Monica M. Metzdorf, MD
Julia S. Barthold, MD, FACS
BASICS
DESCRIPTION
• Sexual activity involving a child or a minor
• Spectrum of pediatric sexual abuse includes intercourse, fondling, pornography, and exhibitionism
EPIDEMIOLOGY
Incidence
∼1% of children sexually abused each year
Prevalence
• 12–25% of girls and 8–10% of boys have been sexually abused by age 18 (12–40% overall)
• Of girls reporting abuse (1)
– 65% reported abuse occurred more than once
– 57% reported that abuser was family member
– 53% reported that the abuse occurred at home
RISK FACTORS
• Occurs in all socioeconomic levels
• Increased risk with:
– Parents who were abused
– Poverty
– Drug or alcohol abuse
– Teen parents
– Parental violence
– Mental illness
– Multiple child caretakers
PATHOPHYSIOLOGY
• American Academy of Pediatrics definition (2):
– Child sexual abuse is the engaging of a child in sexual activities that the child cannot comprehend, for which the child is developmentally unprepared and cannot give informed consent, and that violate the social taboos of society.
– Children cannot consent to any sexual activity, but note that the legal age of consent may vary on a state-by-state basis.
ASSOCIATED CONDITIONS
• Physical abuse
• Emotional abuse
GENERAL PREVENTION
• Education
• Social services
DIAGNOSIS
ALERT
Findings in the evaluation of children with straddle injuries to the external genitalia that should raise concern for sexual abuse include:
• Presence of other nonurogenital trauma.
• Patient <9 mo.
• Perianal, rectal, injury without history of penetrating trauma.
• Findings of more extensive or severe trauma.
• Lack of correlation between reported history and physical findings.
HISTORY
• Child may make a statement of abuse, or abuse is witnessed
• Child brought by law enforcement/social services for evaluation for possible abuse as part of investigation
• Caregiver suspects child may have been abused
• Suspicious findings on routine exam
• Suspicious complaints: Rectal or vaginal bleeding or discharge, especially in prepubertal child
• Presenting symptoms may be general and nonspecific:
– Sleep disturbances
– Abdominal pain, enuresis, encopresis
– Dysuria
• Consider evaluation by trained forensic interviewer
• Avoid leading questions or showing strong emotions/shock: Use “tell me more” or “and then what happened” approach?”
• Parent/caregiver should be interviewed separately to avoid influences/distraction
• Questions asked and verbatim answers in quotation marks should be documented as accurately as possible
PHYSICAL EXAM
• Be familiar with the normal appearance of the prepubertal introitus and hymen (image).
• Do not force exam on uncooperative children.
• Do not use speculum in prepubertal child.
• Do not touch hymen with swabs or other objects.
• Do not perform a digital rectal exam (DRE).
• Educate caretaker and patient that most sexually abused children have a normal physical exam. Absence of physical findings does not exclude abuse.
• Perform complete physical exam including skin, oropharynx, genitalia, and anal area.
• Use frog-leg position with gentle labial traction to visualize female anatomy.
• Consider exam in chest-knee position to confirm suspected abnormalities.
• Consult specialists as appropriate.
• Document thoroughly detailed exam findings and descriptions, using drawings or photos if feasible.
• When severe rectal injury suspected, persistent bleeding or full thickness lacerations, consider exam under anesthesia.
• Exam findings of concern:
– Abrasions or bruising of genitalia.
– Acute or healed tear in posterior aspect of hymen.
– A markedly decreased amount of hymenal tissue.
– Injury or scarring of posterior fourchette, fossa navicularis, or hymen.
– Anal bruising or lacerations.
DIAGNOSTIC TESTS & INTERPRETATION
Lab
• Culture for gonorrhea and Chlamydia.
• Vesicles should be tested for HSV.
• All postmenarchal females should have pregnancy test.
• Presence of semen, sperm, or acid phosphatase; positive culture for gonorrhea or Chlamydia, or a positive test for syphilis or HIV (if prenatal transmission excluded for the STDs) makes sexual abuse a near medical certainty.
