap 19(1): 2-4
- (1999) Pediatrics 103:186-91 [PubMed]
- Adams (2004) J Pediatr Adolesc Gynecol 17:191-7 [PubMed]
- Bays (1993) Child Abuse Negl 17:91-110 [PubMed]
- Hymel (1996) Pediatr Rev 17:236-50 [PubMed]
- Lahoti (2001) Am Fam Physician 63(5):883-92 [PubMed]
- Suniega (2022) Am Fam Physician 105(5): 521-8 [PubMed]