Sexual Abuse in Children

Aka: Sexual Abuse in Children, Child Sexual Abuse

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