Child Sexual Abuse

Child sexual abuse (CSA) refers to the use of children (persons younger than 18 years old) in sexual activities when, because of their immaturity and developmental level, they cannot understand or give informed consent. A wide range of activities is included in sexual abuse, including contact and noncontact activities. Contact activities include sexualized kissing, fondling, masturbation, and digital and/or object penetration of the vagina and/or anus, as well as oral–genital, genital–genital, and anal–genital contact. Noncontact activities include exhibitionism, inappropriate observation of child (eg, while the child is dressing, using the toilet, bathing), the production or viewing of pornography, or involvement of children in prostitution.

The sexual activities are imposed on the child and represent an abuse of the caregiver's power over the child. The sequence of activities often progresses from noncontact to contact over a period of time during which the child's trust in the caregiver is misused and betrayed. The image below depicts suture in place at 6-o'clock position to stop bleeding from injury.

Since the mid-1970s, healthcare professionals have paid serious attention to sexual abuse of children. Despite the recognition of the clinical importance of sexual abuse of children, some pediatricians may not feel adequately prepared to perform medical evaluations. However, pediatricians are often in trusted relationships with patients and families and are in an ideal position to offer essential support to the child and family. Thus, pediatricians need to be knowledgeable about available community resources, such as consultants and referral centers for the evaluation and treatment of sexual maltreatment. One study evaluated residents' and practicing physicians' medical knowledge of child abuse and maltreatment. Using a 30-question survey, the results found an overall average score of 63.3%; these findings highlight the need for increased education in child maltreatment.[7]

Several paradigms have been proposed to help professionals understand the events that surround the sexual maltreatment of children.

Preconditions for sexual abuse

See the list below:

• Motivation of perpetrator: The perpetrator is willing to act on impulses associated with sexual arousal related to children.

• Overcoming internal inhibitions: The perpetrator ignores internal barriers against sexually abusing children.

• Overcoming external inhibitions: The perpetrator is able to bypass the typical barriers in the caregiving environment that normally serve to impede the sexual misuse of children.

• Overcoming child resistance: The perpetrator is able to manipulate the child to the point of involving the child in the sexual activity. Manipulation often involves either implicit or explicit coercion to ensure that the child keeps the inappropriate activities a secret.[8]

Longitudinal progression of sexual abuse

See the list below:

• Engagement: The perpetrator begins relating to the child during nonsexual activities to gain the child's trust and confidence.

• Sexual interaction: The perpetrator introduces sexual activities into the relationship with the child; the perpetrator often begins with noncontact types of activities and, over time, progresses to more invasive forms of contact activities.

• Secrecy: The perpetrator attempts to maintain access to the child and to avoid disclosure of the abuse by coercing the child to keep the activities hidden. Coercion to keep the secret can be explicit (eg, threatening the child or the child's family's safety) or it can be implicit (eg, manipulation of the child's trust to create a fear of losing the "friendship" or "attention" should the truth become known to others).

• Disclosure: Sexual abuse can become known to others either accidentally, when a symptom from the maltreatment or a third party witnessing the abuse leads to an evaluation, or can be purposeful, as when the child reveals the abuse that is taking place and seeks help.

• Suppression: The tumult that occurs after the disclosure prompts the people in the child's caregiving environment to think that they are unable to support the child; thus, these people exert pressure on the child to recant what the child has told in order to go back to the perceived "stable" situation that existed prior to the disclosure.

Sexual abuse typically presents as a pattern of maltreatment that occurs over time. Children or their families usually know the perpetrators, because they often are either relatives or acquaintances.[9]

Traumagenic dynamics model

See the list below:

• Traumatic sexualization: The child's sexual feelings and attitudes are shaped in a developmentally inappropriate and interpersonally dysfunctional manner. The child learns that sexual behavior may lead to rewards, attention, or privileges. Traumatic sexualization may also occur when the child's sexual anatomy is given distorted importance and meaning.

• Betrayal: The child learns that a trusted individual has caused him or her harm, misrepresented moral standards, or failed to protect him or her properly.

• Powerlessness: This is a process of disempowerment in which the child's sense of self-efficacy and will are consistently thwarted by the perpetrator's coercion and manipulation. The child manifests symptoms of fear, anxiety, and impaired coping.

• Stigmatization: The child's self-image incorporates negative connotations and is associated with words such as bad, awful, shameful, and guilty. This stigmatization is consistent with the "damaged goods" mentality originally described by Sgroi et al (1982), in which the child feels deviant and not as whole as he or she felt prior to the abuse.[9, 10]

The evaluation for suspected sexual abuse may be complicated and is often not straightforward. Frequently, nonspecific behavioral changes are the presenting symptoms prompting an evaluation and leading the health care provider to consider sexual abuse as a possible diagnosis. These nonspecific behaviors are not diagnostic of sexual maltreatment and may be observed in other situations where the child manifests stress as well. Nonspecific behavior changes that warrant consideration of the possibility of sexual abuse may include (1) sexualized behaviors, (2) phobias, (3) sleep disturbances, (4) changes in appetite, (5) change in or poor school performance, (6) regression to an earlier developmental level, (7) running away, (8) truancy, (9) aggressiveness and acting out behaviors, and/or (10) social withdrawal, sadness, or symptoms of depression.

One study identified a screening tool to identify which prepubertal children (≤ 12 y) should receive an initial evaluation for alleged sexual assault in a nonemergent setting, as opposed to one in the emergency department.[11] A positive screen, which warranted an immediate evaluation, was considered if an affirmative response was received to any of the following questions:

• Did the incident occur in the past 72 hours, and was there oral or genital to genital/anal contact?

• Was genital or rectal pain, bleeding, discharge, or injury present?

• Was there concern for the child's safety?

• Was an unrelated emergency medical condition present?

This screening tool showed sensitivity of 100% and may help determine which children do not require evaluation in an emergency department for alleged sexual assault.[11]

When physical signs and symptoms are present, the best procedure is to generate an extensive differential diagnosis, progress through a careful workup to exclude the diagnostic options, and, eventually, arrive at a diagnosis. Numerous medical conditions can mimic the possible findings in persons who have been sexually abused; these may be considered as primarily being in the category II nonspecific findings group as proposed in the Clinical section. An organized approach to the diagnostic process is most useful.

