Tuesday, February 7, 2023

Child Sexual Abuse

Practice Essentials

Sexual activities imposed on children represent an abuse of the caregiver’s power over the child. The sequence of activities often progresses from noncontact to contact over a period of time during which the child’s trust in the caregiver is misused and betrayed.

Pediatricians are often in trusted relationships with patients and families and are in an ideal position to offer essential support to the child and family. Thus, pediatricians need to be knowledgeable about available community resources, such as consultants and referral centers for the evaluation and treatment of sexual maltreatment.

Signs and symptoms

In incidents of CSA, the interview with the child is typically the most valuable component of the medical evaluation; the elicited history is frequently the only diagnostic information that is uncovered.

Elements of the history include the following:

General approach that is developmentally sensitive (ie, age-appropriate)

Initial introduction with efforts to build up trust (including both child and caregiver)

Caregiver interview

Child interview, focusing on asking simply worded, open-ended, nonleading questions

Wrap-up and preparation for the physical examination

The general approach to the physical examination follows the standard head-to-toe approach. Elements of the examination include the following:

Determination of structures of interest – Mons pubis, labia majora and minora, clitoris, urethral meatus, hymen, posterior fourchette, and fossa navicularis

Choice of positioning for optimal exposure of prepubertal genital structures – Frog-leg supine position, knee-chest position, or left lateral decubitus position

Calming the child during examination

General observation and inspection of the anogenital area, looking for signs of injury or infection and noting the child’s emotional status

Visualization of the more recessed genital structures, using handheld magnification or colposcopy as necessary

Collection of specimens for sexually transmitted disease (STD) screening and forensic evidence collection

Evaluation of any observable findings – Although most individuals who have been sexually abused present with essentially normal examination findings, observable findings may include (1) those attributable to acute injury or (2) chronic findings that may be residual effects following repeated episodes of genital contact

The Muram diagnostic categorization system classifies prepubertal genital examination findings as follows:

Category I – Genitalia with no observable abnormalities

Category II – Nonspecific findings that are minimally suggestive of sexual abuse but also may be caused by other etiologies

Category III – Strongly suggestive findings that have a high likelihood of being caused by sexual abuse

Category IV – Definitive findings that have no possible cause other than sexual contact (eg, seminal products in a prepubertal female child’s vagina, the presence of a nonvertically transmitted gonorrhea or syphilis infection)

Another classification system, developed by Adams et al on the basis of the Muram approach combined with information from other components of the sexual abuse assessment, includes the following 8 categories of findings
:

Findings documented in newborns or commonly seen in nonabused children (ie, normal variants)

Findings commonly caused by other medical conditions

Findings with no expert consensus on interpretations with respect to sexual contact or trauma (formerly Indeterminate findings)

Findings diagnostic of trauma and/or sexual contact

Residual or healing injuries

Injuries of blunt force penetrating trauma

Infection that confirms mucosal contact with infected bodily secretions (ie, indicating that contact was most likely sexual)

Findings diagnostic of sexual contact (ie, pregnancy or sperm directly taken from a child’s body)

See Presentation for more detail.

Diagnosis

Cultures have traditionally been the criterion standard for cases of possible sexual abuse and are valuable from a forensic evidence standpoint.  Nucleic acid amplification testing (NAAT) has been used widely in the sexually active adolescent and adult populations secondary to its higher sensitivity, noninvasive sample collections, and its utility in testing for both Neisseria gonorrhoeae and Chlamydia trachomatis with one sample, and its lower cost compared to culture.
 NAATs can be used as an alternative to culture with vaginal specimens or urine from girls whereas culture remains the preferred method for urethral specimens or urine from boys and for extra-genital specimens for all children.

Gram stain of vaginal or anal discharge

Genital, anal, and pharyngeal culture for gonorrhea

Genital and anal culture for chlamydia

See above regarding NAAT (Chlamydia, N. gonorrhea)

Serology for syphilis

Culture by using Diamond’s or InPouch TV media (most specific method of diagnosing Trichomonas vaginalis)
  

Wet prep of vaginal discharge for Trichomonas vaginalis, other bacteria, candida, etc.

Culture of lesions for herpes virus

Serology for HIV (based on suspected risk)

Other tests that may be considered include the following:

Collection of forensic evidence via rape kit

Urine toxicology screen (if the abuse or assault was substance-facilitated)

See Workup for more detail.

Management

Medical treatment of CSA is guided by any conditions uncovered. Recommendations include the following:

Treat STDs with appropriate medications

In postmenarchal children, consider the possibility of pregnancy

Recognize the overriding need for emotional support and attention

When sexual abuse is seriously suspected or has been diagnosed, ensure that it is reported to the appropriate child protective services (CPS) agency

When sexual abuse is being considered, consider reporting it, depending on the perceived risk to the child

Keep well-documented medical records; legal proceedings may occur over long periods, and the health care provider cannot rely solely on memory

Mental health consultation is warranted to evaluate and treat acute stress reaction and, later, posttraumatic stress disorder (PTSD).

See Treatment and Medication for more detail.

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