Pediatrics

Sexual Abuse and Assault

OVERVIEW: What every practitioner should knowAre you sure your patient has sexual abuse and assault? What are the typical findings for this disease?

Definitions

Sexual Abuse: When 'a child is engaged in sexual activities that he or she cannot comprehend, for which he or she is developmentally unprepared and cannot give consent, and/or that violate the laws or taboos of society' (Kellogg et al 2006).

Sexual Assault: Any sexual act performed by one person upon another without consent, whether this is due to use of force, the threat of force, or the victim's inability to give consent. The inability to give consent may be due to a number of factors including intoxication and intellectual or developmental capacity.

'Acute Sexual Assault' is a phrase commonly used to describe sexual abuse that has occurred during the previous 72 hours, the acuity indicating the possible utility of postexposure prophylaxis for infections and pregnancy, as well as forensic evidence collection.

Epidemiology

The true incidence and prevalence of sexual abuse in childhood is difficult to determine, as most official statistics include only cases that come to the attention of authorities, and it is well-documented that many cases are never reported.

Prevalence studies have consistently identified that a substantial minority of adults in the United States, both women and men, were sexually abused as children. Rates have varied from approximately 5% to greater than 30% of adults in national samples.

Clinical Presentation

A child may present for evaluation after disclosing sexual abuse. The provider may obtain the information about this disclosure directly from the child, or from the child's caregiver. See the section 'Taking a History' for more information regarding how to proceed in this case.

A child may present for evaluation when there has not been a disclosure of sexual abuse, but the caregiver is concerned that sexual abuse may have occurred. This concern may be triggered by physical symptoms, behavioral concerns, disclosures of other children or adults, or interparental conflict.

Complaints that are nonspecific and about which the caregiver can be reassured:

  • Most cases of vulvovaginitis or generalized genital irritation and redness. Exceptions include cases involving genital bleeding or age-inappropriate discharge, such as purulent discharge in any child regardless of pubertal stage, or any significant discharge in a prepubertal child. 'It's red down there' is a common complaint among parents concerned about possible sexual abuse of their children, but this complaint carries no specificity for sexual abuse, and in the absence of other, more concerning history, requires no further evaluation for sexual abuse.

  • Genital injury, such as straddle injury, if a plausible history is provided

  • Most masturbation by young children, unless it is highly repetitive and perseverative despite redirection, or repeatedly occurs in front of others. Needless to say, masturbation among postpubertal children is developmentally normal.

  • Curiosity about bodies of other children or adults

  • Sexual exploratory behaviors that are mutual between similar-aged peers, i.e., mutual looking at and touching of body parts

Complaints that are potentially abnormal and warrant further evaluation for possible sexual abuse:

  • Unexplained anogenital bleeding or discharge

  • Developmentally inappropriate sexual behavior or language, including sexually aggressive behavior, sexual acts with significantly older or younger children, oral-genital contact, or sexualized behavior or language directed towards adults

  • Unsupervised contact between a child and a known perpetrator of sexual abuse, i.e., registered sex offenders

Evaluation Priorities

Evaluation, treatment, and protection of the child who has been sexually abused will involve many professionals from different disciplines – health care providers, child protective services (CPS), and law enforcement including police and prosecutors. Effort should be made to avoid repeated interviews and exams of the patient. Of course, providers should not hesitate to obtain sufficient information for adequate care and protection of the child.

Hopefully, many providers will have the ability to refer child victims of sexual abuse and assault to a clinic or center with a child abuse pediatrician, or other clinician specializing in performing these evaluations. All sexually abused children may potentially benefit from such an evaluation. Cases that may particularly benefit from early referral to a child abuse clinic include very young victims, children with acute or chronic injuries from their abuse, children who have or are suspected of having sexually transmitted infections or pregnancy, children who are psychiatrically or cognitively impaired, children who are already in the child welfare system, and children with unsupportive caregivers.

The first priority of any medical provider evaluating a child who has been sexually abused is the child's medical care and well-being, including evaluating for injury and infection, providing appropriate postexposure prophylaxis, and assessing mental health and referring to crisis care as appropriate.

The next evaluation priority is the safety of the child, including the safety of the home environment and the ability of the child's caregiver to support and protect the child. CPS is an important resource in making these assessments and in safety planning.