For the purposes of this discussion, the differential diagnosis for each of the following 4 genital findings known to be associated with child sexual abuse is discussed.

Genital bleeding

Identification of the source for the blood is necessary to exclude serious injury. Blood-tinged vaginal or urethral discharge initially may be confused with frank bleeding. Differential diagnoses are as follows:

• Local factors, such as injury (either accidental or nonaccidental) and/or foreign body irritation (eg, small toy parts, clumped toilet tissue [see the images below])

  Prepubertal girl with foul-smelling bloody discharge. On examination, a foreign body in the vagina was found just past the hymenal orifice. The foreign body is lodged in vagina and appears to be toilet tissue that is colonized with bacteria, causing a vulvovaginitis. The foreign body was dislodged with gentle water flushing during examination. Courtesy of Carol D. Berkowitz, MD.

  Genital examination of prepubertal girl with foul-smelling bloody discharge. On examination, a foreign body in the vagina was found lodged just past the hymenal orifice and appears to be toilet tissue that is colonized with bacteria, causing a vulvovaginitis. The foreign body was dislodged with gentle water flushing during examination. Courtesy of Carol D. Berkowitz, MD.

• Dermatologic conditions, such as lichen sclerosis and/or dermatitis (eg, atopic, contact, seborrhea)

• Infections, including sexually transmitted diseases (STDs), fungal infections, and/or nonspecific vulvovaginitis

• Endocrinologic causes, such as estrogen withdrawal as observed in the neonate and/or precocious puberty

• Neoplastic tissue, such as sarcoma botryoides

• Structural abnormalities, such as vulvar hemangioma

Vaginal discharge

Normal physiologic clear-white mucoid discharge (ie, leukorrhea) should be differentiated from pathologic discharges. Differential diagnoses are as follows:

• Local irritation from abusive sexual contact, foreign body, chemical irritants, and restrictive clothing

• Infections, including STDs, fungal infections, nonspecific vulvovaginitis, group A streptococci, Staphylococcus aureus, Haemophilus influenzae, and Mycoplasma species

• Physiologic leukorrhea

• Structural abnormality, such as ectopic ureter, fistula, and draining pelvic abscess

Anogenital bruising

Bruising in the anogenital area most often represents some type of anogenital trauma, either accidental or abusive in origin. Differential diagnoses are as follows:

• Local injury, including straddle injury, accidental impaling injury, accidental blunt trauma, and abusive injury

• Dermatologic conditions, such as mongolian spots, lichen sclerosis, and vascular nevi

• Systemic manifestations of other disorders, such as bleeding diathesis and vasculitis

Anogenital redness

This finding typically represents the result of inflammation. Differential diagnoses are as follows:

• Local irritation from sexual abuse, poor hygiene, restrictive clothing, and chemicals

• Anatomic/structural factors such as perianal fissuring and rectal prolapse

• Dermatologic conditions, such as lichen sclerosus, psoriasis, and dermatitis (atopic, contact, seborrhea)

• Infections, such as STDs, nonspecific vulvovaginitis, pinworm, scabies, fungal infections with Candida species, and perianal cellulitis or warts

• Systemic manifestations of other disorders, such as Crohn disease, Kawasaki syndrome, and Stevens-Johnson syndrome

Prevalence

Professionals conservatively use child sexual abuse (CSA) prevalence estimates of 20% in women and 5–10% in men. A classic prevalence study of New England male and female college students done by Finkelhor, which used a definition that included both contact and noncontact abuse with older perpetrators and children younger than 17 years, revealed that 19.2% of female students (1 in 5 women) and 9% of male students (1 in 10 men) reported sexual misuse during their childhoods.[12] These figures are believed to be conservative estimates; other studies using different methodologies support using these figures as reasonable prevalence estimates. Analysis by various experts of 16 prevalence studies of nonclinical North American samples supports setting the upper end of prevalence figures at about 17% for women and 8% for men.

Incidence

According to the US federal government’s official report, Child Maltreatment 2019, approximately 656,000 children were determined to be victims of child abuse and neglect; the overall child maltreatment rate was 8.9 victims per 1000 children in the population.[13] The data show that 74.9% of victims were neglected, 17.5% were physically abused, and 9.3% were sexually abused. For federal fiscal year 2019, approximately 3.5 million children received either an investigation or alternative response at a rate of 47.2 children per 1000 in the population. The number of children who received a CPS response increased nationally by 3.5% from 2015 to 2019. 

The Fourth National Incidence Study of Child Abuse and Neglect (NIS-4) was mandated by the Keeping Children and Families Safe Act of 2003 (P.L. 108-36) and aimed to estimate the current national incidence, severity, and demographic distribution of child abuse and neglect in the United States based on standardized research definitions.[14] The NIS-4 collected data from a nationally representative sample of 122 counties in 2 phases (2005 and 2006). The NIS-4 is the single most comprehensive source of information about the current incidence of child abuse and neglect in the United States and is based on a nationally representative sample.

The NIS-4 used 2 sets of standardized definitions of maltreatment. Children identified under the “Harm Standard” were considered to be maltreated only if they had already experienced demonstrable harm or injury from the abuse or neglect. The second set (the “Endangerment Standard”) included those children identified under the Harm Standard as well as those who experienced abuse or neglect that put them at risk of harm.

Compared with the NIS-3 (1993),[15] the NIS-4 (2005/2006) reflected a 26% decline in the rate of overall Harm Standard maltreatment, as the incidence rate fell from 23.1 cases to 17.1 cases per 1000 children in the population. The overall incidence of children who experienced maltreatment, under the Endangerment Standard, displayed no statistical change since the NIS-3. While significant decreases in the incidence of overall abuse and all specific categories of abuse were noted, a significant increase in the incidence of emotional neglect was observed.

