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Sexual Abuse: The "Hidden Pediatric Problem"
Marcella Donaruma, MD | September 12, 2022
| Contributor Information
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Images from Percinoto AC, Danelon M, Crivelini MM, Cunha RF, Percinoto C. BMC Res Notes. 2014;7:467. [Open access.] PMID: 25053204, PMCID: PMC4114792.
Sexual Abuse: The "Hidden Pediatric Problem"
Marcella Donaruma, MD | September 12, 2022 | Contributor Information
The images reveal Condyloma acuminata in the tongue and palate of a sexually abused male child.
Child sexual abuse is a global problem that affects both sexes and remains underreported, which makes it difficult to obtain accurate figures on the scope of this issue.[1] Reasons for underreporting include varying definitions of child sexual abuse; victims' fear of being disbelieved and/or receiving further harm from the perpetrator(s); and societal stigma.[1,2]
The US CAPTA (Child Abuse Prevention and Treatment Act) Reauthorization Act of 2010 (Public Law [PL] 111-320) defines sexual abuse (42 United States Code [USC] §5106g(4)) to include the following[3]:
"The employment, use, persuasion, inducement, enticement, or coercion of any child to engage in, or assist any other person to engage in, any sexually explicit conduct or simulation of such conduct for the purpose of producing a visual depiction of such conduct; or
"The rape, and in cases of caretaker or inter-familial relationships, statutory rape, molestation, prostitution, or other form of sexual exploitation of children, or incest with children."
However, the legal definition of sexual violence and misconduct varies from state to state,[4,5] underscoring the difficulty in determining the true prevalence of child sexual abuse. For more information on state laws, visit the Child Welfare Information Gateway.
Image courtesy of Marcella Donaruma, MD.
Sexual Abuse: The "Hidden Pediatric Problem"
Marcella Donaruma, MD | September 12, 2022 | Contributor Information
Diagnosing Sexual Abuse
Children who have experienced sexual abuse may not immediately exhibit sexual behavior problems; the time between the abuse and manifestation of concerning sexual behavior has been reported to be between 2.2 and 2.7 years for children aged 6-9 years and 3-4 years for those aged 10-12 years.[6] Many victims do not disclose such abuse until they are adults.[2]
Although affected children may present with highly specific sexually reactive behaviors—such as inserting objects into body cavities after abuse, as seen in the radiograph above, which reveals a lock, coin, and nail in the vaginal vault—there is no single pathognomonic sign of sexual abuse or sexually problematic behavior.[6]
It is important to keep in mind that in the course of normal development, most young children (aged 2 to 5-6 years) may exhibit the following behavior(s)[6]:
Self-stimulatory behavior, by touching their genitals in public or at home
Voyeurism, in attempting to look at others who are nude
Exhibitionism, by exposing their genitals to others
Other behaviors related to personal boundaries, such as standing too close to others
Behaviors that are insertive, aggressive, coercive, or difficult to distract the child away from are the most worrisome for past experience of inappropriate contact.[6]
The American Academy of Pediatrics (AAP) recommends that pediatricians provide longitudinal sexual education to parents, children, and adolescents.[7] In addition, all adolescents should be asked about unwanted sexual contact during routine visits in conjunction with discussions of overall sexual health.
Image courtesy of Marcella Donaruma, MD.
Sexual Abuse: The "Hidden Pediatric Problem"
Marcella Donaruma, MD | September 12, 2022 | Contributor Information
Consider Sexual Abuse
The photograph shows patchy bruising as well as petechiae scattered over the prepubertal hymen of a toddler who was sexually abused.
When a concern for sexual abuse arises, a detailed history should be obtained from a parent or caretaker without the child present—and then gathered from the child independently, if he/she is developmentally capable.[8] Meticulous, clear documentation is essential, including the use of photographs and/or diagrams as necessary.
A medical history is vital not only to form a plan that addresses the child's safety but also to determine whether the family should be referred to a child protective services agency, as well as to assess the need to incorporate forensic evidence collection into the physical examination and evaluate for any indication of a need for mental health services.[8] If the child is able to cooperate with a discussion of the history of present illness, take care to use age-appropriate language and open-ended questions.
