Education Gaps
1. Clinicians should be aware that, in most cases, sexual abuse of a
child is distinctly different from adult sexual assault. Usually there is
no physical evidence of the abuse and delayed disclosure is
common.
2. Developmental and behavioral histories are important components
of a medical history for a sexual abuse diagnosis. Clinicians must
be aware of normal sexual behaviors in children. The child’s
developmental level also informs the approach to evaluation,
including how much information can be obtained directly from the
child.
Child sexual abuse is one of the most challenging forms Although sexual abuse may appear to many to be a new
of child maltreatment encountered by pediatric clinicians. phenomenon, it has a long, dark history. The abuse of
It is a highly emotional topic in our society, and although children has been a part of the history of all cultures for
the legal and medical definitions appear to be relatively millennia. Reports from England and France in the 18th
straightforward, it is very difficult to operationalize them and 19th centuries leave a clear record that children were
in real-life circumstances. Social contexts affect awareness experiencing sexual abuse with some frequency. It was not
and cultural norms. High-profile cases with sports figures until the 1970s that child welfare agencies and other pro-
and clergy as well as the spread of the Internet, social fessionals increasingly recognized the breadth and conse-
media, and access to sexualized imagery have raised quences of sexual abuse in all of its forms. (4)(5)
awareness of this phenomenon but also added to its In 2014, there were an estimated 702,000 substantiated
complexity. (1) Parents look to pediatric clinicians for victims of child maltreatment, of whom 8.2% were victims of
support and prevention messaging. Societal factors can sexual abuse. (6) Prevalence data vary, depending on the pop-
also influence the interpretation of sexual behaviors, mak- ulation, abuse definitions, and survey design. Recent estimates
ing it difficult to determine what is normal or may be an note a rate of non-peer-related childhood sexual abuse at 11%
indicator of abuse. In addition, the gathering of informa- for females and 2% for males. (7) When peer and stranger
tion concerning the event(s) can be difficult, and the assaults are included in questionnaires, the rates increase,
physical evidence for sexual abuse can be absent or unclear, especially during the period of adolescence. (7) Children are
making a definitive statement that abuse has occurred more likely to be abused by a person they know than by a
difficult to accomplish. One key concept is vital: child stranger. (6)
sexual abuse is distinctly different in most circumstan-
ces from the acute sexual assault of an adolescent or adult
patient. Knowledge of the unique features of this type of PSYCHOLOGICAL ENVIRONMENT
maltreatment informs the approach to evaluation and
The psychological environment in which child sexual abuse
management. A 2013 American Academy of Pediatrics
occurs is influenced by the victim’s age, developmental
Clinical Report “The Evaluation of Children in the Primary
level, and relationship with the perpetrator. Preschool chil-
Care Setting When Sexual Abuse Is Suspected” is a valu-
dren have limited communication skills, which makes it
able resource. (2)
hard for the child to articulate his or her distress. Adolescent
girls are at higher risk than boys. (7) Adolescents seek
independence, but at the same time want to be accepted
DEFINITIONS
by others and experiment with new relationships and ways
Sexual abuse occurs when a child or youth is engaged in of interacting with others. As a result, they may place
sexual activities that are developmentally inappropriate themselves at risk of being sexually exploited, often without
and for which the child is emotionally or physically unpre- taking into consideration the consequences of their behav-
pared. (3) It involves the sexual gratification of an adult with ior. Developmentally disabled individuals are at particularly
little regard to cultural taboos or the needs and the develop- high risk for sexual abuse due to their physical or cognitive
mental level of the child. Moreover, it can combine a variety limitations. (8)
of forms of abuse, including physical and psychological ab- Children of single parents and those living in homes
use, both of which can have profoundly disturbing effects on with other psychosocial stressors appear to be at greater
the developing child or youth. Sexual abuse can be divided risk. (9) Children living in families where there is parental
broadly into 2 forms: contact and noncontact abuse. Non- conflict or a poor relationship between the child and parent
contact abuse involves exposing the child to sexual acts that are also considered at risk. (10) Nonoffending caretakers
he or she cannot comprehend. It includes exposure to or may be complicit or deny that abuse is taking place. (11) Con-
inclusion in pornography. It also includes exhibitionism by versely, families may fear the social ramifications if abuse
which the child is exposed to inappropriate sexualized is revealed. Importantly, clinicians must remember that
content. (4) Contact abuse can be divided into acts involv- there is no association between sexual abuse and ethnicity
ing nonpenetration, such as touching and fondling or or socioeconomic status. (12)
masturbation. The other forms of contact abuse involve Children are curious, seek attention and affection, and
penetration of the vagina, mouth, or anus. trust authority. There is a disparity in power between a child
Infancy Oral gratification, penile erections with bladder and bowel distention, genital self-stimulation in both genders
by 18 months.
