Laboratory Studies
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:
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Gram stain of vaginal and/or anal discharge
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Genital, anal, and pharyngeal culture for gonorrhea
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Genital and anal culture for chlamydia
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Serology for syphilis
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Wet prep of vaginal discharge for Trichomonas vaginalis
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Culture of lesions for herpes virus
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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.
Other Tests
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.
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Carefully follow procedures outlined in standard forms that are included in the rape kit.
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Maintain a documented "chain of custody"; the actual kit is extremely important.
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Cultures for STDs are not part of the rape kit and should be handled separately based on the typed culture procedures.
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Finally, place clothing in a paper bag and not in plastic, which may seal in moisture and lead to evidence degradation.
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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
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Possible factors influencing the decline in substantiated cases of child sexual abuse. Courtesy of David Finkelhor, PhD.
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Adverse Childhood Experience (ACE) Pyramid. Courtesy of the Centers for Disease Control and Prevention (CDC) [https://www.cdc.gov/violenceprevention/aces/about.html].
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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.
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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.
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Girl in knee-chest position. Hymenal orifice is crescentic, thin, translucent, and without interruption or scarring. Courtesy of Carol D. Berkowitz, MD.
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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.
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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.
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Girl in frog-leg supine position, exhibiting annular hymenal orifice. Tissue is thin and translucent without disruption or scarring. Courtesy of Carol D. Berkowitz, MD.
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Girl in frog-leg supine position exhibiting hymenal orifice, which is crescentic and has symmetric attenuation at lateral margins. No scarring is present. Courtesy of Carol D. Berkowitz, MD.
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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.
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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.
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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.
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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.
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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.
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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.
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Infant girl with imperforate hymen and absence of a hymenal orifice. Courtesy of Carol D. Berkowitz, MD.
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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.
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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.
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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.
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Genital examination of girl in frog-leg supine position after genital trauma. Examination reveals suture in place at 6-o'clock position to stop bleeding from injury. Hymenal edge is irregular and asymmetric. Courtesy of Carol D. Berkowitz, MD.
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US Maltreatment Trends, 1990-2019. Courtesy of David Finkelhor, PhD [Finkelhor D, Saito K, Jones L. Updated Trends in Child Maltreatment, 2019. Crimes Against Children Research Center, University of New Hampshire. February 2021. Online at: http://unh.edu/ccrc/pdf/CV203%20-%20Updated%20trends%202019_ks_df.pdf.].