Image courtesy of Marcella Donaruma, MD.
Sexual Abuse: The "Hidden Pediatric Problem"
Marcella Donaruma, MD | September 12, 2022 | Contributor Information
Shown is gonorrhea in a 5-year-old girl, a clear indication of sexual contact with infected bodily secretions. Even if she is reluctant to disclose any abusive contact, referral to a child protection agency is warranted.
NOTE: Healthcare professionals are mandated to report suspected child abuse and neglect, including suspected sexual abuse, to appropriate government agencies.[8] (See slide 19 for more information.)
There are nearly 900 children's advocacy centers (CACs) in the United States, many of which provide agency, investigative, legal, mental health, and medical services to victims of child sexual abuse. Find a CAC at the National Children's Alliance Website: www.nationalchildrensalliance.org/.
In addition, the National Center for Missing & Exploited Children (NCMEC) has a CyberTipline and a phone number (1-800-THE-LOST [1-800-843-5678]) that can be used to report suspected pediatric sexual exploitation.[9] These reporting mechanisms are available 24 hours, 7 days a week.
Image courtesy of Marcella Donaruma, MD.
Sexual Abuse: The "Hidden Pediatric Problem"
Marcella Donaruma, MD | September 12, 2022 | Contributor Information
Common Presenting Complaints
Signs and/or symptoms that should trigger consideration of sexual abuse in a child include lower urinary tract symptoms such as itching, frequency, dysuria, new onset of secondary enuresis, and/or gastrointestinal complaints such as constipation, encopresis, or chronic recurrent abdominal pain.[10,11] Occasionally, girls with vulvovaginitis[10,11] (diffuse erythema and interlabial debris shown) or infections such as pinworms[11] exhibit frequent genital scratching, which may be mistaken for "excessive" masturbatory activity.
A genital examination should be included as a component of all routine physical examinations, because this practice delivers a clear message that genital health is as important as that of the rest of the body.[8] Providers can also give children a valuable tool in mobilizing adults in cases of inappropriate contact by encouraging the use of clear and specific terminology for the genitalia during visits with children and their families, rather than whimsical or euphemistic names such as "pouf-pouf" or "pocketbook."
Image courtesy of Marcella Donaruma, MD.
Sexual Abuse: The "Hidden Pediatric Problem"
Marcella Donaruma, MD | September 12, 2022 | Contributor Information
Physical Examination from Head to Toe … Including the Genitalia
Many children who are sexually abused are victims of other forms of abuse as well.[8] A complete physical examination may reveal signs of comorbid physical abuse and neglect, and/or it may reveal extragenital injury incurred during an acute sexual assault. Findings such as the suction petechiae[10] shown in the image above offer an opportunity to collect evidence that may be forensically useful, such as the assailant's DNA transferred through saliva.[12]
Image courtesy of Marcella Donaruma, MD.
Sexual Abuse: The "Hidden Pediatric Problem"
Marcella Donaruma, MD | September 12, 2022 | Contributor Information
The Anogenital Examination
Shown is a septated hymen, which is a normal hymenal variant. Care must be taken to determine the degree of the septation. A cotton swab passed gently behind the tissue bridge can establish if the division is isolated to the hymenal membrane or represents a septated vagina or perhaps further genital tract abnormalities. A prepubertal hymen should not be manipulated but referred to a subspecialist if posterior vagina cannot be visualized around the septation.
Images courtesy of Marcella Donaruma, MD.
Sexual Abuse: The "Hidden Pediatric Problem"
Marcella Donaruma, MD | September 12, 2022 | Contributor Information
Examination Technique
The best way to visualize the external female genitalia, including the hymen, is by labial separation and labial traction, using the following technique[8,13]:
Place the child in either the frog-leg or lithotomy position (alternatively, prone knee-chest position); then, grasp each of the labia majus with a gloved thumb and forefinger. Avoid gripping the labia minora, which are attached to the underlying fascia and, therefore, are less mobile.
