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CSA

In incidents of child sexual abuse (CSA), the interview with the child is typically the most valuable component of the medical evaluation. Elicited history is frequently the only diagnostic information that is uncovered. Additionally, if performed in a sensitive and knowledgeable manner, the history-taking process can be a first step in the healing process for the child who is sexually traumatized. Regardless of the history provided, the members of the interdisciplinary team need to demonstrate an open, nonjudgmental, and caring attitude toward the child; the willingness to advocate for the child must be demonstrated as the evaluation unfolds.

• General principles for successful history taking

  • To assist in creating a comfortable and nonthreatening environment, allow an extended period of time when taking the history in children who are suspected of being sexually abused.
  • When interviewing the child, use a developmentally sensitive approach to the questioning so that the child can understand what is being asked and is able to answer as accurately as possible.
  • Rely on nonleading questions as much as possible to permit the child to relate information in a credible and reliable framework.
  • An interview often has a healing value for children, enabling them to start to feel some control with what occurs in their lives in contrast to the abusive situation that took away the control they should have with their own bodies.
  • In an effort to demystify the information-gathering process, consider permitting children to sit where they want to sit, slowing down the pace of the interview if it starts to go too fast, permitting time for play breaks, and encouraging children to use their own words for body parts.
• Initial introduction with efforts to build up trust

  • During the initial meeting, the health care provider and any members of the interdisciplinary team who are involved with the treatment of the child should introduce themselves to the child and caregiver.
  • At this point, the primary health care provider should explain how the evaluation usually proceeds, including the need to first speak alone with the caregiver and then alone with the child.
  • After these initial conversations, ask the caregiver to rejoin the child for a physical examination, which frequently is understood as a "check-up" by the child.
• Caregiver interview

  • Ensure that caregivers who accompany children have an opportunity to describe their concerns, provide information about the children's health, and outline any information they have related to the suspected abuse.
  • By interviewing the caregiver first, the interviewer allows the child an extra bit of time to become familiarized with the clinical setting and, hopefully, to become more comfortable with the environment.
  • Initially explain to the caregiver the extent to which the information elicited during the interview is required to be shared with child protective services (CPS) staff and law enforcement personnel who may be involved with the case.
  • Clarifying the limits of confidentially in suspected incidents of child sexual abuse is paramount to avoid feelings of betrayal later if and when information is shared with the various involved agencies.
• Child interview

  • When verbal children are interviewed when the caregivers are not present, children may not provide the most valuable information.
  • Using a sensitive approach and building on what has been learned in the warm-up and caregiver interview components, begin with nonthreatening topics such as favorite activities, school subjects, and personal interests.
  • Once rapport has been established in the interview, ask the children why they have come to the doctor's office.
  • By focusing on asking simply worded, open-ended, nonleading questions, the person taking the history can progress through the standard "what, when, where, and how" questions, which are important to the medical evaluation of suspected child sexual abuse.
  • The full potential of the interview can be realized by a reliance on such questioning as "tell me more" followed by "and then what happened?"
  • Supporting the child for working hard to answer the questions (but not for the content of the answers) is vital to the credibility of the information elicited.
  • The clinician must understand the developmental capacity of the child and work within the child's abilities to garner the information needed. Thus, children may not know dates but they remember holidays; children may remember something happened before or after school began.
  • Asking children to explain what they mean to avoid misunderstanding important points in the history is always appropriate.
  • Using the child's words for body parts may make the child more comfortable with difficult conversations about sexual activities.
  • Using drawings may also help children describe where they may have been touched and with what they were touched.
  • Meticulous documentation is a necessity for these types of histories, because the documentation may be considered as evidence in subsequent legal proceedings emanating from the overall investigation.
  • To the extent possible, document specific quotes that the child makes about the abusive events.
  • Often, entries made in medical charts by health care providers of children's words detailing their own sexual victimization assist those advocating for children as they argue for suitable protection from people and situations that may be threats to the children's well-being.
  • Consider videotaping or audiotaping the interview if the jurisdiction permits this.
• Wrap-up and preparation for the physical examination