The forensic or criminal aspect of responding to child sexual abuse is indeed important, but in the clinical setting, the medical care and safety of the child must come first. Reporting to and working with police are discussed in the 'Reporting' section.

Taking a History in Cases of Suspected Sexual Abuse

When taking a history during a medical visit for child sexual abuse, it is extremely important to separate the child and the caregiver. The caregiver should not provide his or her history within the child's hearing, and the child should speak to the provider without the parent present. This is true for any verbal child, but is particularly important in young (preschool to early elementary school-aged) children, who are intrinsically suggestible. Doing otherwise can exert a strong effect on the quality of the information obtained at the medical visit, and subsequently, by any professionals who need to obtain information from the child about his or her abuse. Separating child and caregiver at these stressful times can cause trepidation, but if the provider is supportive and reassuring and treats this as a routine and necessary part of the evaluation, the caregiver will usually accept its necessity.

The provider's goals in taking a history of sexual abuse are several. The child's current symptoms that may be indicative of injury or infection, as well as the risk of injury or infection as indicated by the specific abuse history, should be assessed. The perpetrator's potential access to the patient, and the safety of the home environment, are also important to evaluate. The supportiveness of the parent or caregiver is also important to assess, as it is a crucial component of both the child's mental health and recovery from abuse, as well as maintenance of the child's safety.

Taking a history of sexual abuse from a child can be intimidating for the non-specialty provider. Young children have a strong need to please adults, and the very act of asking them questions in the manner one would question an adult can influence the answers they provide. Younger patients may also not clearly distinguish between what is real and what is make-believe. Detailed questioning of very young children (<6 years), or of children who have not disclosed sexual abuse and are being evaluated due to behavioral or environmental concerns, is best performed by providers with specialty training in this area. Of course, providers may need to obtain some minimal amount of information for diagnosis, treatment, and/or referral. Efforts should be made to obtain the information first from collateral sources; however, at times, the only source of this information will be the child.

When some questioning of the younger victim of child sexual abuse is required, it is important to use 'non-leading' questions. A 'leading' question is one that may suggest to the patient what answer he or she should provide, whether intentionally or otherwise. In particular, specifically naming the suspected offender ('Did daddy...') or suspected act (...touch your peepee?) should be avoided.

Leading: Did mommy hit you?

Nonleading: How did you get this (booboo/mark/injury)?

Children with nonspecific complaints or behaviors, such as genital irritation or age-normative exploratory behaviors, should not be asked 'did someone touch you there?' or 'who taught you that?'. It should not be assumed that anyone touched them or taught them these behaviors. Such questions can easily elicit affirmative answers from children because they feel compelled to offer an explanation, even if they do not have one themselves.

Some children may have difficulty discussing their abuse with the medical provider. If this is the case, it is better to defer questioning to a professional specializing in sexual abuse, rather than ask questions that may be inadvertently directive or leading.

Timing of Evaluation

Some children require urgent evaluation for sexual abuse and sexual assault. These include any of the following:

  • Patients whose most recent episode of abuse was within the previous 72 hours and may have left biological evidence (discussed under 'Forensic Evidence Collection') or caused infection or pregnancy risk

  • Patients who have bleeding or pain as a result of their assault

  • Patients with symptoms of potential sexually transmitted infections – genital discharge or itching, fever, pain

  • Suspected pregnancy as a result of abuse

  • Patients with a nonbelieving or unsupportive caregiver, who may therefore be unable or unwilling to protect the child

Patients who do not fulfill one of the above criteria may be seen by the local child abuse-trained medical provider at the provider's next available appointment, or at the primary care office's next appointment if no specialty care is available, and the patient does not need to be seen in an emergency department for abuse evaluation.

Physical Examination

The physical exam in cases of suspected abuse is, in most ways, not fundamentally different than other exams that most providers perform. However, the patient and/or caregivers may have particular anxieties about the exam, and so it should be explained thoroughly. One of the most important factors influencing the comfort of the patient during the exam is the comfort of the provider performing it. A calm, confident provider will help inspire these same feelings in the patient.