2-3 years Gender identification, enjoy displaying nude body.
3-6 years Display sexual behavior and understand gender differences; masturbation is common. Like to touch bodies,
may include genitals and breasts of parents. Child identifies with parent of same sex.
6-7 years Still interested in sexuality, but overt behaviors are diminished. Remain curious about sex; use “dirty” words but
are more modest than younger children. Learn from peers.
Puberty/adolescence Display fewer family-related sexual behaviors and more interest in peers.
No single behavior is associated absolutely with sexual the child’s medical needs. The medical history should
abuse, but there is a strong suggestion of association include all standard components, including any seem-
between certain sexual behaviors and sexual abuse (Table ingly unrelated past history, because children may have
2). Children with a history of abuse or exposure to inap- other unidentified medical issues. The basis for concerns
propriately sexualized material tend to display behaviors of sexual abuse likely are provided by the caregiver but
that are imitative of adult sexual behavior. (27) Sexual could be supplemented by information from law enforce-
behavior is also related to a child’s family context. Family ment or social services. The type, timing, and chronicity
nudity is related to greater sexual behavior across all ages. of abuse inform testing and treatment recommendations.
(28) In general, sexually abused children exhibit a greater Review of systems should identify any genitourinary or
frequency of age-inappropriate sexual behaviors than either gastrointestinal symptoms that may be relevant, such as
normative or psychiatric outpatient samples. (28) More sex- dysuria, discharge, enuresis, encopresis, genital pain, or
ual behavior is seen in children with medical evidence of bleeding, or any somatic complaints that could be asso-
sexual abuse or a history of penetrative abuse, abuse by an ciated with abuse. Numerous medical signs and symp-
immediate family member, abuse by more than 1 perpetra- toms have been associated with sexual abuse. In several
tor, or abuse over a long period of time. series, symptoms mimicking urinary tract infections were
Of note, abnormal sexual behaviors may not always be commonly seen in children with substantiated reports of
attributed to the experience of sexual abuse. (29) However, abuse. (30) However, as with behaviors, many signs and
when present, they warrant an evaluation. The evaluator symptoms are not specific for abuse and can be seen in
should consider psychological stressors (emotional abuse, children who have not been abused. (29)(31) A detailed
physical abuse, parental separation) and family dysfunction family and social history can help to identify other risk
as alternative causes of the behavior. Children who are factors.
inappropriately exposed to sexualized material may also The physical examination should be explained in ad-
act out the behaviors or in response to what that they have vance to the child and caregiver, describing the genital
observed (eg, television, Internet, printed images, social
media, sexual violence). If, after such an evaluation, con-
cerns about abuse persist, a report to authorities should be
TABLE 2. Abnormal Sexual Behavior
considered and medical and behavioral health evaluations
should be obtained. (2) • Puts mouth on sex parts. • Makes sexual sounds.
• Asks to engage in sex acts. • Engages in kissing with the
TAKING A HISTORY tongue.
• Masturbates with object. • Undresses other people.