Exert gentle traction in the direction of the examiner (as if pulling up a knee sock). When performed with good technique, the child tolerates the examination with little to no discomfort, and the hymen is easily visualized in relation to the introitus and vaginal canal. A postpubertal hymen may be manipulated with a cotton swab to improve visualization of both the hymen rim and the base.
Image courtesy of Marcella Donaruma, MD.
Sexual Abuse: The "Hidden Pediatric Problem"
Marcella Donaruma, MD | September 12, 2022 | Contributor Information
As appropriate, for evaluation of the anus, use gentle traction on the buttocks to expose the anal sphincter while the child is in the supine knee-chest position,[8,13] the prone knee-chest position, or the lateral decubitus position.[13] Alternatively, use the technique of gluteal lift in the prone knee-chest position.[13]
Similarly, in male children, perform a thorough examination of the external genitalia and the perianal region.
In general, avoid speculum evaluation in prepubertal children in the office setting.[8,13] Shown is another view of the labial traction technique.
Images courtesy of Carol D Berkowitz, MD.
Sexual Abuse: The "Hidden Pediatric Problem"
Marcella Donaruma, MD | September 12, 2022 | Contributor Information
"Normal" Is the Most Common Finding on
The images are from two different girls who experienced sexual abuse. Genital examination findings in the frog-leg supine position were unremarkable in both girls. In the left image, the annular hymenal orifice reveals thin and translucent tissue without disruption or scarring. In the right image, the crescentic hymenal orifice has symmetric attenuation at the lateral margins, and no scarring is present.
The absence of physical findings does not exclude the possibility of sexual abuse and/or penetration.[8,10,14] And although a vast majority of clinical examinations will have "normal" findings despite a compelling history of abuse, it is still important to perform a thorough physical examination to expressly address the individual patient's own wellness after suffering sexual abuse.[8]
The properties of vaginal and anal tissue allow for stretch and accommodation, and thus contribute to the low frequency of overt genital injury in sexual abuse victims.[11] Tissue resilience is often compounded by a frequent delay in an outcry of abuse, during which time the evidence of trauma may heal completely.[8]
Image of imperforate hymen and absence of a hymenal orifice courtesy of Carol D Berkowitz, MD.
Sexual Abuse: The "Hidden Pediatric Problem"
Marcella Donaruma, MD | September 12, 2022 | Contributor Information
Congenital Abnormality of the Hymen
All newborn baby girls without major urogenital anomalies will have an uninterrupted posterior vaginal rim of hymenal tissue on physical examination, typically apparent in abundance (ie, thickened) due to the transient effects of maternal estrogen.[11,15]
Imperforate hymen (shown) is the most frequent congenital malformation of the female genital tract.[16,17] Isolated occurrence is its most common presentation, with an incidence estimated at 0.1% of live-born baby girls. Most cases of imperforate hymen remain asymptomatic until puberty.[16,17]
Image courtesy of Marcella Donaruma, MD.
Sexual Abuse: The "Hidden Pediatric Problem"
Marcella Donaruma, MD | September 12, 2022 | Contributor Information
Not All Genital Bleeding Is from Abuse
Vaginal bleeding is relatively rare in prepubertal girls and necessitates a thorough evaluation when present.[11,15] The differential diagnosis is wide and includes infection, trauma, endocrine dysfunction, retained foreign body, and genital malignancy.
The image shown was obtained in a premenarchal 5-year-old girl brought to the emergency department due to unexplained blood in her underwear. She denied any experience of inappropriate contact. The physical examination demonstrated that the blood was a result of a prolapsed urethra. Clinicians provided reassurance and a prescription for topical estrogen cream.
Images courtesy of Marcella Donaruma, MD.
Sexual Abuse: The "Hidden Pediatric Problem"
Marcella Donaruma, MD | September 12, 2022 | Contributor Information
Recognizing Vaginal Trauma
Loci on the hymen are commonly referenced to that of a clock face, with 12 o'clock at the urethra and 6 o'clock toward the perineal body.