A question that often arises when performing an exam after suspected abuse regards the role of photography. Cases of suspected abuse are exempt from the requirement of specific consent for photography. Photos are the optimal form of documentation of abusive findings, and should be taken when possible. Written descriptions of findings, including location, description, and measurements, are not replaced by photos and should be included in the record for every exam. Photos may be included in the medical record, and sometimes must be shared with any investigating authorities. This sharing typically does not require a release if it is part of an investigation of suspected child maltreatment. However, providers should be familiar with the laws governing release of these images in the jurisdiction where they practice, as there are sometimes special legal protections of such images. If photos are not possible, drawings of exam findings should be included in the record.

The following are exam findings which may be of particular interest in cases of suspected sexual abuse. They should be looked for and if found, documented thoroughly.

Skin: document any evidence of trauma – bruising, including any pattern; petechiae; abrasions; lacerations

Head: scalp swelling or hematoma, traction alopecia

Eyes: subconjunctival hemorrhage, periorbital bruising or petechiae

Nose: nasal swelling, tenderness to palpation, bruising, epistaxis, septal hematoma

Pinnae: bruising or petechiae

Oropharynx: palatal petechiae, buccal mucosal injury, dental injury

Neck: suction ecchymoses ('hickeys'), ligature marks, petechiae

Torso: bruises, bites, abrasions

Extremities: bruises, bites, abrasions

Genitals: bruising, active bleeding, petechiae, lacerations or other mucosal disruption (discussed in greater detail below)

Anus: bruising, active bleeding, lacerations (discussed in greater detail below)

Genital Examination

Explain the exam in detail before starting. Give the patient as much control over the examination as possible. Allow a supportive caregiver or advocate to be present. Anesthesia is not required except for prepubertal patients requiring a speculum examination (see below).

One of the most important ways providers can be prepared for the genital exam of a child with suspected sexual abuse is to be familiar and comfortable with the normal anatomy and normal variants of both pre- and postpubertal boys and girls (Figure 1). Less experienced providers are more likely to call a normal finding abnormal, than to miss a true abnormality.

Figure 1.

Normal genital exam in a prepubertal girl, with genital structures adequately exposed by patient positioning and labial traction (see text).

The single most important piece of information about the physical examination in child and adolescent victims of sexual abuse is that in the vast majority of cases, it will be normal. This is true even with a clear history of penetrating assault, and is well-supported by the medical literature regarding child sexual abuse. This is important to inform the expectations of providers, the patient and his or her caregivers, and authorities.

Female patients: Place younger patients insupine frogleg position and older patients in lithotomy position. Complete a visual inspection of the inner thighs, labia majora, and perineal body. Document Tanner stage and any trauma. Without any manipulation, female genital structures beyond the labia majora cannot be adequately visualized (Figure 2). Therefore, perform labial separation (Figure 3). In most cases, separation will not allow complete visualization of the anatomy as required; if this is the case, perform labial traction (Figure 4). Describe each structure and note if any traumatic injuries, such as bruising, petechiae, abrasions, or laceration/transection, are present or not. Indicate the location of any findings by superimposing the face of a clock on the genital structures (Figure 5) such that the urethra is at 12 o'clock and the anus is at 6 o'clock, and noting the 'hour' of the finding (i.e., 'ecchymosis of the hymen at the 5 o'clock position').

Figure 2.

Inspection of external female genitalia without labial separation or traction. Hymen cannot be visualized.

Figure 3.

Labial separation- gently separating labia majora allows for limited visualization of the hymen.

Figure 4.

Labial traction: grasping the labia majora and gently pulling laterally and down is necessary to adequately visualize all hymenal tissue and other genital structures.

Figure 5.

Use of clock hours to describe locations on the genital anatomy. The urethral is in the 12 o'clock position, and the 6 o'clock position is toward the anus.

Prepubertal females have a hymen that is thin, translucent, and very sensitive (Figure 6). Different examination positions and techniques may be necessary to visualize the hymen, but the unestrogenized hymen should never be touched or manipulated directly, as this would cause the patient pain. A few drops of saline may help 'float' the edge of the thin, adherent unestrogenized hymen for better visualization. Postpubertal, estrogenized hymens are thicker, pale, and redundant (Figure 7). Even with good labial traction, moistened cotton swabs may be needed to fully visualize all of the estrogenized hymenal tissue (Figure 8 and Figure 9). If an exam abnormality is detected, it must be thoroughly documented and also confirmed with a second exam technique when possible, such as with moistened cotton swabs in a postpubertal female as described.