  • After the child interview concludes, the caregiver can be invited back in the room to help facilitate the transition to the physical examination.
  • Being honest and empathetic with the child is critically important.
  • Therefore, do not promise that needles are not to be used unless absolutely sure that obtaining blood is not necessary; if not sure, reassure children that blood is obtained only if needed and, if blood is needed, children are told at the end of the examination.
  • Inform children if genital swabs are to be collected; allow them to handle the swabs in order to gain some comfort with the procedure.
  • If a colposcope is to be used during the physical examination, introduce it as a "special camera" that the doctor uses that does not touch the child.
  • After an appropriate discussion, leave the room and allow the child to prepare for the examination by suitable disrobing and putting on a gown with the caregiver's assistance.

  
  

  Physical

  As opposed to adult sexual abuse and in general, authorities agree that more than three fourths of physical examinations of children suspected of having been sexually abused are without definitive findings of sexual abuse. Heger and colleagues conducted a comprehensive study that included the review of physical examinations performed on 2,384 children evaluated for suspected child sexual abuse in a regional referral.^[11] They found that, overall, only 4% of the children had abnormal findings. Of 182 children specifically referred for evaluation of a suspected finding identified by a health care provider, the child abuse specialist only found 8% of these children with a finding (this is the group expected to have the highest likelihood of a finding on examination due to the initial concern from the referring health care provider).

  Additionally, of children who reported either vaginal or anal penetration, only 5.5% had physical examination findings. Thus, Heger and colleagues concluded that the vast majority of suspected child sexual abuse physical examinations are likely to not discover physical findings (what are commonly referred to as "normal" physical examination findings). Numerous reasons are believed to account for this general lack of findings. First, the child and family typically know the perpetrators, and physical force is not often a major component as in adult sexual assaults. Disclosure of the abuse frequently is delayed, and evaluations may be performed weeks to months after the abusive contact. Finally, mucous membranes that compose the genital structures heal rapidly and, often, without obvious scarring. See the imags below.

  Girl in frog-leg supine position, exhibiting annular hymenal orifice. Tissue is thin and translucent without disruption or scarring. Photo courtesy of Carol D. Berkowitz, MD.Girl in frog-leg supine position exhibiting hymenal orifice, which is crescentic and has symmetric attenuation at lateral margins. No scarring is present. Photo courtesy of Carol D. Berkowitz, MD.

  The general approach to the physical examination follows the standard examination techniques for a comprehensive physical examination (ie, complete head-to-toe approach). When examining the child who is suspected of being sexually abused, place particular emphasis on the genital and anal examination; however, children should experience this more thorough inspection of their anogenital anatomy only in the context of a complete examination. In this way, children receive messages that their whole bodies and health are important; this helps to avoid any undue focus on their anogenital areas.

  • Examining genital and perianal structures: To perform a complete examination of the child's genitalia and perianal structures for abnormalities attributed to abuse, the examiner first must understand the basic anatomy of this body area. Initially considering the female prepubertal genitalia with minimal palpation, externally inspect the vulvar structures. Tissues of interest are mons pubis, labia majora, labia minora, clitoris, urethral meatus, hymen, fossa navicularis, and posterior fourchette. The postpubertal child may require a more extensive examination requiring internal examination of the vagina and cervix, depending on the suspected type of contact. This section focuses on the external examination of the prepubertal female genitalia. Child Abuse and Neglect: Physical Abuse includes a detailed description of the examination of the female adolescent patient. Structure descriptions are as follows:

    • Mons pubis
      • This genital structure is the skin-covered mound of fatty tissue above the pubic symphysis.
      • Due to maternal estrogen effect, the neonate's mons pubis appears generous and rounded; however, as the estrogen effect decreases, the roundness is lost until the child's endogenous estrogen level increases at the time of puberty.
      • In response to circulating hormones, the mons pubis is the site for pubic hair growth during pubertal development and adulthood.
    • Labia majora
      • These bilateral skin-covered longitudinal folds of fatty and connective tissue serve as external protection for the more recessed vulvar structures.
      • The neonate's labia majora are thicker due to maternal estrogen effect, and this decreases over time.
      • The child's labia majora do not completely cover the internal structures.
      • During puberty, pubic hair grows on the skin covering the labia majora as well.
    • Labia minora
      • These bilateral, thin, mucous membrane longitudinal folds are observed medial and more recessed in relation to the skin-covered labia majora.
      • Because of maternal estrogen, the neonate's labia minora are frequently larger than expected and may protrude beyond the labia majora; however, this decreases over time.
      • Anteriorly, the labia divide into lateral and medial components, with the lateral labial component fusing centrally to form the prepuce of the clitoris.
      • The medial labial components fuse to form the clitoral frenulum.
      • Posteriorly, the labia fuse to form the posterior fourchette.
      • No hair grows on the labia minora.
    • Clitoris
      • The clitoris is the small, cylindrical, erectile structure composed of a prepuce, frenulum, glans, and body.
      • Similar to the other structures described above, the maternal estrogen effect causes a transient enlargement of this structure, which decreases over weeks to months after birth.
    • Urethral meatus
      • This genital structure is the round outlet of the urinary system inferior to the clitoris.
      • This outlet may be difficult to routinely visualize in the child, but urethral tissue occasionally may prolapse, creating a beefy red donut-shaped protrusion at the site of the meatus.
    • Hymen
      • The hymen is the mucous membrane sheetlike structure that has an opening and is situated at the entrance to the vagina, sitting in a recessed fashion between the medial aspects of labia minora. See the images below.Girl in frog-leg supine position exhibiting hymen. Hymen is septate; a band of tissue crosses the hymenal orifice. Tissue is thin with no scarring present. Photo courtesy of Carol D. Berkowitz, MD.Infant girl with imperforate hymen and absence of a hymenal orifice. Photo courtesy of Carol D. Berkowitz, MD.
      • Hymenal tissue is very sensitive to estrogen, and the estrogenized hymen is pink and opaque compared to the relatively unestrogenized hymenal tissue, which generally is thin, translucent, and reddish with an obvious lacy vascular pattern. See the images below.Adolescent girl in supine position demonstrating estrogenized tissue. Hymen is thicker, pink, and fairly opaque with no vessels visible. Tissue is redundant. Photo courtesy of Carol D. Berkowitz, MD.Genital examination of adolescent girl revealing estrogenized hymenal tissue that is pink, thick, and opaque. Orifice appears irregular, secondary to significant redundancy of tissue. Photo courtesy of Carol D. Berkowitz, MD.Genital examination of adolescent girl demonstrating estrogenized hymenal tissue that is pink, thick, and opaque. Orifice is irregular due to areas of redundancy, especially at the 9-o'clock position. Photo courtesy of Carol D. Berkowitz, MD.
      • The shape of the hymenal orifice varies, and the various shapes are generally described as crescentic (half-moon), annular (circular), fimbriated (redundant tissue that folds over on itself like excess ribbon around an opening), septate (column of tissue that crosses the opening), and cribriform (series of small openings). See the images below.Infant girl in frog-leg supine position. Hymenal orifice is crescentic (little time is present at 12-o'clock posterior). Hymen is thin and translucent with vessels visible. Hymenal edge is regular and without interruption. Photo courtesy of Carol D. Berkowitz, MD.Girl in knee-chest position. Hymenal orifice is crescentic, thin, translucent, and without interruption or scarring. Photo courtesy of Carol D. Berkowitz, MD.Infant girl in frog-leg supine position. Hymenal orifice is annular, with tissue present around entire opening. Some redundancy is present. Photo courtesy of Carol D. Berkowitz, MD.Infant girl in frog-leg supine position. Genital examination reveals translucent hymenal membrane with significant redundant tissue making hymenal orifice difficult to appreciate in this photo. With further traction applied to both labia majora, the hymenal orifice could be observed. Photo courtesy of Carol D. Berkowitz, MD.
      • The shape of the orifice can be further described by the appearance of clefts, bumps, notches, tags, and the presence of thickening or thinning at the orifice's edge. See the image below.Infant girl in frog-leg supine position. Hymenal orifice is annular with a "bump" at 1-o'clock position and a small "notch" at 10-o'clock position. Hymenal membrane is thin and translucent, with no interruption or scarring. Photo courtesy of Carol D. Berkowitz, MD.
      • The observed size of the hymenal orifice varies, depending on the state of relaxation of the child, the position of the child, and examiner technique.
      • As such, most authorities agree that measurement of the hymenal orifice has limited utility in the evaluation.
    • Posterior fourchette: Formed by the posterior meeting of the labia minora, the posterior fourchette is the floor of the fossa navicularis.
    • Fossa navicularis: The fossa navicularis is the space bounded by the posterior fourchette and the point where the hymen attaches to the inferior aspect of the vaginal wall at its entrance.
  • Standard positioning: To expose the prepubertal genital structures as fully as possible, several standard positions are used, namely frog-leg supine, knee-chest, and the left lateral decubitus.