The NIS-4 reported an estimated sexual abuse incidence rate of 1.8 cases per 1000 (or a total of 135,300); this represented 24% of the total number of children known to have been abused. The NIS-4 used a definition that subsumed a range of behaviors, including intrusion, child’s prostitution or involvement in pornography, genital molestation, exposure or voyeurism, providing sexually explicit materials, failure to supervise the child’s voluntary sexual activities, attempted or threatened sexual abuse with physical contact, and unspecified sexual abuse.

The 2005/2006 NIS-4 incidence figure of 1.8 cases per 1000 children represents a statistically significant decrease (44%) in the rate of sexual abuse from the 1993 NIS-3, from 3.2 children per 1000 in 1993 to 1.8 children per 1000 in 2005-2006. The incidence of Harm Standard physical abuse and emotional abuse also decreased since the NIS-3, but those decreases did not match the sexual abuse decrease, either in size or in statistical strength. The number of children who experienced physical abuse decreased by 15%, whereas the number who suffered emotional abuse decreased by 27%. The decreases in incidence rates were 23% for physical abuse (from 5.7 cases to 4.4 cases per 1000 children) and 33% for emotional abuse (from 3.0 cases to 2.0 cases per 1000 children).

The NIS-4 Harm Standard estimates for physical, sexual, and emotional abuse do not differ statistically from the NIS-2 Harm Standard (1986) estimates for the component categories of abuse. Thus, the decreases since 1993 in the categories of Harm Standard abuse have returned their incidence rates to levels that are statistically equivalent to what they were at the time of the NIS-2 in 1986.

Finkelhor, Saito, and Jones at the Crimes Against Children Research Center have been tracking trends in child maltreatment statistics collected by the US government and have found a national decline in the incidence of both physical and sexual abuse that began in the middle of the 1990s and continued through 2019.[16]

Child neglect saw a 13% decline in 2019, and sexual abuse substantiations have seen a 62% downward trend from the peak annual incidence observed in 1992. There was an overall decline in physical abuse of 56% in 2019.

Finkelhor and Jones, over the years, have explored potential reasons for the decline in child sexual abuse and have focused on factors that may be impacting the actual incidence, as well as factors that may be influencing the reporting and investigation of reported cases, which may then downstream the number of substantiated cases. The possibility for the reported decline in child sexual abuse may result from change in attitudes, policies, and standards for reporting and investigating. These changes might account for some of the decline but they would not represent the entire picture. They indicate the need for a more balanced and questioning approach since decreasing trends in child sexual abuse are less clear (see image below).[17]

Optimistically, prevention efforts, incarceration, and treatment of perpetrators (along with other societal factors) may actually be decreasing the number of children who are harmed by sexual abuse. On the other hand, more pessimistically, fears of lawsuits and retribution, higher thresholds set for investigation and substantiation, and changes in policies and procedures may be changing the numbers but not impacting the actual amount of children under abuse.

No consensus has been reached about what may be causing the steady decline; Finkelhor and Jones draw attention to the idea that factors such as increasing economic prosperity, increasing numbers of agents of social intervention, and increasing availability of highly effective psychiatric medications may very well be leading to a decline in incidence with a resultant decline in substantiations.

Mortality/Morbidity

Numerous psychological and medical consequences have been described as associated with sexual abuse. Psychological disorders are reported as having an increased incidence in those who have been abused sexually and include depression, eating disorders, anxiety disorders, substance abuse, somatization, posttraumatic stress disorder (PTSD), dissociative disorders, psychosexual dysfunction in adulthood, and numerous interpersonal problems, including difficulties with issues of control, anger, shame, trust, dependency, and vulnerability.

PTSD and its relationship to sexual abuse have received considerable professional attention. The diagnosis of PTSD in the context of sexual abuse requires the occurrence of maltreatment and (1) frequent reexperiences of the event via intrusive thoughts and/or nightmares; (2) avoidance behavior and a sense of numbness toward common events; and (3) increased arousal symptoms, such as jumpiness, sleep disturbance, and/or poor concentration. Note that no universal short-term or long-term impact of sexual abuse has been identified, and the presence or absence of various symptoms or conditions does not indicate nor disprove the occurrence of sexual abuse.

Medical sequelae of sexual abuse include numerous medical conditions, including functional GI disorders (eg, irritable bowel syndrome, dyspepsia, chronic abdominal pain), gynecologic disorders (eg, chronic pelvic pain, genital or anal tears), and various forms of somatization involving neurologic conditions and pain syndromes. Additionally, children may contract STDs via sexual abuse, and postpubertal females may become pregnant.

In groundbreaking work, Felitti et al explored the connection of exposure to childhood abuse and household dysfunction to subsequent health risks and the development of illness in adulthood in a series of studies referred to as the Adverse Childhood Experiences (ACE) studies.[18] Of 13,494 adults who completed a standard medical evaluation in 1995 and 1996, 9,508 completed a survey questionnaire that asked about their own childhood abuse and exposure to household dysfunction; the investigators then made correlations to risk factors and disease conditions.

In order to assess exposure to child abuse and neglect, the ACE questionnaire asked about categories of child maltreatment, specifically psychological, physical, and sexual abuse. When asking about sexual abuse, the questionnaire asked the patients if an adult or person at least 5 years older then had ever (1) touched or fondled them in a sexual way; (2) made them touch the adults or older person’s body in a sexual way; (3) attempted oral, anal, or vaginal intercourse with them; or (4) actually had oral, anal, or vaginal intercourse with them. In order to assess exposure to household dysfunction the ACE questionnaire asked questions by category of dysfunction, such as having a household member who had problems with substance abuse (eg, problem drinker, drug user), mental illness (eg, psychiatric problem), or criminal behavior (eg, incarceration) and having a mother who was treated violently.