Figure 6.

Normal prepubertal female unestrogenized genital examination. Full visualization of the hymen is done with adequate labial traction. Never touch an unestrogenized hymen with moistened cotton swabs, as this would be painful for the patient. Prone position may be used to verify any abnormalities of the hymen.

Figure 7.

Estrogenized hymenal tissue is thicker and redundant. The edge of the hymen is everted in this image and is easily visualized, but this will often not be the case. Moistened cotton swabs may be used to fully visualize the hymenal tissue.

Figure 8.

Moistened cotton swab may be used to fully visualize estrogenized hymen by moving labial tissue away from the more medial genital structures, or by using the moistened cotton swab to move and fully visualize the hymen itself.

Figure 9.

Moistened cotton swab used to fully visualize the estrogenized hymen and demonstrate a deep notch or partial transection of the hymen at the 7 o'clock position

Speculum examinations are not a routine part of the physical exam for suspected sexual abuse, and should only be performed in the acute setting if vaginal bleeding, adnexal pain, or retained foreign body is suspected. Any prepubertal girl requiring a speculum examination should have this performed under anesthesia.

Male patients: Place the patient in supine position. Complete a visual inspection of the penis, urethral meatus, scrotum, and perineal body.

Anal Examination (for both genders)

Place the patient in supine knee-chest (i.e., 'cannonball') position. Gently separate at the gluteal cleft. Document any abrasions, bruises, or fissures. Many normal or nonspecific anal findings can be mistaken for trauma (see Table I). True anal abnormalities due to sexual abuse are rare, and if found, are usually in the setting of acute assault with a clear history of penetrating anal injury.

Table I.

Normal anal findings commonly mistaken for trauma
Finding Often mistaken for... How to differentiate?
Venous congestion Perianal bruising Will notice increasing coloration during exam, as this finding is a product of dependent position. Have patient walk around and then return to supine knee-chest position. True bruising wil remain unchanged, whereas venous congestion will have improved and then increasing discoloration will be seen again.
Pectinate line (Figure 10) Anal bruising or other trauma Anal dilation, which is normal with relaxation, allows visualization of the pectinate line, a normal anatomical feature which appears red and 'saw-toothed.'
Diastasis ani (Figure 11) Anal scarring Smooth, regular wedge-shaped areas at 12 and 6 o'clock – always in the midline. Will not change over time, so a second exam may be necessary to verify. (The appearance of anal trauma will continue to evolve.)
Failure of midline fusion/'perineal groove' (Figure 12) Anal scarring While present since birth, this congenital anatomical variant is rarely well-documented in past medical records. Will not change over time, so a second exam may be necessary to verify. (The appearance of anal trauma will continue to evolve.)

Figure 10.

The pectinate line, a normal anatomical feature of the anal canal demarcating the transition from squamous to columnar epithelium.

Figure 11.

Diastasis ani.

Figure 12.

Failure of midline fusion, a congenital finding of mucosal tissue along the midline on the perineal body. Has been observed to resolve at puberty.

The vast majority of physical examinations will be normal, even with a history of penetration. Schedule follow-up exams with a child abuse pediatrician or Child Advocacy Center when possible.

Forensic Evidence Collection – the 'Rape Kit'

Before starting the physical examination, determine if forensic evidence collection is required. Forensic evidence collection should be offered to patients when:

1. The history includes contact with the potential for transfer of biological materials (saliva, seminal fluid) AND

2. The incident occurred within 72 hours of the examination.

If the above criteria are met, obtain consent to complete the forensic evidence collection. Adolescents may refuse parts or all of this examination. Patients should not and cannot be forced to undergo an evidence collection. The 'kit' is not a medical procedure, and is never required for the health care of a patient.