The medical history guides evaluation and treatment as well
• Inserts objects in vagina/anus. • Asks to watch explicit
as the subsequent report to authorities. In cases for which
television.
some information has already been gathered by other in-
• Imitates sexual intercourse. • Imitates sexual behavior
vestigators, the clinician may not need to obtain additional with dolls.
information, unless there are missing details relevant to
Along with any other injury or signs of abuse, the much labial separation so as to cause an iatrogenic dehis-
examiner should document the child’s Sexual Maturity cence in the area of the posterior fourchette.
Rating stage and provide a full description of the genital The hymen, a ring of tissue that surrounds the vaginal
and anal anatomy. Working knowledge of basic anatomy opening (Fig 4), is recessed and less readily visible. In the
(Figs 1 and 2), normal variants, and findings that may be absence of a major pelvic deformity, all females are born
confused with sexual abuse trauma is required. If photo- with a hymen. The misconception that the hymen tissue
graphic documentation is not available, a body diagram with completely covers the vaginal opening until it is “broken”
genital views may be a helpful addition to the chart. To see with first intercourse is still prevalent and even reinforced
the entirety of the external female genital anatomy, gentle in the lay culture. However, complete obstruction of the vag-
labial separation with downward and outward traction is inal canal by a hymen without an opening is an abnormal
usually needed for the examination (Fig 3). This can gen- variant that is known as an imperforate hymen. The condition
erally be accomplished with minimal discomfort to the may require surgical intervention at the onset of menstruation.
patient. The examiner should be careful not to apply too There is wide variation in the normal configuration of the
hymen (Figs 5 and 6). The tissue can be loose and folded
upon itself, resulting in a bunched or redundant appear-
ance. This is the most common configuration among in-
fants and adolescents. Children younger than age 3 years
typically have a circular or annular hymen. During the tod-
dler years, hymens may take on a half moon or crescentic
appearance. Occasionally, the hymen has a very small open-
ing (microperforate). A band of tissue that stretches across
the hymenal opening is a septum, and a hymen with this
feature is described as septate.
Before puberty, the hymen is very thin and can be almost
transparent. With puberty comes an increase in estrogen
and a subsequent increase in the hymen’s thickness and
ability to stretch, which explains why there is not necessarily
injury to the hymen with penetration of the vaginal orifice.
(42) A cotton swab may be used to help delineate folded-over
edges of an estrogenized hymen. (Such examination should
Figure 2. Female anatomy. Finkel M. Physical examination. In: Finkel MA,
Giardino AP, eds. Medical Evaluation of Child Sexual Abuse: A Practical be avoided in a prepubertal child because any contact with
Guide. 3rd ed. Elk Grove Village, IL: American Academy of Pediatrics;
the fragile hymen tissue before it is fully estrogenized can be
2009:59. Copyright 2009 American Academy of Pediatrics.
Reproduced with permission. painful.) Alternatively, a drop of clean saline can help “float”
the edges of the hymen and make identification easier. Figure 6. Thick, estrogenized adolescent hymen. Kristine Fortin and
Normal variations in the hymen edge can be confused with Carole Jenny. Pediatrics in Review. 2012;33:19-32. 2012 by American
Academy of Pediatrics. Reproduced with permission.
healed trauma. (43) The diagnosis of healed injuries, indic-
ative of penetrating trauma, is best left to experienced ex-
aminers due to the challenges in differentiating between
reality, most children with a proven history of sexual abuse
normal variants. Any question about the significance of
(based on perpetrator confession) have normal findings on
findings should prompt referral to a specialist.
genital examination for many reasons. (24)(34) In many
Acute injuries can include abrasions, contusions, and
situations, the type of sexual contact is not injurious, such
commonly lacerations through the hymen. Injuries can
as rubbing the genitals outside of clothing or exposing
heal quickly, within days. (44) In describing any physical
the child to pornography. Other contact, such as fondling,
finding, it is common to use a “face of the clock” orien-
may cause minor irritation or a superficial injury that heals
tation. For example, with the child in the supine position, a
quickly. (44) Because delayed disclosures are common,
finding may be noted at the “3 o’clock position” of the
some children do not receive timely medical examinations,
hymen.
allowing more serious injuries the time to heal completely.