The images shown were obtained in an adolescent girl. An acute (bleeding and erythema present) hymenal transection can be seen at the 3 o'clock position, as well as erythema and bruising in the area from 7 to 10 o'clock. The transected hymen is confirmed by lifting the edges of the injury with cotton swabs. This injury finding is generally consistent with penetrating trauma of the vagina[13] and may have been the result of either consensual intercourse or sexual assault.
When evidence of genital injury is present, it helps to guide the examiner to obtain additional medical evaluation for pregnancy and sexually transmitted infections (STIs),[8,11] as well as to consider forensic evidence collection on the basis of details of the patient history. Typically, any assault within a minimum of 72 hours of the examination warrants an attempt at evidence collection if the patient is willing to cooperate with the process.[8,11] Consult state laws for the specific time frame for evidence collection, which may vary from 72 to 120 hours after the event.
Image courtesy of Marcella Donaruma, MD.
Sexual Abuse: The "Hidden Pediatric Problem"
Marcella Donaruma, MD | September 12, 2022 | Contributor Information
Anal Injury Is Less Common Than Genital Injuries
Acute anogenital injury is rare at the time of evidence collection; the majority of sexual assault survivors have no genital injuries on examination.[12,18]
The photograph of a child's anus demonstrates rare posttraumatic findings from forceful introduction of an object into the rectum. Note the irregular red-violet bruising around the verge, patulousness of the sphincter muscles, circumferential edema, and loss of landmarks, as well as the numerous perianal fissures at 5, 7, 9, 10, and 11 o'clock. This presentation of multiple anal fissures, swelling, and discoloration is highly suggestive of sexual abuse.[19,20]
Image courtesy of Marcella Donaruma, MD.
Sexual Abuse: The "Hidden Pediatric Problem"
Marcella Donaruma, MD | September 12, 2022 | Contributor Information
Genital injury does not equal abuse and checking a patient's history is vital. Children are capable of incurring accidental genital injury. However, these situations are uncommon and are accompanied by specific and consistent histories. Toilet seat or toybox lid injuries to the glans occur most frequently in male toddlers during toilet training, a time when they are more frequently unclothed, though accidental compression injuries and zipper-related penile injury (ZIRPIs) can occur along the developmental spectrum.[21]
Girls of all ages likewise can experience a straddle injury (shown) when they fall with extension at the hips across an object. This history often includes a bicycle seat/handlebars, the edge of a skate or shoe, or other firm unyielding narrow site of impact. In a straddle injury, the pubic ramus bears the brunt of the impact, and the overlying junction of the labia minor and major is where external injury is most often found.
Images courtesy of Carol D Berkowitz, MD.
Sexual Abuse: The "Hidden Pediatric Problem"
Marcella Donaruma, MD | September 12, 2022 | Contributor Information
Vaginal Discharge Should Prompt Consideration of Sexual Abuse
The images show a foreign body in the vagina just past the hymenal orifice in a prepubertal girl with foul-smelling bloody discharge. The foreign body appeared to be toilet tissue that was colonized with bacteria, causing a vulvovaginitis, and was dislodged with gentle water flushing during the examination.
As with vaginal bleeding, vaginal discharge in the prepubertal girl requires a thorough evaluation to diagnose the underlying cause. Such discharge in the young girl is most often caused by vaginal foreign bodies (shown) although, in rare instances, it may signal sexual abuse.[11,15]
The incidence of STIs in prepubertal abuse victims is low,[8,10,13] and published studies are scarce. Testing for STIs is indicated in this population when there is a history of contact with bodily fluids, signs of infection or injury on genital examination, a high-risk or known infected assailant, or parental/patient request for testing.[8] A positive test result for gonorrhea, chlamydia, Trichomonas vaginalis, syphilis, or human immunodeficiency virus (HIV) is diagnostic of sexual abuse in this age population, once vertical transmission has been excluded.[8,10,11,13,22,23]
Image courtesy of Marcella Donaruma, MD.
