Continuing Education Activity
Sexual abuse of children is the involvement of children or adolescents in sexual activities that he or she does not fully comprehend and can include exhibitionism, fondling, oral-genital contact, and rectal or vaginal penetration. By adulthood, 26% of girls and 5% of boys experience sexual abuse. It is the healthcare provider's responsibility to advise the parents and enlist help from other medical specialists or child protective services. A variety of nonspecific presenting symptoms including but not limited to pain, anogenital bleeding, vaginal/urethral discharge, dysuria, urinary tract infection, sexualized behavior, and suicidality are possible. It is also common for the initial presentation to be suspected of sexual abuse in the absence of any physical symptoms. In such cases, it is important to be mindful that the assailant is often an individual that is close to the victim, such as a close relative or even the parent. All patients presenting within 72 hours of the suspected abuse or presenting with any concerning symptoms should be evaluated emergently, preferably by a sexual assault nurse examiner or child abuse pediatrician if available. This activity highlights the role of the interprofessional team in caring for these children that have experienced child sexual abuse and neglect.
- Review the factors that increase risk of child abuse.
- Describe the history and physical exam of a child with suspected abuse.
- Summarize the legal and medical management of child abuse
- Identify the role of the interprofessional team in caring for children that have experienced child sexual abuse and neglect.
Sexual abuse of children is the involvement of children or adolescents in sexual activities that he or she does not fully understand and can include exhibitionism, fondling, oral-genital contact, and rectal or vaginal penetration. By adulthood, 26% of girls and 5% of boys experience sexual abuse. It is the healthcare provider's responsibility to advise the parents and enlist help from other medical specialists or child protective services. A variety of nonspecific presenting symptoms including but not limited to pain, anogenital bleeding, vaginal/urethral discharge, dysuria, urinary tract infection, sexualized behavior, and suicidality are possible. It is also common for the initial presentation to be suspected sexual abuse in the absence of any physical symptoms. In such cases, it is important to be mindful that the assailant is often an individual that is close to the victim, such as a close relative or even the parent. All patients presenting within 72 hours of the suspected abuse or presenting with any concerning symptoms should be evaluated emergently, preferably by a sexual assault nurse examiner or child abuse pediatrician if available. In those presenting without symptoms and greater than 72 hours following the suspected abuse, specialized outpatient follow-up should be arranged for further evaluation and treatment. A good understanding of state-specific legislation regarding consent and treatment of minors is essential when treating victims of child sexual abuse.
Many factors increase the risk of child abuse, including individual, family, environmental, and social factors. Children that have a physical disability, mental disability, or other behavioral disorders are also at higher risk for abuse, especially if the family lacks the socio-economic resources to assist them. 
The following specific factors may increase the risk of abuse:
- Abused as children
- Attachment problems
- Chronic behavior problems
- Frequent moving
- Hostile environment
- Isolation from friends and family
- Low self-esteem
- Medical problems
- Mental or physical disability
- Mental health problems
- Nonbiological relationships
- Poor social network
- Punitive child-rearing styles
- Substance abuse
- Unrealistic expectations
- Young parents
- Acute environmental problems
- Substance abuse
- Perceived need for discipline/punishment
The fourth National Incidence Study on Child Abuse and Neglect found that emotional neglect among American children has significantly increased in recent years. The number of neglected children has increased by 101%, from 584,100 in 1993 to 1,173,800 in 2006. Females between the ages of 12 to 24 have been shown to be the demographic at highest risk of becoming victims of sexual assault and rape. Greater than 50% of the rapes targeting women happen during childhood, and between 5% and 25% of adults report being victims of child sexual abuse. Fewer than half of all sexual assaults are ever reported to the police. It is believed that many statistics on child sexual abuse and neglect vastly underestimate its incidence.
History and Physical
Child protection investigators conduct thorough interviews with victims of child sexual abuse, which typically serve as the best source of evidence for prosecutors. It is therefore important in the emergent setting for healthcare providers to limit their interview of the child to the pertinent medical history that addresses the relevant clinical presentation. Note the presence or absence of prior genitourinary trauma, urinary tract or anogenital infections, discharge, as well as toileting concerns.