In addition to the questionnaire information, the standardized medical examination of the adult assess risk factors and actual disease conditions. The risk factors included smoking, severe obesity, physical inactivity, depressed mood, suicide attempts, alcoholism, any drug abuse, a high lifetime number of sexual partners, and a history of STDs. The disease conditions included ischemic heart disease, cancer, stroke, chronic bronchitis, emphysema, diabetes, hepatitis, and skeletal fractures. Once all of the data were collected and analyzed, Felitti et al reported that the most prevalent ACE was substance abuse (25.6%), the least prevalent ACE was criminal behavior (3.4%), and the prevalence of sexual abuse was 22%. In total, 52% of the respondents to the questionnaire had one or more exposure, and 6.2% of respondents had 4 or more exposures. The following were findings in respondents who experienced 4 or more ACEs compared with those who had none:

See the list below:

• Risk of alcoholism, drug abuse, depression, and suicide attempt increased 4-12 fold

• Rates of smoking, poor self-rated health, and high number of sexual partners and STDs increased 2-4 fold

• Physical inactivity and severe obesity increased 1.4-1.6 fold

The major finding of the ACE studies was a graded relationship between the number of exposures to maltreatment and household dysfunction during childhood to the presence in later life of multiple risk factors and several disease conditions associated with death in adulthood. The image below graphically depicts the hypothesized connection between ACEs and later risk-taking behaviors and the development of life-threatening conditions.

Race

White and black children differed significantly in their rates of experiencing overall maltreatment during the 2005-2006 NIS-4 study year. An estimated 12.6 per 1000 white children experienced maltreatment, compared with 24.0 per 1000 black children. The incidence rate for black children was nearly 2 times the rate for white children. The rate for black children was also significantly higher than that for Latino children (14.2 per 1000), with black children 1.7 times more likely to experience maltreatment than Latino children. An estimated 2.6 per 1000 black children were sexually abused, which is nearly 2 times the rate of 1.4 per 1000 white children. The difference between black and white children in their rates of sexual abuse is statistically marginal.

Changes in the incidence rate of abuse were significantly related to race/ethnicity. There was a significant change in overall abuse since the NIS-3 related to the child’s race and ethnicity. The differential decreases were 43% for white children, 27% for Latino children, and 17% for black children.

Sex

Sex-related differences are noted in the reported incidence of sexual abuse. In the NIS-4, a statistically significant difference was noted, with girls experiencing sexual abuse at more than 5 times the rate of boys (3.0 per 1000 girls compared with 0.6 per 1000 boys). The Child Maltreatment 2014 report does not separately report the number of sexual abuse cases by sex, however, it does report that the victimization rates for younger boys (< 1 and 1-5 years) are consistently higher than girls of the same age. At the same time, the victimization rates for older girls (6-10 and 11-17 years) are consistently higher than boys the same age. This is especially true for girls ages 11-17; the victimization rate is 35% higher for girls in this age group.[13]  Douglas and Finkelhor have conducted extensive studies on child sexual abuse incidence rate trends and conclude that the overwhelming majority of rigorous studies report a higher incidence of sexual abuse among girls, with females typically representing 78-89% of cases.[16]

Age

Age distribution for child sexual abuse was not reported in a detailed manner in the NIS-4. The Child Maltreatment 2014 report shows that the youngest children are the most vulnerable to all types of maltreatment. In FFY 2014, 27.4% of victims of all types of maltreatment were younger than 3 years of age. Victimization of all types of abuse for children younger than 1 year was 24.4% per 1,000 children in the population of the same age.[13]  

For recovery from the emotional trauma associated with child sexual abuse (CSA), prognosis varies depending on a number of abuse-specific and individual and environmental factors. These factors include the following:

• The child's inherent coping mechanisms and response to trauma and its aftermath

• Response evident in the child's environment to the victimization

• Age when the abuse occurred

• Relationship of the perpetrator to the child

• Length of time over which the abuse occurred

• Pattern of the abuse

The response within the caregiving environment to the victimization appears to have an important impact on the ability of the child to work through the difficult issues raised by the sexual abuse.

Looking at children 5 years after presentation for sexual abuse and comparing them to a similarly aged group of children who were not abused, one study found that the children who were sexually abused displayed the following:

• More disturbed behavior

• Lower self-esteem

• Increased tendency for depression

• Increased tendency for anxiety

Retrospective studies of adults with severe personality disorders characterized by dissociation, impaired interpersonal relationships, and self-mutilation have found a high and significant correlation with histories of sexual abuse.

Prognosis related to any physical injury or infection resulting from the sexual abuse is expected to follow a typical healing course and respond to standard medical interventions.

Paolucci et al's meta-analysis of 37 studies involving 25,367 individuals reported no universal response to child sexual abuse; however, they did confirm that in most cases the experience is negative and that clear evidence proves a link between child sexual abuse and subsequent negative short-term and long-term developmental effects.[24]  Paolucci et al conclude that, rather than thinking about a single, specific child sexual abuse response syndrome, the data support a much more complex, multifaceted model of traumatization.

In incidents of child sexual abuse (CSA), the interview with the child is typically the most valuable component of the medical evaluation. Elicited history is frequently the only diagnostic information that is uncovered. Additionally, if performed in a sensitive and knowledgeable manner, the history-taking process can be a first step in the healing process for the child who is sexually traumatized. Regardless of the history provided, the members of the interdisciplinary team need to demonstrate an open, nonjudgmental, and caring attitude toward the child; the willingness to advocate for the child must be demonstrated as the evaluation unfolds.

• General principles for successful history taking

  • To assist in creating a comfortable and nonthreatening environment, allow an extended period of time when taking the history in children who are suspected of being sexually abused.

  • When interviewing the child, use a developmentally sensitive approach to the questioning so that the child can understand what is being asked and is able to answer as accurately as possible.

  • Rely on nonleading questions as much as possible to permit the child to relate information in a credible and reliable framework.

  • An interview often has a healing value for children, enabling them to start to feel some control with what occurs in their lives in contrast to the abusive situation that took away the control they should have with their own bodies.

  • In an effort to demystify the information-gathering process, consider permitting children to sit where they want to sit, slowing down the pace of the interview if it starts to go too fast, permitting time for play breaks, and encouraging children to use their own words for body parts.

• Initial introduction with efforts to build up trust

  • During the initial meeting, the health care provider and any members of the interdisciplinary team who are involved with the treatment of the child should introduce themselves to the child and caregiver.