A common misconception among families, profes-
sionals, and even medical clinicians is that sexual abuse
can be diagnosed based on physical examination alone. In ANOGENITAL FINDINGS
Neisseria gonorrhoeae Swabs of the posterior pharynx and anal mucosa in boys and girls, swabs Culture
of vulva in prepubertal girls or vaginal canal in postmenarchal girls,
swabs of the urethra in boys (if urethral discharge present, a meatal
specimen is adequate)
Vulvar secretions from prepubertal girls or vaginal secretions from NAATs
postmenarchal girls or urine sample from girls (no data for use with
urine from boys or extragenital sites for girls/boys)
Chlamydia trachomatis Swabs of anus in both boys and girls, swabs of vulva in prepubertal girls or Culture
vaginal canal in postmenarchal girls, a meatal specimen only if urethral
discharge in boys; pharyngeal specimens not indicated
Vaginal specimens or urine from girls/adolescent males (no data for use NAATs
with urine from boys or extragenital sites for girls/boys)
Trichomonas vaginalis Swabs of vulvar or vaginal mucosa/secretion Culture wet mount
Bacterial vaginosis Swabs of vulvar or vaginal mucosa/secretion vaginal specimen Wet mount
Human immunodeficiency virus Serum Antibody
PCR
Syphilis Serum RPR
Hepatitis (A,B, and C) Serum Antibody
PCR
Herpes simplex virus Swab of lesion Culture
PCR
NAAT¼nucleic acid amplification test; PCR¼polymerase chain reaction; RPR¼rapid plasma reagin.
Baseline X X X X X
6 Weeks X X
3 Months X
6 Months X (if baseline antibody negative X (if baseline antibody negative X X X
and after immunization) and after immunization)
through different developmental stages. (59) Some children Studies have shown that belief by the mother (or at least
respond minimally; others may have more extreme reac- a protective adult caregiver) in a child’s disclosure is a pos-
tions. Very young children, who are more concrete in their itive mediator for a more favorable psychological outcome.
understanding of right and wrong, may cope well with little (11)(62) Children with abuse involving penetration, vio-
adverse effect, especially if contact is limited and not inju- lence, a close relationship with the perpetrator, multiple
rious and their caregiver is protective. offenders, of longer duration, or with more frequent
Variable lists of behaviors associated with abuse can be contact are usually at higher risk for negative impact.
found, many of which are nonspecific and can result from (63) Factors associated with greater distress include higher
other causes of emotional stress. Some of the more com- levels of cognitive functioning, children who blame them-
mon manifestations include psychiatric disturbances such selves or view their experiences as threatening, a dys-
as depression, anxiety, posttraumatic stress disorder, low functional family or lack of social support, other forms of
self-esteem, and sexual dysfunction. (58) Younger children abuse, and close relationship between the mother and the
may act out or have problems in school. They may appear offender. (64)
anxious or sad. A range of internalizing and externalizing Evidence-based mental health treatments are available.
behaviors can be observed in adolescents. Some respond When children are identified and appropriately referred,
with social withdrawal, aggression, self-mutilation, sub- good outcomes are possible for those with a history of sexual
stance abuse, school problems, truancy, promiscuity, (60) abuse. Therefore, it is essential to know about community
prostitution, and runaway behavior. Others develop dis- resources available for families. The National Child Trau-
torted body images leading to eating disorders. Still others matic Stress Network is an organization that offers helpful
may have suicidal ideation or attempts. Many describe a resources for professionals and families (http://www.nctsn.
sense of powerlessness, betrayal, and stigmatization. (61) org/). Long-term follow-up and monitoring of these patients
Hepatitis B Depends on vaccination status of victim, type of contact, and disease risk of offender
Gonorrhea Weight ‡45 kg Ceftriaxone 250 mg IM once
Weight <45 kg 25–50 mg/kg IM once, not to exceed 125 mg IM
Chlamydia Weight ‡45 kg Azithromycin 1 g PO once
Weight <45 kg Erythromycin base or ethylsuccinate 50 mg/kg/day PO divided into 4 doses
daily for 14 days
Trichomonas Weight ‡45 kg Metronidazole 2 g PO in a single dose OR tinidazole 2 g PO in a single dose
Weight <45 kg Metronidazole 15 mg/kg per day PO divided into 3 doses daily for 7 days,
not to exceed 2 g/day
IM¼intramuscularly; PO¼orally.
