Medical management of pediatric sexual abuse

Pediatric sexual abuse is increasingly recognized as a major social and medical problem, yet the topic has been addressed in only a very limited fashion within most undergraduate medical programs. Many physicians are reluctant to initiate involvement with these cases, perhaps because of their relative lack of experience or because they know legal proceedings may follow.

Most young victims of sexual abuse have no physical signs of trauma or infection, and require very little in the way of active intervention. They and their families do, however, need a patient and understanding individual to listen to their concerns and offer appropriate reassurance. The guiding principle throughout the evaluation should remain “do no harm.” In addition to identifying the medical and psychological needs of the patient, a good assessment may help protect the child from further abuse. However, if misinterpretation of clinical findings occurs, there may be significant adverse social and legal consequences for the child, the family, and the alleged abuser.

The physician should begin by assessing the urgency of the situation and determining where and when the full evaluation of the problem should be carried out. If possible, the evaluation is best done in the quieter, more controlled environment of a clinic rather than the busy, chaotic emergency department. Immediate assessments are generally only necessary if the abuse has been recent (<24 hours), the child has genital bleeding, or there are other concerns for occult trauma.[1,2]

History

One of the most important steps in initiating an assessment for pediatric sexual abuse is to obtain as much of the history as possible from ancillary personnel (parents or guardians, police, social workers). Unnecessary repetition with family members is best avoided.

The child should not be present during this interview. If the child has not yet undergone a proper forensic interview by police or government officials, then ask no questions of the child, but carefully record any spontaneous, relevant comments the child makes. Indeed, often the most critical component of a sexual abuse investigation is the statement the child is able to give to forensic interviewers.

One of the obvious difficulties in interpreting a young child’s disclosure of abuse is their often limited vocabulary of proper anatomical terms and their concept of what is meant by “inside the vagina.” Clarification of the child’s disclosure is not necessary though, as the disclosure serves merely as a guide to treatment considerations and collection of forensic evidence. Pertinent historical factors that have been shown to be positive predictors of abnormal genital findings include time since the assault (<24 hours) and the presence of blood afterward.[1,2]

It is important that the parent or guardian understand the concept of separate medical and forensic investigations. Establishing who is responsible for these separate investigations from the outset and how their roles may at times overlap is useful in maintaining a therapeutic relationship with the family.

Physical exam

Although much emphasis is often placed on the physical examination, it remains only one part of the overall investigation. Many kinds of inappropriate sexual touching leave no physical signs. Indeed, it has been clearly shown that most pediatric victims of sexual abuse have normal examinations.[1-3] This fact should be emphasized with parents as well as investigative personnel.

It is imperative that the physician understands the normal anatomy of both the male and female genitalia, and appreciates the range of normal and abnormal. As many physicians do not include examination of the genitalia in their well child checkups, the assessment of victims of alleged sexual abuse may be approached with significant trepidation.

In general, prepubescent children should have a parent or a reassuring adult who is known to them present during the examination. The adult and older child should be told what the exam will entail in advance. The younger child may be prompted on what you will be doing as the exam progresses. Often simple, age-appropriate questions oriented as a review of systems will guide the child through the various bodily parts being examined. Frequent reassurance and subtle distraction techniques are often helpful. Do not force the examination. The child must be relatively cooperative and relaxed to permit proper visualization and evaluation of the genital structures. If the child’s cooperation cannot be maintained, then the physician must decide if the examination is medically necessary. If so, then examination under general anesthesia or with procedural sedation may be indicated. Otherwise, the assessment should be rebooked and the child reassured.

A complete physical examination should be carried out with comment on any unusual emotional state or demeanor. Complete examination of all areas of the skin will ensure no areas of bruising or petechiae are missed.

Examination of the genitalia is usually achieved with inspection only. With very young children this may be carried out in the context of a diaper change. Toddler-age children are often the most challenging, with inspection sometimes best done on the parent’s lap. With young girls, the examination is generally performed in the frog-leg position first. If any abnormalities are suspected then the child should be examined in the prone knee-chest position, allowing gravity to pull the margins of the hymen down into clear view. Examination in the knee-chest position should not be pursued if the child shows any reluctance or discomfort.

A systematic approach to examining the various genital structures is helpful (Figure 1). The labia majora, labia minora, and posterior fourchette are generally seen first. With gentle separation or traction, the clitoris, urethra, fossa navicularis, hymen, and vaginal vault may come into view. The recessed and relatively protected position of these latter structures is an important point and one that often needs review when testifying in court.

When describing the hymen, one should comment on its general shape (annular, crescentic, septate, or cribriform) (Figure 2) and the integrity of the hymen margin. One should comment on the presence of lacerations, notches, bumps or unusual vascular patterns. In describing any abnormalities, it helps to relate their position to the numbers on the face of a clock, with the 12 o’clock position being anterior/superior and the 6 o’clock position being posterior/inferior. When describing the thickness of the hymen, refer to the distance from outside the vagina to inside the vagina. When describing the width of the hymen, refer to the distance from the inner rim of the hymen to where it attaches on the muscular wall of the vagina or fossa navicularis (Figure 3). The hymen is generally widest at the 6 o’clock position. Although the labia are often injured with accidental trauma, hymen injuries are rarely the result of unintentional trauma.[4] Colposcope examination should be carried out if available and if the examiner is comfortable with this technique.

Anal examination entails visualization only and should not include a digital rectal exam. Assessment may be performed with the child lying on his or her side, in prone knee-chest position or supine with the knees tucked into the chest. In many cases, the anal findings will be nonspecific, as it is quite uncommon to have abnormal anal findings, even with legally confirmed cases of sexual abuse.[1,4,5] The physician should note any evidence of bruising, fissuring, funneling, or gaping. Some children will exhibit minor anal dilatation if left in the knee-chest position long enough or if there is stool present in the rectal vault. Anal dilatation of greater than 2 cm, however, would be of concern. In young children suspected of having experienced either anal or vaginal penetration, a careful abdominal assessment is needed to rule out occasionally subtle bowel or vaginal perforation.