Prepubertal examinations will provide a low yield of forensic evidence after 24 hours, while adolescents and adults will generally have a higher yield for a longer time. This is due to the different vaginal environments pre- and post-puberty. Evidence persists very briefly in the oral and anal cavities, and may persist longer in the postpubertal vagina. However, the most likely source of a 'positive' result for forensic evidence is clothing or bedding. Underwear should always be collected if there is a history of anogenital contact with potential body fluid transfer (genital/oral), and bedding from the location where the assault occurred should be collected whenever possible.

Forensic evidence kits vary somewhat between states, as they are generally created by the agencies responsible for analyzing them. If a provider may be responsible for performing forensic evidence collections, it is best to be familiar with the contents and documentation of the kit used in the jurisdiction where he or she practices.

If forensic evidence collection is indicated, read the kit instructions, set up the room prior to starting the examination, and complete the paperwork enclosed in the kit. This will generally include a consent form, to be signed by the parent/guardian or the patient, as indicated by the requirements of the local jurisdiction.

If available, an ultraviolet lamp can be used to aid in the detection of bodily fluids on the patient's skin and/or clothing. The lamp must have a wavelength between 420-450 nm to fluoresce body fluid. Of note, a Wood's lamp does not emit this wavelength and is thus not useful for this purpose. Light sources of appropriate wavelength are sold under brand names such as 'Bluemaxx.' Any areas of fluorescence should be documented and swabbed with a moistened cotton swab, to be included in the kit. While seminal fluid will fluoresce under an appropriate light source, other substances can as well (i.e. toothpaste), and so while it is important to swab any areas of fluorescence, it is also important to know that fluorescence alone is not diagnostic of sexual contact.

The mandates of forensic evidence collection vary somewhat by jurisdiction, and ultimately practices are dictated by the crime lab that will be processing the evidence. For many labs, evidence collection is only required from the sites on the body deemed necessary by the patient's history. For example, if there is no history of any oral contact during the alleged assault, no evidence collection from the mouth is required, and such a specimen may not be processed if collected. However, other labs expect specimens to be obtained from the mouth, genitals, and anus each time forensic evidence is collected. This practice is based on the observation that children's disclosures of sexual abuse are often incomplete and incremental, and children's histories of assault are sometimes poor predictors of evidence recovery. Ultimately, a provider who will be collecting forensic evidence needs to be aware of the expectations of the local forensic laboratory.

Some patients who are over the age of consent may choose to have forensic evidence collected without an immediate report to law enforcement. These patients include those who report an incident that the provider is not mandated to report under the state's mandated reporting law. An example would be a patient over the age of consent who reports an incident involving another person of consenting age who is not a household member, and who therefore does not pose an ongoing threat to the patient's safety. The details of cases that must be immediately reported vary by state, and it is important for each provider to be familiar with the laws in the state where he or she practices. It is important to notify these patients that the crime lab will not examine the kit for forensic evidence until a report has been made to law enforcement, but the kit can be collected and held until that time. Further information about interacting with law enforcement is discussed in the 'Reporting' section.

Laboratory Testing and Prophylactic Medications

It is important to perform testing for sexually transmitted infections and pregnancy after any sexual abuse or sexual assault which may have placed the patient at risk for these. Testing should be performed regardless of how much time has elapsed since the last episode of abuse. This is particularly important in acute sexual assault (<72 hours), when medications may be given to prevent infection and pregnancy.

Laboratory testing to be performed at the first visit for any victim of sexual abuse whose abuse history indicates that they are at risk, i.e., mucosal contact with blood or bodily fluids:

HIV (buccal or serum)

Rapid plasma reagin (RPR)

Acute hepatitis panel

Gonorrhea (see note)

Chlamydia (see note)

Urine pregnancy – should also be sent on peripubertal children who have not had first menses, due to the possibility that they may be ovulating

Providers must follow the relevant regulations regarding infections reportable to departments of health when the diagnosis of any of the above is made during the course of sexual abuse evaluation and treatment.

A note about gonorrhea and chlamydia: Culture is the gold standard method for diagnosis of gonorrhea and chlamydia. However, difficulties in obtaining adequate specimens and transporting samples for culture can result in false negative findings. The most common test now available for diagnosis of genital gonorrhea and chlamydia infection is the nucleic acid amplification test (NAAT). The available research shows NAAT to be at least as sensitive as culture for these organisms. NAAT can also be performed on a urine specimen; however, this must be a first-void, 'dirty' urine collection in order to have appropriate sensitivity. Testing for gonorrhea of the pharynx and rectum should also be performed in cases where a history of these types of assault has been provided. A positive NAAT for gonorrhea or chlamydia in a prepubertal child requires a second confirmatory test due to the low prevalence of these infections in this population. A second NAAT on a different nucleic acid sequence, or a culture, can be used as this confirmatory test.