Imaging
None needed unless more extensive physical abuse is suspected
Diagnostic Procedures/Surgery
Consider exam under anesthesia
DIFFERENTIAL DIAGNOSIS
• Accidental trauma (straddle injuries, toilet-lid injury to penis, masturbation injuries)
• Anal fissure
• Hemangioma
• Hematochezia
• Henoch–Schönlein purpura
• Lichen planus
• Nonspecific vaginitis
• Normal anatomic variants (perihymenal bands, prominent linea vestibularis)
• Physical abuse
• Poor hygiene
• Urethral prolapse
• Vaginitis
• Vaginal foreign body
TREATMENT
GENERAL MEASURES
• Mental health evaluation is essential (3)
• Acute evaluation and treatment of injuries
MEDICATION
First Line
• Varies with presentation
– Pain medication as appropriate
– Postexposure prophylaxis (PEP) for prevention of pregnancy and STDs should be offered to adolescents
– PEP generally not indicated for prepubertal children
Second Line
N/A
SURGERY/OTHER PROCEDURES
• Consider exam under anesthesia
• Depends upon findings/injuries
ADDITIONAL TREATMENT
Radiation Therapy
N/A
Additional Therapies
N/A
Complementary & Alternative Therapies
N/A
ONGOING CARE
PROGNOSIS
• Need for mental health support, especially in:
– Patients reporting suicidal or self-injurious thoughts
– More intrusive forms of assault
– More violent assaults
– Longer period of molestation
– Closer relationship of perpetrator to victim
COMPLICATIONS
• Psychological
– Eating disorders
– Depression and anxiety
Suicidal behaviors
Self-injury
– Posttraumatic stress disorder
– Sexual dysfunction
• Pregnancy
• STDs/STI’s
FOLLOW-UP
Patient Monitoring
• Follow-up exams for healing of injuries
• Evaluation for development of STDs/STIs
• Evaluation for development of pregnancy and discussion of this possibility with the postpubertal child
• Emotional support/therapy
Patient Resources
• Darkness to Light: National Resources Related to Child Sexual Abuse. http://www.d2l.org/site/c.4dICIJOkGcISE/b.6069289/
• Safehorizon. http://www.safehorizon.org/?gclid=CL-kg7OT5LkCFVGi4AodQXwA6w
• The National Child Traumatic Stress. Network http://www.nctsn.org/trauma-types/sexual-abuse
REFERENCES
1. Schoen C, Karen Davis, Karen Scott Collins, et al. The Commonwealth Fund survey of the health of adolescent girls. New York, NY: Commonwealth Fund; 1997. Available at: http://www.commonwealthfund.org/∼/media/Files/Publications/Fund%20Report/1997/Nov/The%20Commonwealth%20Fund%20Survey%20of%20the%20Health%20of%20Adolescent%20Girls/Schoen_adolescentgirls%20pdf.pdf
2. American Academy of Pediatrics. Guidelines for the evaluation of sexual abuse of children: Subject review. American Academy of Pediatrics Committee on Child Abuse and Neglect. Pediatrics. 1999;103(1):186–191.
3. Adams J, Kaplan RA, Starling SP, et al. Guidelines for medical care of children who may have been sexually abused. J Pediatr Adolesc Gynecol. 2007;20(3):163–172.
ADDITIONAL READING
• Bernard D, Peters M, Makoroff K. The evaluation of suspected pediatric sexual abuse. Clin Pediatr Emerg Med. 2006;7:161–169.
• Buckingham ET, Daniolos P. Longitudinal outcomes for victims of child abuse. Curr Psychiatry Rep. 2013;15:342.
• Flaherty EG, Sege R. Barriers to physician identification and reporting of child abuse. Pediatr Ann. 2005;34:349–356.
• Kellogg N, American Academy of Pediatrics Committee on child abuse and neglect. The evaluation of sexual abuse in children. Pediatrics. 2005;116(2):506–512.
See Also (Topic, Algorithm, Media)
Sexual Abuse, Pediatric Image 
CODES
ICD9
• 995.53 Child sexual abuse
• V15.41 History of physical abuse
ICD10
• T74.22XA Child sexual abuse, confirmed, initial encounter
• T76.22XA Child sexual abuse, suspected, initial encounter
• Z62.810 Personal history of physical and sexual abuse in childhood
CLINICAL/SURGICAL PEARLS
• Pediatric providers should remain alert to signs and symptoms that suggest the possibility of sexual abuse.
• The clinician is obligated to report any suspected case of childhood sexual abuse.
• Sensitivity during the history and exam and providing the victim access to psychological and social work support are key factors in the case of children who have been sexually abused.