    • Frog-leg supine position
      • This position is ideal for optimal visualization of the genital structures and for a fair degree of comfort for the child.
      • The child lays supine on the examining table or on the caregiver's lap and flexes her knees, bringing the heels of her feet together while abducting her hips; thus, her legs can move laterally, providing an excellent view of the external genitalia.
    • Knee-chest position
      • The knee-chest position provides clear observation of the anus; it also offers an opportunity to examine the vulvar structures, including the hymen, from a different vantage point.
      • This position can be helpful in assessing a difficult-to-visualize hymenal orifice.
      • As the child kneels down, resting her chest against her knees on the examination table and moving her buttocks superiorly, the anterior abdominal wall falls forward, and the hymenal tissues may be extended somewhat more than in the frog-leg supine position.
      • The main disadvantage to this position is that children may feel vulnerable and are often uncomfortable remaining in this position.
    • Left lateral decubitus
      • This alternative position is most appropriate for anal examination and most commonly is used with boys.
      • The left lateral decubitus position does not offer a clear visualization of the female vulvar structures.
      • The child lies on his left side with knees flexed and buttocks placed toward the examining table's edge and the examiner.
  • Calming the child during examination: In addition to positioning, make efforts to keep the child engaged and calm during the examination. Often, calming the child is accomplished by talking to the child and explaining what to expect during the examination. Additionally, proper attention to modesty is necessary, and the use of a quiet room, with adequate privacy, is essential. Use gowns and drapes as appropriate.
  • Genital and anal examination: Examiners may find it helpful to progress through the genital and anal examination in a fairly routine sequence, during both the actual examination and the subsequent documentation.

    • General observation and inspection
      • The genital examination begins with general observation and inspection.
      • With the child in the appropriate position and with adequate light and privacy, look for signs of injury on the skin surfaces, make a judgment about the presence and character of pubic hair for sexual maturity rating purposes, and look for any obvious signs of infections.
      • Note the child's emotional status.
    • Visualizing the more recessed genital structures
      • Once the inspection is completed with gloved hands, the examiner may use gentle palpation to move the tissues and further visualize the more recessed genital structures.
      • By applying gentle lateral traction to the labia majora, the labia minora and hymen may be observed more clearly.
      • Magnification, provided by a hand-held magnifying glass or colposcope, may be helpful during the genital examination. The colposcope has the advantage of providing an excellent light source and having the capability to take photographs during the examination.
      • Internal examinations and the use of instruments are almost never necessary in the prepubertal examination for suspected child sexual abuse.
      • If deemed necessary because of a serious finding (eg, bleeding with no identified source), arrange an examination under anesthesia.
    • Collection of specimens
      • At this point in the examination, specimens may be collected for STD screening and forensic evidence collection.
      • These procedures are described in more detail in the Workup section.
    • Possible observable findings: Most individuals who have been sexually abused present with essentially normal examination findings. However, possible observable findings include (1) those attributable to acute injury if the examination is performed a relatively short time after the sexual contact or (2) chronic findings that may be residual effects following repeated episodes of genital contact, which have occurred over an extended period of time.
      • Examples of acute trauma include subtle erythema, abrasions, lacerations, friability, bleeding, and disruption of the hymen. Additionally, if the perpetrator ejaculated on or near the child's genitalia, seminal products may be found. Signs related to the existence of STDs may also be present. These signs may include vaginal discharge, signs of vulvovaginitis, and characteristic lesions, such as the viral lesions observed in genital herpes and the warts observed with human papilloma virus infection (ie, condyloma acuminata). See the images below.Genital examination of girl revealing bruising on medial aspects of labia minora, hymenal trauma with disruption of hymenal tissue, and fresh blood. Photo courtesy of Carol D. Berkowitz, MD.Infant girl with significant bruising that involved labia minora and labia majora, hymenal trauma with disruption of hymen, and fresh blood. Photo courtesy of Carol D. Berkowitz, MD.Genital examination 10 days after infant girl presented with significant bruising that involved labia minora and labia majora, hymenal trauma with disruption of hymen, and fresh blood. Bruising on vulvar structure is nearly resolved. Hymen is healing and no blood is observed. Photo courtesy of Carol D. Berkowitz, MD.
      • Chronic findings that may be found include scars on the genital skin and mucous membranes, remodeled hymenal tissue from repeated trauma, and disrupted vascular patterns in the translucent tissues. Healing occurs in these tissues. Over months to years of abusive contact, angular margins in hymenal tissue tend to smooth out, and, with the onset of puberty, the appearance of estrogen and resultant hypertrophy of the genital mucous membranes tend to obscure subtle changes.
  • Muram diagnostic categorization system: From a historical perspective, the Muram categorization system is of note and offers valuable insight into how various prepubertal genital examination findings may assist diagnosis.