Although the physical exam is often unremarkable in cases of child sexual abuse, a detailed exam is of tremendous value to ensure the present well-being of the child. Examiners should document the general appearance including the emotional state of the child. The skin, hair, and oropharynx should be carefully inspected for any signs of trauma. Asking the child about any painful areas is essential before palpation. It is not necessary to perform a speculum examination in the prepubertal patient. A thorough anogenital examination should be done with the patient in a careful positioning in the supine, frog-leg position. Fully visualize relevant female anatomy to include the labia majora, labia minora, posterior fourchette, clitoris, urethra, hymen, vaginal vault, and fossa navicularis. Any signs of trauma should be clearly documented. Accidental genital trauma can cause bruising or abrasions to the labia and/or posterior fourchette. However, the hymen is rarely injured as a result of accidental genital trauma due to its anatomical positioning. It is therefore essential to detail both the shape and integrity of the hymen. In male victims of child abuse, the physical exam should detail circumcision status as well as any visible signs of trauma. Both male and female patients should undergo an anal examination that describes the presence or absence of anal dilatation. Larger than 2 cm anal dilatation should raise suspicion for trauma in cases of suspected sexual abuse.
Between 2% and 12% of child sexual abuse victims have gonorrhea, and up to 10% have been shown to have chlamydia on initial presentation. As such, it is imperative to test for sexually transmitted infections in the following high-risk situations: patient at high risk for or has sexually transmitted infection (STI), sibling with STI, or parents or patient request testing. A urine specimen should be sent for nucleic acid amplification technique testing for gonorrhea and chlamydia, and culture should be used to confirm positive test results. Pediatric patients do not typically have vesicles or ulcerations; however, if present they should be swabbed for viral studies. Guidelines currently recommend forensic evidence collection within 24 hours of sexual contact for prepubescent patients and 72 hours in older adolescents. Some locations have extended the timeframe for evidence collection to 5 to 7 days. Forensic evidence collection kits vary across jurisdictions, and care must be taken to package and label evidence to preserve the chain-of-evidence properly. The Woods light may be a useful adjunct for specimen collection. Clothing including underwear worn at the time of abuse should be placed in a sealed paper bag.
Treatment / Management
An efficient initial assessment is essential to ensure reliable outcomes for the patient and families affected by child sexual abuse. Involving relevant specialists including physicians, nurses, social workers, and mental health professionals is key to providing optimal therapeutic treatment. Sexually transmitted infection and pregnancy prophylaxis should be considered as part of the management for older female and adolescent patients. Otherwise, specific treatment should be based on the individual clinical presentation and relevant findings. In emergent settings, it is important that all victims of child sexual abuse have a medical and psychological follow-up in place.
- Innocently acquired infection during sexual abuse
- Lower genitourinary trauma
- Perianal streptococcal infections
Child sexual abuse can have lifelong effects on both physical and mental health and well-being. Adolescents are at increased risk for a number of conditions as they enter adulthood including anxiety, depression, low self-esteem, hospitalization for mental health disorders, social phobias, and post-traumatic stress disorder. Additionally, victims of child sexual abuse are at a higher risk of becoming victims of intimate partner violence as well as sexual assault in adulthood. Chronic medical illnesses such as irritable bowel syndrome, fibromyalgia, obesity, and sexually transmitted infections also are more prevalent in adult survivors of child sexual abuse. Studies have revealed child sexual abuse survivors to be more prone to addiction to tobacco, alcohol, and illicit drugs.
Pearls and Other Issues
The history from the child remains the single best criterion for diagnosing suspected sexual abuse. Research has shown that healthcare professionals tend to over-rely on the physical exam, which is often unremarkable in cases of child sexual abuse. A physician with reasonable suspicion that abuse or neglect of a child has or might occur is legally obligated to report to child welfare authorities in their respective jurisdiction.
Enhancing Healthcare Team Outcomes
All healthcare workers including nurse practitioners have a legal and moral duty to report child abuse. In all cases, suspicion for physical abuse mandates a report to child protective services and/or law enforcement. The provider does not need to be certain that abuse has occurred, rather they should report when they are suspicious that abuse has occurred or will occur. Consultation with specialists or a child maltreatment team can be helpful in guiding the evaluation and response.