Sexual Abuse: The "Hidden Pediatric Problem"
Marcella Donaruma, MD | September 12, 2022 | Contributor Information
Sexually Transmitted Infections
Herpes simplex virus (HSV) can be transmitted via sexual and nonsexual modes, as can human papillomavirus (HPV).[8,10,22] The presence of HSV lesions (shown) or findings consistent with HPV infection should prompt an evaluation for comorbid STIs. Furthermore, if they are found in prepubertal patients, a referral to a child protective services agency is recommended in addition to testing.[11,13,15]
Typical STI screening tests include genital specimens for gonorrhea and chlamydia (preferably via urine nucleic acid amplification test [NAAT]); Venereal Disease Research Laboratory (VDRL) or rapid plasma reagin (RPR) studies to screen for syphilis; and HIV testing. NAAT for Trichomonas vaginalis is preferable to culture of vaginal secretions.[24] Cultures for gonorrhea and chlamydia may also be collected from the rectum and/or oropharynx; these tests may be guided by the patient history and physical examination findings.
Image courtesy of Marcella Donaruma, MD.
Sexual Abuse: The "Hidden Pediatric Problem"
Marcella Donaruma, MD | September 12, 2022 | Contributor Information
Shown are perianal warts in a 2-year-old child.
Postexposure STI prophylaxis is not recommended in asymptomatic prepubertal victims owing to the low incidence of STIs in this population.[11,22] Older victims of sexual abuse should receive appropriate STI prophylaxis.[11,25] HIV antiretroviral prophylaxis should be considered on an individual basis, regardless of the child's age, on the basis of the likelihood the assailant(s) is/are infected; consult with a specialist in treating HIV-infected children if prophylaxis is being considered.[25]
Consider a pregnancy test if the female patient is postmenarchal. Pregnancy or the presence of sperm or semen is diagnostic of sexual contact.[11,13]
Image courtesy of Medscape/Joyce A Adams, MD.
Sexual Abuse: The "Hidden Pediatric Problem"
Marcella Donaruma, MD | September 12, 2022 | Contributor Information
These vesicular lesions were found on the labia majora of a child who also gave a history of being sexually abused. Culture results revealed HSV-2.
Reporting Suspected Child Sexual Abuse
Medical care providers are responsible for the safety of their patients. Thus, clinicians are mandated reporters once there is a reasonable suspicion that a child may be a victim of abuse or neglect.[8]
The US Department of Health and Human Services has published information regarding the designated groups of professionals that are required to report cases of suspected child abuse and neglect, as well as reporting by other persons, the responsibilities of institutions in making reports, standards for making a report, and confidentiality of the reporter's identity. In addition, summaries of laws for all US states and territories are included. This publication, Mandatory Reporters of Child Abuse and Neglect, can be found at the Child Welfare Information Gateway at: https://www.childwelfare.gov/topics/systemwide/laws-policies/statutes/manda/.
Note that the Health Insurance Portability and Accountability Act provisions do not apply to health information shared in the course of maintaining a child's safety and well-being. Therefore, health information can be shared with appointed investigators when that information contributes to keeping the child safe.[26,27]
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Contributor Information
Author
Marcella Donaruma, MD
Program Director, Child Abuse Pediatrics Fellowship
Baylor College of Medicine
Texas Children's Hospital
Houston, Texas
Disclosure: Marcella Donaruma, MD, has disclosed no relevant financial relationships.
Editor
Olivia Wong, DO
Section Editor
Medscape Drugs & Diseases
New York, NY
Disclosure: Olivia Wong, DO, has disclosed no relevant financial relationships.
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References
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US Department of Justice, National Sex Offender Public Website (NSOPW). Raising awareness about sexual abuse: facts and statistics. Available at: https://www.nsopw.gov/. Accessed September 1, 2022.
Child Welfare Information Gateway. Definitions of Child Abuse and Neglect. Washington, DC: US Department of Health and Human Services, Children's Bureau; 2014. Available at: https://www.childwelfare.gov/pubPDFs/define.pdf. Accessed September 1, 2022.
US Department of Health & Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children's Bureau. Child Maltreatment 2015. Washington, DC: HHS; January 19, 2017. Available at: https://www.acf.hhs.gov/cb/resource/child-maltreatment-2015. Accessed September 1, 2022.
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