1. Child sexual abuse can be the most challenging form of child maltreatment. Which REQUIREMENTS: Learners
of the following scenarios is most reasonably considered to be an example of sexual can take Pediatrics in
abuse? Review quizzes and claim
A. A 4-year-old boy pinching his 4-year-old schoolmate on the penis during a scuffle. credit online only at:
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C. A 16-year-old boy holding the buttocks of his 15-year-old girlfriend as they kiss To successfully complete
consensually. 2017 Pediatrics in Review
D. A 22-year-old male babysitter showering in the nude with a 10-year-old girl in his articles for AMA PRA
charge. Category 1 CreditTM, learners
E. Two 6-year-old children playing “doctor” and examining each other’s genitalia. must demonstrate a
2. An 8-year-old boy discloses to his mother that an adult male babysitter has touched him in minimum performance
the genital area on multiple occasions. The child presents to the primary care physician’s level of 60% or higher on
office for evaluation. What critical principle should be followed when initially interviewing this assessment, which
this child? measures achievement of
A. Ask directed questions to get a better description of the behaviors. the educational purpose
B. Ask open-ended questions so as not to suggest an answer. and/or objectives of this
C. Take a skeptical stance to avoid a false report. activity. If you score less
D. The history should be obtained from the mother alone to avoid traumatizing the than 60% on the
child. assessment, you will be
E. The interview should be in depth, thorough, and explore all the details of the given additional
alleged assault. opportunities to answer
questions until an overall
3. A 10-year-old girl discloses to her mother that her stepfather, who lives with them,
60% or greater score is
visits her room frequently at night and gets into the bed with her. The most
achieved.
recent incident was 2 weeks ago. She states that he removed her clothes and his
and “rubbed” his genitalia against hers. The mother calls her local pediatrician
and asks for advice. What is the best next step in the management of this This journal-based CME
child? activity is available through
A. Tell the mother to confront the stepfather and demand answers. Dec. 31, 2019, however,
B. The child should be evaluated in an emergency department credit will be recorded in
immediately. the year in which the
C. The child should be interviewed in a Child Advocacy Center within learner completes the quiz.
1 week.
D. The child should be seen by the primary care physician within 2 days.
E. Wait for the next incident and then collect forensic evidence.
4. You have just performed a thorough physical examination of an 11-year-old girl for
possible sexual abuse. The child gives a very clear history of genital-to-genital contact with
2017 Pediatrics in Review
a 22-year-old uncle, including vaginal penetration. The incident occurred 3 weeks ago.
now is approved for a total
The genitourinary examination shows no bruises, tears, discharge, or obvious
of 30 Maintenance of
damage to the hymen. You have no physical examination findings to corroborate the
Certification (MOC) Part 2
child’s story. The investigating police officer asks why there are no physical findings
credits by the American
to prove the allegations. Which of the following is the best response to this common
Board of Pediatrics through
question?
the AAP MOC Portfolio
A. A negative physical examination proves that the assault never occurred. Program. Complete the first
B. If there was no struggle from the girl, there will be no trauma. 10 issues or a total of 30
C. In most cases of proven sexual assault, the genital examination yields normal quizzes of journal CME
results. credits, achieve a 60%
D. Prepubertal children commonly lie about sexual assaults. passing score on each, and
E. The assault must have occurred at a much earlier date than stated. start claiming MOC credits
as early as October 2017.
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