Testing for drugs commonly used to facilitate sexual assault may be useful for medical management, as well as for forensic purposes. Testing should be performed if the victim provides any history of unexplained motor impairments, blackout, memory lapse, or other unexplained changes in mentation or sensorium. The forensic evidence kit may require additional samples of urine and blood so that the crime lab can test for these drugs as well. These samples often must be refrigerated; providers should be aware of the storage requirements for the specimens prior to collection, which should be well-enumerated in the kit instructions.

Of note, serologic testing for HSV antibodies has no utility in the evaluation and treatment of the victim of sexual assault and should not be performed. If a patient has vesicular lesions concerning for HSV, the lesions should be cultured directly.

Pregnancy and STI prophylaxis:

Pharmacologic prophylaxis is most effective when initiated within the first 72 hours after sexual assault.

Emergency contraception should be offered to any adolescent victim of a sexual assault that placed the patient at risk of pregnancy. This includes peripubertal children who may not have undergone menarche, but may be ovulating and therefore at risk of pregnancy. Plan B is a common form of emergency contraception, but an effective regimen can be devised from any OCP available. The emergency contraceptive dosing of various OCP's are available here: http://ec.princeton.edu/questions/dose.html#dose. The emergency contraceptive 'ella' is approved for use up to 5 days after sexual contact.

STI prophylaxis should be offered to any patient reporting a sexual assault, including types of contact that would place the patient at risk for these infections:

Gonorrhea prophylaxis: ceftriaxone 250 mg IM x 1

Chlamydia prophylaxis: azithromycin 1g PO or IV x 1

Trichomonas prophylaxis (may be offered to adolescent patients): metronidazole 2 g PO x 1

HIV prophylaxis:

Victims of sexual abuse and sexual assault are at risk for HIV infection. The overall rate of HIV transmission from sexual abuse is quite low; however, it will vary depending on patient and perpetrator factors, as well as the type of contact that has occurred during the alleged assault. The medical evaluation of suspected sexual assault should include an assessment of the patient's risk for HIV infection, which will inform the decision about providing HIV postexposure prophylaxis medication (HIV PEP). As with other prophylaxis medications discussed above, PEP efficacy is greatest within the first 72 hours after sexual assault.

Factors that may indicate that a patient's HIV risk following assault is elevated include the following:

  • anogenital mucosal injury, or an assault that places the patient at high risk for such injury (i.e., penetrating anal contact)

  • an assault involving multiple perpetrators

  • an alleged perpetrator with known HIV infection or known risk factors for HIV infection, such as intravenous drug use, history of incarceration, or men who have sex with men

Assaults that do not involve any penetration of the mouth, vagina, or anus are very low-risk and generally do not warrant PEP without other risk factors being present.

Most commonly, the alleged perpetrator's HIV status and risk factors will be unknown at the time of the medical evaluation. The provider needs to incorporate the known history with the patient and family's degree of concern, and provide PEP when indicated by the clinical risk assessment, patient and family concern, or the combination thereof.

The standard medication regimen for HIV PEP is the combination medication lamivudine/zidovudine 150 mg/300 mg tablets, sold under the brand name 'Combivir.' The dosage is one tablet BID for 28 days. This can only be used in patients of weight greater than 40 kg. There are newer HIV PEP protocols utilizing other drugs such as Truvada; the choice of medication should be dictated by local practices at the provider's institution as well as drug availability. For smaller patients, the provider must consult with a pediatric infectious disease specialist to derive an appropriate medication regimen. The medication can cause nausea, vomiting, malaise, and fatigue, and compliance will be improved if the patient is forewarned of these potential side effects. The medication is generally better-tolerated if given with food, and the side effects generally lessen as the four-week regimen proceeds. In some high-risk patients, an additional antiretroviral medication may be added to the regimen, in consultation with a pediatric infectious disease specialist.