  • At this point, the primary health care provider should explain how the evaluation usually proceeds, including the need to first speak alone with the caregiver and then alone with the child.

  • After these initial conversations, ask the caregiver to rejoin the child for a physical examination, which frequently is understood as a "check-up" by the child.

• Caregiver interview

  • Ensure that caregivers who accompany children have an opportunity to describe their concerns, provide information about the children's health, and outline any information they have related to the suspected abuse.

  • By interviewing the caregiver first, the interviewer allows the child an extra bit of time to become familiarized with the clinical setting and, hopefully, to become more comfortable with the environment.

  • Initially explain to the caregiver the extent to which the information elicited during the interview is required to be shared with child protective services (CPS) staff and law enforcement personnel who may be involved with the case.

  • Clarifying the limits of confidentially in suspected incidents of child sexual abuse is paramount to avoid feelings of betrayal later if and when information is shared with the various involved agencies.

• Child interview

  • When verbal children are interviewed when the caregivers are not present, children may not provide the most valuable information.

  • Using a sensitive approach and building on what has been learned in the warm-up and caregiver interview components, begin with nonthreatening topics such as favorite activities, school subjects, and personal interests.

  • Once rapport has been established in the interview, ask the children why they have come to the doctor's office.

  • By focusing on asking simply worded, open-ended, nonleading questions, the person taking the history can progress through the standard "what, when, where, and how" questions, which are important to the medical evaluation of suspected child sexual abuse.

  • The full potential of the interview can be realized by a reliance on such questioning as "tell me more" followed by "and then what happened?"

  • Supporting the child for working hard to answer the questions (but not for the content of the answers) is vital to the credibility of the information elicited.

  • The clinician must understand the developmental capacity of the child and work within the child's abilities to garner the information needed. Thus, children may not know dates but they remember holidays; children may remember something happened before or after school began.

  • Asking children to explain what they mean to avoid misunderstanding important points in the history is always appropriate.

  • Using the child's words for body parts may make the child more comfortable with difficult conversations about sexual activities.

  • Using drawings may also help children describe where they may have been touched and with what they were touched.

  • Meticulous documentation is a necessity for these types of histories, because the documentation may be considered as evidence in subsequent legal proceedings emanating from the overall investigation.

  • To the extent possible, document specific quotes that the child makes about the abusive events.

  • Often, entries made in medical charts by health care providers of children's words detailing their own sexual victimization assist those advocating for children as they argue for suitable protection from people and situations that may be threats to the children's well-being.

  • Consider videotaping or audiotaping the interview if the jurisdiction permits this.

• Wrap-up and preparation for the physical examination

  • After the child interview concludes, the caregiver can be invited back in the room to help facilitate the transition to the physical examination.

  • Being honest and empathetic with the child is critically important.

  • Therefore, do not promise that needles are not to be used unless absolutely sure that obtaining blood is not necessary; if not sure, reassure children that blood is obtained only if needed and, if blood is needed, children are told at the end of the examination.

  • Inform children if genital swabs are to be collected; allow them to handle the swabs in order to gain some comfort with the procedure.

  • If a colposcope is to be used during the physical examination, introduce it as a "special camera" that the doctor uses that does not touch the child.

  • After an appropriate discussion, leave the room and allow the child to prepare for the examination by suitable disrobing and putting on a gown with the caregiver's assistance.

As opposed to adult sexual abuse and in general, authorities agree that more than three fourths of physical examinations of children suspected of having been sexually abused are without definitive findings of sexual abuse. Heger and colleagues conducted a comprehensive study that included the review of physical examinations performed on 2,384 children evaluated for suspected child sexual abuse in a regional referral.[19] They found that, overall, only 4% of the children had abnormal findings. Of 182 children specifically referred for evaluation of a suspected finding identified by a health care provider, the child abuse specialist only found 8% of these children with a finding (this is the group expected to have the highest likelihood of a finding on examination due to the initial concern from the referring health care provider).

Additionally, of children who reported either vaginal or anal penetration, only 5.5% had physical examination findings. Thus, Heger and colleagues concluded that the vast majority of suspected child sexual abuse physical examinations are likely to not discover physical findings (what are commonly referred to as "normal" physical examination findings). Numerous reasons are believed to account for this general lack of findings. First, the child and family typically know the perpetrators, and physical force is not often a major component as in adult sexual assaults. Disclosure of the abuse frequently is delayed, and evaluations may be performed weeks to months after the abusive contact. Finally, mucous membranes that compose the genital structures heal rapidly and, often, without obvious scarring. See the imags below.

The general approach to the physical examination follows the standard examination techniques for a comprehensive physical examination (ie, complete head-to-toe approach). When examining the child who is suspected of being sexually abused, place particular emphasis on the genital and anal examination; however, children should experience this more thorough inspection of their anogenital anatomy only in the context of a complete examination. In this way, children receive messages that their whole bodies and health are important; this helps to avoid any undue focus on their anogenital areas.

• Examining genital and perianal structures: To perform a complete examination of the child's genitalia and perianal structures for abnormalities attributed to abuse, the examiner first must understand the basic anatomy of this body area. Initially considering the female prepubertal genitalia with minimal palpation, externally inspect the vulvar structures. Tissues of interest are mons pubis, labia majora, labia minora, clitoris, urethral meatus, hymen, fossa navicularis, and posterior fourchette. The postpubertal child may require a more extensive examination requiring internal examination of the vagina and cervix, depending on the suspected type of contact. This section focuses on the external examination of the prepubertal female genitalia. Child Abuse and Neglect: Physical Abuse includes a detailed description of the examination of the female adolescent patient. Structure descriptions are as follows:

  • Mons pubis

    • This genital structure is the skin-covered mound of fatty tissue above the pubic symphysis.

    • Due to maternal estrogen effect, the neonate's mons pubis appears generous and rounded; however, as the estrogen effect decreases, the roundness is lost until the child's endogenous estrogen level increases at the time of puberty.

    • In response to circulating hormones, the mons pubis is the site for pubic hair growth during pubertal development and adulthood.

  • Labia majora

    • These bilateral skin-covered longitudinal folds of fatty and connective tissue serve as external protection for the more recessed vulvar structures.