    • 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 then sexual contact (eg, seminal products in a prepubertal female child's vagina, the presence of a nonvertically transmitted gonorrhea or syphilis infection)
  • Alternate classification

    • Adams and colleagues have built upon the Muram classification approach and have combined it with information from other components of the sexual abuse assessment.^[12] These clinical investigators propose an approach to the interpretation of medical findings in suspected child sexual abuse that offers a sound basis from which the examining health care provider can a differential diagnosis and offer a diagnostic impression at the conclusion of the health care evaluation. According to the 2008 update, Adams and colleagues propose an approach that has the following 8 categories of findings:^[13]
      • Findings documented in newborns or commonly seen in nonabused children (ie, normal variants)
      • Findings commonly caused by other medical conditions
      • Indeterminate findings (ie, insufficient/conflicting research data so requires caution in interpretation)
      • Findings diagnostic of trauma and/or sexual contact
      • Residual/healing injuries
      • Injuries of blunt force penetrating trauma
      • Presence of infection that confirms mucosal contact with infected bodily secretions (ie, contact most likely to have been sexual)
      • Diagnostic of sexual contact (ie, pregnancy or sperm directly taken from a child's body)
    • Because of the complexity of evaluation and the expertise required to accurately identify and interpret examination findings, Adams et al conclude their 2008 update with a call for standardization of the training of medical professionals who perform suspected child sexual abuse evaluations to ensure appropriate and continuing competence.

    
    

    Laboratory Studies

    Children who have been abused sexually are at risk of contracting STDs including gonorrhea, chlamydia, syphilis, condyloma acuminata, herpes simplex virus, human immunodeficiency virus (HIV), pediculosis pubis, and trichomoniasis vaginalis.

    Rapid tests are not appropriate for prepubertal children in the context of a child sexual abuse (CSA) evaluation because of their higher potential for false-positive results.

    Cultures remain the criterion standard and are valuable from a forensic evidence standpoint.

    Depending on the contact suspected and the clinical situation recommended, testing includes the following:

    • Gram stain of vaginal and/or anal discharge
    • Genital, anal, and pharyngeal culture for gonorrhea
    • Genital and anal culture for chlamydia
    • Serology for syphilis
    • Wet prep of vaginal discharge for Trichomonas vaginalis
    • Culture of lesions for herpes virus
    • Serology for HIV (based on suspected risk)

    The American Academy of Pediatrics (AAP) views nonvertically transmitted gonorrhea, syphilis, chlamydia, and HIV as diagnostic of sexual abuse in the prepubertal child.^[14]

    In a child, the AAP views the presence of T vaginalis as highly suggestive of sexual abuse.

    Nonvertically transmitted condyloma acuminata and herpes with no clear history of autoinoculation are also suggestive of sexual abuse.