If HIV PEP is to be given, medication compliance and appropriate follow-up are of particular importance. In anticipation of possible side effects of the antiretroviral medications, CBC, BUN/creatinine, and liver functions should be measured prior to starting the medication. PEP is only effective in seronegative patients, so a baseline HIV test should be obtained as well. CBC, BUN/Cr, and liver functions should be repeated at the follow-up visits at 2 and 4 weeks after initiation of the medication, as well as if there is any right upper quadrant tenderness or other symptom of possible medication intolerance. Repeat HIV testing should be performed at 4 weeks, 3 months, and 6 months after the assault.

Serial laboratory testing after sexual assault should be obtained after acute evaluation. This testing confirms the efficacy of any prophylaxis that was given, confirms the tolerance of HIV PEP if it is administered, and gives the provider an opportunity to reevaluate the patient's health and need for support following the assault. A sample schedule for follow-up testing is provided in Table II.

Table II.

A schedule for laboratory follow-up after acute sexual assault
Test Acute evaluation 2 weeks 4-6 weeks 3 months 6 months
Urine pregnancy x x
Gonorrhea x x
Chlamydia x x
RPR x x
Acute hepatitis panel x
HIV x x x x
If taking HIVPEP:
CBC x x x
Liver function profile x x x
BUN/Cr x x x

Reporting

All health care providers should be familiar with the laws governing mandatory reporting in their respective states. All states have mandatory reporting laws, but the details vary from state to state. The documentation required of providers after reporting is also state-specific.

Online resource for state-specific information: http://www.childwelfare.gov/systemwide/laws_policies/statutes/manda.cfm

Child Protective Services (CPS) agency mandates and the scope of agencies' activities also vary between states. For example, some CPS agencies investigate cases wherein the alleged perpetrator and victim are both children, on the premise that children who perform sexually abusive acts toward other children may have been abused themselves, and are also at risk for continuing these behaviors without intervention. These behaviors may also be triggered by other inappropriate exposures in the child's environment, such as viewing pornography or witnessing adult sexual behavior. Other state CPS agencies do not investigate such cases. Providers should be familiar with the mandates of the CPS agency in the state where they practice.

Another area of variation between states is the mandate to report to law enforcement. In some jurisdictions, the medical provider is responsible for making the initial report to police. In others, the CPS agency is responsible for making this report. As for the other factors described above, it is important for providers to be familiar with the reporting mandates in their respective states.

Concern about patient privacy law often arises in the context of reporting to authorities and interacting with law enforcement. HIPAA contains specific exemptions allowing the reporting of abuse or neglect of vulnerable patients. Individual states also have their own patient privacy statutes; in some states, these are more restrictive than the federal statute, while in other states the patient privacy regulations defer to the federal statute's language on this subject. Again, providers must be familiar with the relevant regulations in their states.

As mentioned above, positive test results for designated sexually transmitted infections must be reported to departments of health.

It is important to recognize that the medical provider is not the final arbiter of whether or not child abuse has occurred. The mandate to report only requires a 'reasonable suspicion' that child abuse may have occurred. The authorities will make the ultimate determination of whether or not there is evidence of abuse, including whether or not a crime occurred, and who may be culpable.

The patient's family should be notified that a report to CPS and/or law enforcement is being made. Providers are often anxious about transmitting this news to a family, but explaining the legal mandate, i.e., "I am required by law to make this report," rather than describing it as a choice, i.e., "I feel I must..." is often received with surprising acceptance.

Follow-up Care

As previously mentioned, child and adolescent victims of sexual abuse and sexual assault benefit from specialty care, and should be referred to a specialty provider whenever possible. Triaging the urgency of this referral is discussed in the 'Timing of Evaluation' section.

In some jurisdictions, medical evaluation of child sexual abuse is performed in hospital-based clinics. In others, the medical evaluation is performed at children's advocacy centers (CACs). Providers should be familiar with local available resources and referral streams.

The array of providers and agencies that may be involved in sexual abuse cases can be dizzying. Law enforcement advocates (LEA) or other victims' advocates can be particularly helpful to the patient and family in navigating the judicial process and identifying supportive resources.