    • The neonate's labia majora are thicker due to maternal estrogen effect, and this decreases over time.

    • The child's labia majora do not completely cover the internal structures.

    • During puberty, pubic hair grows on the skin covering the labia majora as well.

  • Labia minora

    • These bilateral, thin, mucous membrane longitudinal folds are observed medial and more recessed in relation to the skin-covered labia majora.

    • Because of maternal estrogen, the neonate's labia minora are frequently larger than expected and may protrude beyond the labia majora; however, this decreases over time.

    • Anteriorly, the labia divide into lateral and medial components, with the lateral labial component fusing centrally to form the prepuce of the clitoris.

    • The medial labial components fuse to form the clitoral frenulum.

    • Posteriorly, the labia fuse to form the posterior fourchette.

    • No hair grows on the labia minora.

  • Clitoris

    • The clitoris is the small, cylindrical, erectile structure composed of a prepuce, frenulum, glans, and body.

    • Similar to the other structures described above, the maternal estrogen effect causes a transient enlargement of this structure, which decreases over weeks to months after birth.

  • Urethral meatus

    • This genital structure is the round outlet of the urinary system inferior to the clitoris.

    • This outlet may be difficult to routinely visualize in the child, but urethral tissue occasionally may prolapse, creating a beefy red donut-shaped protrusion at the site of the meatus.

  • Hymen

    • The hymen is the mucous membrane sheetlike structure that has an opening and is situated at the entrance to the vagina, sitting in a recessed fashion between the medial aspects of labia minora. See the images below.

      Girl in frog-leg supine position exhibiting hymen. Hymen is septate; a band of tissue crosses the hymenal orifice. Tissue is thin with no scarring present. Courtesy of Carol D. Berkowitz, MD.
      Infant girl with imperforate hymen and absence of a hymenal orifice. Courtesy of Carol D. Berkowitz, MD.

    • Hymenal tissue is very sensitive to estrogen, and the estrogenized hymen is pink and opaque compared to the relatively unestrogenized hymenal tissue, which generally is thin, translucent, and reddish with an obvious lacy vascular pattern. See the images below.

      Adolescent girl in supine position demonstrating estrogenized tissue. Hymen is thicker, pink, and fairly opaque with no vessels visible. Tissue is redundant. Courtesy of Carol D. Berkowitz, MD.
      Genital examination of adolescent girl revealing estrogenized hymenal tissue that is pink, thick, and opaque. Orifice appears irregular, secondary to significant redundancy of tissue. Courtesy of Carol D. Berkowitz, MD.
      Genital examination of adolescent girl demonstrating estrogenized hymenal tissue that is pink, thick, and opaque. Orifice is irregular due to areas of redundancy, especially at the 9-o'clock position. Courtesy of Carol D. Berkowitz, MD.

    • The shape of the hymenal orifice varies, and the various shapes are generally described as crescentic (half-moon), annular (circular), fimbriated (redundant tissue that folds over on itself like excess ribbon around an opening), septate (column of tissue that crosses the opening), and cribriform (series of small openings). See the images below.

      Infant girl in frog-leg supine position. Hymenal orifice is crescentic (little tissue is present at 12-o'clock posterior). Hymen is thin and translucent with vessels visible. Hymenal edge is regular and without interruption. Courtesy of Carol D. Berkowitz, MD.
      Girl in knee-chest position. Hymenal orifice is crescentic, thin, translucent, and without interruption or scarring. Courtesy of Carol D. Berkowitz, MD.
      Infant girl in frog-leg supine position. Hymenal orifice is annular, with tissue present around entire opening. Some redundancy is present. Courtesy of Carol D. Berkowitz, MD.
      Infant girl in frog-leg supine position. Genital examination reveals translucent hymenal membrane with significant redundant tissue making hymenal orifice difficult to appreciate in this photo. With further traction applied to both labia majora, the hymenal orifice could be observed. Courtesy of Carol D. Berkowitz, MD.

    • The shape of the orifice can be further described by the appearance of clefts, bumps, notches, tags, and the presence of thickening or thinning at the orifice's edge. See the image below.

      Infant girl in frog-leg supine position. Hymenal orifice is annular with a "bump" at 1-o'clock position and a small "notch" at 10-o'clock position. Hymenal membrane is thin and translucent, with no interruption or scarring. Courtesy of Carol D. Berkowitz, MD.

    • The observed size of the hymenal orifice varies, depending on the state of relaxation of the child, the position of the child, and examiner technique.

    • As such, most authorities agree that measurement of the hymenal orifice has limited utility in the evaluation.

  • Posterior fourchette: Formed by the posterior meeting of the labia minora, the posterior fourchette is the floor of the fossa navicularis.

  • Fossa navicularis: The fossa navicularis is the space bounded by the posterior fourchette and the point where the hymen attaches to the inferior aspect of the vaginal wall at its entrance.

• Standard positioning: To expose the prepubertal genital structures as fully as possible, several standard positions are used, namely frog-leg supine, knee-chest, and the left lateral decubitus.

  • Frog-leg supine position

    • This position is ideal for optimal visualization of the genital structures and for a fair degree of comfort for the child.

    • The child lays supine on the examining table or on the caregiver's lap and flexes her knees, bringing the heels of her feet together while abducting her hips; thus, her legs can move laterally, providing an excellent view of the external genitalia.

  • Knee-chest position

    • The knee-chest position provides clear observation of the anus; it also offers an opportunity to examine the vulvar structures, including the hymen, from a different vantage point.

    • This position can be helpful in assessing a difficult-to-visualize hymenal orifice.

    • As the child kneels down, resting her chest against her knees on the examination table and moving her buttocks superiorly, the anterior abdominal wall falls forward, and the hymenal tissues may be extended somewhat more than in the frog-leg supine position.

    • The main disadvantage to this position is that children may feel vulnerable and are often uncomfortable remaining in this position.

  • Left lateral decubitus

    • This alternative position is most appropriate for anal examination and most commonly is used with boys.

    • The left lateral decubitus position does not offer a clear visualization of the female vulvar structures.