Fluorescent light examination should be carried out if there is the possibility of isolating seminal fluid. This may guide the examiner to areas that should be swabbed for forensic evidence.

Investigations

The investigations carried out following an alleged sexual assault can be divided into two broad groups: medical and forensic. What exactly is collected will depend on both the history and the physical exam.

Forensic evidence is not collected routinely, as pediatric sexual abuse differs significantly from adolescent or adult assaults. In a recent study of prepubescent victims of sexual assault, forensic evidence was recovered in only 24.9% of cases.[2] Over 90% of children with positive evidence were seen within 24 hours of the assault. The majority of evidence was found on clothing and linens, a fact that may be helpful to police and other investigative personnel. No swabs taken from the child’s body were positive for sperm/semen after 9 hours.

Evidence should be collected from the anus or vaginal area if there has been disclosure of genital contact with these areas in the previous 24 hours. The child’s underwear should be placed in a paper bag and sealed by the nurse or examiner. Suspicious areas should be wiped with a swab moistened with sterile water and slides made for sperm analysis. Swabs for analysis of protein 30 (a protein present in semen) must be air dried and placed in an open-ended transport tube. Swabs for salivary protein analysis may be collected from any areas suspicious for bites or suction injuries. These swabs are also air dried and placed in open-ended transport tubes. All forensic materials should be properly labeled and packaged, with appropriate chain-of-evidence documentation. Specimens not immediately handed over to police must be stored in locked cupboards or fridges.

The clinical picture also dictates the necessity for any medical investigations. These tests may include swabs for gonorrhea and chlamydia, as well as serology for HIV, hepatitis B and C, and syphilis. Immediate collection of these tests following an acute assault is generally recommended. However, if an asymptomatic child presents after a non acute assault, screening for sexually transmitted diseases (STDs) is not indicated. The overall prevalence of STDs in pediatric victims of sexual assault is extremely low (1% to 5%). HIV screening is suggested if the offender is known to be HIV-positive or in a high-risk group, if there is significant parental or patient anxiety, or if the child lives in an area of high HIV prevalence.

Treatment

Treatment begins at first contact with the family. A timely, thorough, and reassuring approach to the assessment often alleviates significant anxiety in family members and, thus, the child as well. In up to 80% of prepubescent children seen for alleged sexual assault, the findings are normal.[1-3] Any positive findings should be explained in simple terms, emphasizing the relatively insignificant impact they generally have on the child’s future health and development.

Injuries should be treated as needed. Lacerations extending into the vagina are not common and should be assessed by a gynecologist, as the full extent of the laceration must be determined. The vaginal wall is extremely thin in the prepubescent child and may be perforated more easily than in the older child.

STD prophylaxis is rarely necessary, but should be offered in cases of oral-genital, genital-genital, or anal-genital contact by the abuser. A single dose of azithromycin (12–15 mg/kg p.o.) may be advisable. Tetanus immunization status should be confirmed and updated if necessary. HIV prophylaxis is rarely indicated.

Report

A proper medicolegal report should be dictated and typed for future reference. The report should include the pertinent historical factors and who relayed them. A description of the physical findings and some comment as to whether they are consistent with the history provided is useful. It should be noted that a normal physical exam does not preclude the occurrence of abuse. Documentation of any tests performed should be included.

If the police or Ministry of Children and Family Development (MCFD) have not yet been involved, the physician should initiate involvement. In BC, health care providers are required by law to report any concern or suspicion that a child has experienced abuse to the MCFD. Ministry workers may or may not involve police from the outset, but it should be made clear when forensic evidence has been collected.

The parent or guardian should be informed that a written document will be prepared and should be advised of its general content. Police, social workers, or lawyers may request a copy of the report; however, appropriate release of information (ROI) forms should be completed and submitted before any confidential information is handed over.

Before the child’s discharge, the family should be advised of local crisis counseling services available to assist with issues of this nature.

Follow-up

The physician should ensure the child is seen within the next 1 to 2 weeks to reassess any injuries and evaluate the development of possible sequelae.

This follow-up also allows the physician to reassess the child’s emotional condition and to answer any further queries the parents or guardian may have. As most abusers of young children are known to the family before the assault, it is often very difficult for the parents or guardian. A sympathetic, nonjudgmental approach may assist significantly in reassuring them and allowing them to optimize their support of their child.

Summary

Although challenging and at times difficult, assessments of young children suspected of being sexually abused can be extremely reassuring for both patients and families. As most prepubescent victims of sexual assault will have a normal examination, the physician is frequently in the position of providing significant reassurance to a family in crisis. Although complex cases are best managed by a multidisciplinary team, relatively straightforward cases may be managed very well by pediatricians or family doctors who have an established relationship with the family.

Health care providers must be clear about their role within the larger investigative process, and it is vital that the physician remain focused on what is best for the patient. The physician must work cooperatively with other investigative team members, and may be helpful in providing guidance and education to police, social workers, and court personnel.

Optimal management of these difficult cases can have a significant positive and therapeutic impact on both the patient and family.

Competing interests
None declared.

Margaret Colbourne, MD, FRCPC

Dr Colbourne is a clinical assistant professor in the UBC Department of Pediatrics, a pediatric emergency medicine physician at BC’s Children’s Hospital, Vancouver, BC, and a pediatrician with the Child and Family Clinic (Child Protection Service Unit) at BC’s Children’s Hospital.