What to tell victims of sexual abuse and their families? As devastating as sexual abuse can be, children can and do recover from its effects. Points to emphasize with caregivers of sexually abused children:

  • Believe your child!! The support and belief of the patient's caregivers is one of the most crucial contributors to positive outcome after child sexual abuse. Conversely, when a child has performed the difficult and sometimes terrifying act of disclosing sexual abuse and has been met by a parent who does not believe them, the consequences can be singularly devastating. Even if a parent is struggling to come to terms with what their child has disclosed, that struggle needs to remain an internal one, and the parent needs to voice and demonstrate belief of the child.

  • Parents should not question their children regarding the abuse allegation. If a child raises the subject him/herself and wants to discuss it with the parent, the parent should voice and demonstrate support. However, repeated questioning can inadvertently make a child feel that they have done something wrong, as well as interfere with the civil and criminal investigative process.

  • Tell and show your child that you will protect him or her.

  • Obtain early, sexual abuse-specific mental health care. Not all providers are proficient in treating the sequelae of sexual abuse, or aware of the most current literature regarding the most effective therapeutic modalities. Counseling with a provider specifically proficient in addressing sexual abuse should be sought, with the understanding that this may not be immediately available in all areas. Parents may worry that counseling will add to the trauma that their child has experienced, particularly since many children do not demonstrate outward signs of trauma or distress following their disclosures, but this myth should be anticipated and addressed. Apart from a believing and supportive caregiver, prompt and appropriate mental health care is one of the most important factors in optimizing recovery from sexual abuse.

  • Be hopeful! Praise the parent for supporting the child, and offer hope for the future. Sexual abuse and assault are incredibly common, and most victims go on to lead healthy and productive lives.

  • Be vigilant. Sexual abuse of children can occur in very brief periods of time – minutes, not hours. Children should be supervised by a trusted adult at all times, particularly if they are playing with older children or children who have themselves been abused. This is not intended to stigmatize or marginalize children who have been victimized, but rather recognizes that they are at increased risk of developmentally abnormal sexual behaviors themselves.

  • New media have opened up an entirely new panorama of risk for children and teens. Parental controls and direct supervision of media and online activities are necessary to prevent exploitation of children via these avenues.

What is the evidence?

AAP recommendations regarding evaluation of child sexual abuse:

Jenny, C. "and the American Academy of Pediatrics Committee on Child Abuse and Neglect. The evaluation of children in the primary care setting when sexual abuse is suspected". Pediatrics. vol. 132. 2013. pp. e558-e567.

Foundational references regarding the predominance of normal exams in child sexual abuse evaluation:

Adams, JA, Harper, K, Knudson, S, Revilla, J. "Examination findings in legally confirmed child sexual abuse: it's normal to be normal". Pediatrics. vol. 94. 1994. pp. 310-7.

Kellog, ND, Menard, SW, Santos, A. "Genital anatomy in pregnant adolescents: 'normal' does not mean "nothing happened"". Pediatrics. vol. 113. 2004. pp. e67-9.

Forensic evidence collection in prepubertal children:

Christian, CW, Lavelle, JM, De Jong, AR. "Forensic findings in prepubertal victims of sexual assault". Pediatrics . vol. 106. 2000. pp. 100-4.

Sexually transmitted infections following sexual abuse:

Shapiro, RA, Makoroff, KL. "Sexually transmitted diseases in sexually abused girls and adolescents". Curr Opin Obstet Gynecol. vol. 18. 2006. pp. 492-7.

Sexual behaviors in children:

Friedrich, WN, Fisher, JL, Dittner, CA. "Child Sexual Behavior inventory: normative, psychiatric, and sexual abuse ". Child Maltreat. vol. 6. 2001. pp. 37-49.

Kellogg, ND. "Committee on Child Abuse and Neglect, American Academy of Pediatrics. Clinical report--the evaluation of sexual behaviors in children". Pediatrics. vol. 124. 2009. pp. 992-8.

www.childwelfare.gov/systemwide/laws_policies/state.

www.cdc.gov/mmwr/pdf/rr/rr5912.pdf.

http://www.cga.ct.gov/2003/olrdata/jud/rpt/2003-r-0376.htm.

http://ec.princeton.edu/questions/dose.html#dose.

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