    • The child lies on his left side with knees flexed and buttocks placed toward the examining table's edge and the examiner.

• Calming the child during examination: In addition to positioning, make efforts to keep the child engaged and calm during the examination. Often, calming the child is accomplished by talking to the child and explaining what to expect during the examination. Additionally, proper attention to modesty is necessary, and the use of a quiet room, with adequate privacy, is essential. Use gowns and drapes as appropriate.

• Genital and anal examination: Examiners may find it helpful to progress through the genital and anal examination in a fairly routine sequence, during both the actual examination and the subsequent documentation.

  • General observation and inspection

    • The genital examination begins with general observation and inspection.

    • With the child in the appropriate position and with adequate light and privacy, look for signs of injury on the skin surfaces, make a judgment about the presence and character of pubic hair for sexual maturity rating purposes, and look for any obvious signs of infections.

    • Note the child's emotional status.

  • Visualizing the more recessed genital structures

    • Once the inspection is completed with gloved hands, the examiner may use gentle palpation to move the tissues and further visualize the more recessed genital structures.

    • By applying gentle lateral traction to the labia majora, the labia minora and hymen may be observed more clearly.

    • Magnification, provided by a hand-held magnifying glass or colposcope, may be helpful during the genital examination. The colposcope has the advantage of providing an excellent light source and having the capability to take photographs during the examination.

    • Internal examinations and the use of instruments are almost never necessary in the prepubertal examination for suspected child sexual abuse.

    • If deemed necessary because of a serious finding (eg, bleeding with no identified source), arrange an examination under anesthesia.

  • Collection of specimens

    • At this point in the examination, specimens may be collected for STD screening and forensic evidence collection.

    • These procedures are described in more detail in the Workup section.

  • Possible observable findings: Most individuals who have been sexually abused present with essentially normal examination findings. However, possible observable findings include (1) those attributable to acute injury if the examination is performed a relatively short time after the sexual contact or (2) chronic findings that may be residual effects following repeated episodes of genital contact, which have occurred over an extended period of time.

    • Examples of acute trauma include subtle erythema, abrasions, lacerations, friability, bleeding, and disruption of the hymen. Additionally, if the perpetrator ejaculated on or near the child's genitalia, seminal products may be found. Signs related to the existence of STDs may also be present. These signs may include vaginal discharge, signs of vulvovaginitis, and characteristic lesions, such as the viral lesions observed in genital herpes and the warts observed with human papilloma virus infection (ie, condyloma acuminata). See the images below.

      Genital examination of girl revealing bruising on medial aspects of labia minora, hymenal trauma with disruption of hymenal tissue, and fresh blood. Courtesy of Carol D. Berkowitz, MD.
      Infant girl with significant bruising that involved labia minora and labia majora, hymenal trauma with disruption of hymen, and fresh blood. Courtesy of Carol D. Berkowitz, MD.
      Genital examination 10 days after infant girl presented with significant bruising that involved labia minora and labia majora, hymenal trauma with disruption of hymen, and fresh blood. Bruising on vulvar structure is nearly resolved. Hymen is healing and no blood is observed. Courtesy of Carol D. Berkowitz, MD.

    • Chronic findings that may be found include scars on the genital skin and mucous membranes, remodeled hymenal tissue from repeated trauma, and disrupted vascular patterns in the translucent tissues. Healing occurs in these tissues. Over months to years of abusive contact, angular margins in hymenal tissue tend to smooth out, and, with the onset of puberty, the appearance of estrogen and resultant hypertrophy of the genital mucous membranes tend to obscure subtle changes.

• Muram diagnostic categorization system: From a historical perspective, the Muram categorization system is of note and offers valuable insight into how various prepubertal genital examination findings may assist diagnosis.

  • Category I - Genitalia with no observable abnormalities

  • Category II - Nonspecific findings that are minimally suggestive of sexual abuse but also may be caused by other etiologies

  • Category III - Strongly suggestive findings that have a high likelihood of being caused by sexual abuse

  • Category IV - Definitive findings that have no possible cause other then sexual contact (eg, seminal products in a prepubertal female child's vagina, the presence of a nonvertically transmitted gonorrhea or syphilis infection)

• Alternate classification

  • Adams and colleagues have built upon the Muram classification approach and have combined it with information from other components of the sexual abuse assessment.[1] These clinical investigators propose an approach to the interpretation of medical findings in suspected child sexual abuse that offers a sound basis from which the examining health care provider can a differential diagnosis and offer a diagnostic impression at the conclusion of the health care evaluation. According to the 2008 update, Adams and colleagues propose an approach that has the following 8 categories of findings:[2]

    • Findings documented in newborns or commonly seen in nonabused children (ie, normal variants)

    • Findings commonly caused by other medical conditions

    • Indeterminate findings (ie, insufficient/conflicting research data so requires caution in interpretation)

    • Findings diagnostic of trauma and/or sexual contact

    • Residual/healing injuries

    • Injuries of blunt force penetrating trauma

    • Presence of infection that confirms mucosal contact with infected bodily secretions (ie, contact most likely to have been sexual)

    • Diagnostic of sexual contact (ie, pregnancy or sperm directly taken from a child's body)

  • Because of the complexity of evaluation and the expertise required to accurately identify and interpret examination findings, Adams et al conclude their 2008 update with a call for standardization of the training of medical professionals who perform suspected child sexual abuse evaluations to ensure appropriate and continuing competence.

Children who have been abused sexually are at risk of contracting STDs including gonorrhea, chlamydia, syphilis, condyloma acuminata, herpes simplex virus, human immunodeficiency virus (HIV), pediculosis pubis, and trichomoniasis vaginalis.

Rapid tests are not appropriate for prepubertal children in the context of a child sexual abuse (CSA) evaluation because of their higher potential for false-positive results.

Cultures remain the criterion standard and are valuable from a forensic evidence standpoint.

Depending on the contact suspected and the clinical situation recommended, testing includes the following:

• Gram stain of vaginal and/or anal discharge

• Genital, anal, and pharyngeal culture for gonorrhea

• Genital and anal culture for chlamydia

• Serology for syphilis

• Wet prep of vaginal discharge for Trichomonas vaginalis

• Culture of lesions for herpes virus

• Serology for HIV (based on suspected risk)

The American Academy of Pediatrics (AAP) views nonvertically transmitted gonorrhea, syphilis, chlamydia, and HIV as diagnostic of sexual abuse in the prepubertal child.[20]

In a child, the AAP views the presence of T vaginalis as highly suggestive of sexual abuse.

Nonvertically transmitted condyloma acuminata and herpes with no clear history of autoinoculation are also suggestive of sexual abuse.

The collection of forensic evidence, via the rape kit, may be indicated if the child presents within 72 hours of last sexual contact with the perpetrator and if a belief exists that the perpetrator may have left evidence on the child's body. The 72-hour standard that triggers forensic evidence collection in cases of suspected child sexual abuse is derived from adult pathology studies of adult sexual assault cases. As more pediatric studies are performed based on the timing of forensic evidence collection, this 72-hour standard may be changed to reflect the unique issues present in most cases of child sexual abuse.

For example, in 2000, Christian et al evaluated forensic evidence in prepubertal victims of sexual assault.[21] Forensic evidence was found in 25% of children, all of whom were evaluated within 44 hours of assault. Sixty-four percent of evidence was found on their clothing and linens. However, only 35% of children in the study had their clothing collected for analysis. No swabs from the children's bodies were positive for blood after 13 hours or for semen after 9 hours.

Using data from evidence-collection kits from children 13 years and younger, one study noted that while the yield was limited, positive DNA results were obtained from a body swab collected at 7-95 hours after assault. Body swabs were less likely than nonbody specimens to yield DNA in children younger than 10 years.[22]

Another study noted that identifiable DNA was collected even when the specimen was obtained beyond 24 hours after the assault; the victim had bathed and/or changed clothes before evidence collection, there was no reported history of ejaculation, and the child had a normal/nonacute anogenital examination.[23]

In addition, consider obtaining a urine toxicology screen if the abuse or assault was substance facilitated, especially in the setting of dating violence.

• Carefully follow procedures outlined in standard forms that are included in the rape kit.

• Maintain a documented "chain of custody"; the actual kit is extremely important.

• Cultures for STDs are not part of the rape kit and should be handled separately based on the typed culture procedures.

• Finally, place clothing in a paper bag and not in plastic, which may seal in moisture and lead to evidence degradation.

• Evidence that may be collected includes the following:

  • Child's clothing that was worn at the time of the sexual contact

  • Swabs for semen, sperm, and acid phosphatase

  • Fingernail scrapings from underneath the child's nails

  • Pubic hairs found on the child's body (If the child has pubic hair, sampling 5-10 hairs, which then are placed in separate envelopes for comparison, is necessary.)

  • Debris found on the child

  • Child's samples of saliva and blood to determine blood type and secretor status

Medical treatment is guided by any conditions uncovered. The incidence of STDs in child sexual abuse (CSA) is low. In prepubertal children, asymptomatic vaginal infections are thought to be increasingly uncommon. Therefore, the Centers for Disease Control and Prevention (CDC) does not recommend prophylaxis for STDs in asymptomatic prepubertal children who are evaluated for possible CSA. In contrast, the CDC recommends that teenaged patients and adults who are sexually abused or assaulted should receive antibiotic prophylaxis for STDs. For more information, see MMWR Recommendation and Report Sexually Transmitted Diseases Treatment Guidelines.

• Treat STDs with appropriate medications based on the infection and the child's age and weight.

• In postmenarcheal children, consider the possibility of pregnancy.

• Recognize the overriding need for emotional support and attention to the psychosocial crisis in which the child and family now find themselves.

• Health care providers are mandated reporters in all 50 states; once sexual abuse seriously is suspected or diagnosed, a report to the appropriate child protective services (CPS) agency is necessary. Attention to the safety of the child is essential. The AAP recommends reporting in the following situations:

  • When a child makes a clear disclosure of abusive sexual contact, with or without specific findings

  • When individuals present with STDs (see Workup section)

  • When physical examination findings are believed to be the result of abusive sexual contact

• When sexual abuse is being considered, the AAP suggests the possibility of reporting, depending on the perceived risk to the child. In such cases, discussion with members of an interdisciplinary team may be helpful.

• Cases of sexual abuse may result in law enforcement action against the alleged perpetrator and possible criminal court proceedings. Well-documented medical records are essential, since legal proceedings may occur over long periods of time. The health care provider cannot rely solely on recollection of the case.

Mental health consultation is warranted to evaluate and treat acute stress reaction and, later, posttraumatic stress disorder (PTSD).

Expert mental health management of stress disorders is warranted because of the burgeoning evidence that psychic trauma in young children has a significant effect.

American Academy of Pedatrics

The 2013 update of the AAP guideline for the evaluation of sexual abuse in children states that the medical assessment of suspected child sexual abuse should include obtaining a history, performing a physical examination, and obtaining appropriate laboratory tests. The role of the physician includes determining the need to report suspected sexual abuse; assessing the physical, emotional, and behavioral consequences of sexual abuse; providing information to parents about how to support their child; and coordinating with other professionals to provide comprehensive treatment and follow-up of children exposed to child sexual abuse.[20]

Whenever the issue of possible child sexual abuse arises in the office setting, 5 important issues should be addressed.

1. The child's safety - The health care provider must determine whether the child is at any risk for additional harm if he or she returns home.
2. Reporting to authorities - In the absence of imminent risk, the physician needs to determine if there is evidence of suspected abuse that would require him or her to contact law enforcement or child protection.
3. The child's mental health - The child should be assessed for possible mental health problems (e.g., PTSD, depression). If any are identified, appropriate emergency mental health care should be sought.
4. Need for physical examination - The physician should perform a thorough physical examination to determine whether the child has been injured, particularly if a child is reporting genital or anal pain or bleeding.
5. Need for forensic evidence collection - If the abuse was recent and involved exchange of bodily fluids, the child should be immediately referred to those capable of gathering forensic evidence.