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Child Sexual Abuse and the Primary Care Provider
Kathleen Opdebeeck, MD
Summer 2003
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How many children are
sexually abused?
By age 18:
12% to 25% of all girls
8% to 10% of all boys
Pediatric Review
Vol. 17, 1996 |
Primary
care providers often perform the exam that first raises suspicions that a child
has been sexually abused. When this happens, the provider must act in a way
that may appear to conflict with their roles of family advocacy and support.
Objectivity may be difficult.
Often it is a child’s behavior that suggests abuse. A health care
provider needs be knowledgeable about typical child behavior at
various developmental levels.
In
children, behaviors that are cause for concern include:
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Anxiety, fearfulness, withdrawal
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Sexual play or sexual acting out not
appropriate for developmental level
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Sleep disturbances
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Somatic complaints
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Change in school performance
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Low self esteem, depression, self-injurious
behavior
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Providers
also need to be aware of family issues such as domestic abuse, substance abuse,
interpersonal boundary issues, and divorce or separation of the parents (see
Factors that Place Children at Risk,
EPSDT
Care for Kids Newsletter,
winter 2003).
Information about training resources related to diagnosis and treatment
of child sexual abuse can be found on page 5.
The medical examination
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Most
physicians formulate an initial diagnosis based on the patient’s history. They
then perform a medical examination, and use what they learn to refine that
diagnosis. But in child abuse cases, diagnostic criteria may be flawed.
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Results of a physical
examination
will be within normal limits in 80%
of child victims of sexual
abuse.
Pediatrics, 1994
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Most
children do not spontaneously disclose sexual abuse. When a child who may have
been sexually abused is seen in a primary care physician’s office, the
physician should be supportive, ask open-ended non-leading questions, and not
draw hasty conclusions. Both the child
and the parent should be prepared in a calm and reassuring atmosphere. A
hostile, crying mother will upset the child and affect the physician’s
objectivity.
It
is important that all alleged victims of child sexual abuse have a medical
exam. A complete general exam should be performed first. Then a genital exam
should be carried out to look for signs of trauma or infection that need urgent
treatment.
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During
the medical exam:
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Identify and treat
injuries
- Screen for
infections and pregnancy
- Give anticipatory
guidance as appropriate to the developmental level of the child
- Reassure the child;
for example, that they are normal, that they are not to blame, that they are
virgins
- Document findings
for court use
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Physical
findings of sexual abuse are often nonspecific or absent. Molestation may not
produce injuries. Injuries may be superficial and heal in a few days. Even if
penetration has occurred, there may be no physical evidence. Some variations
may be normal or nonspecific. Small areas of irritation or abrasions on the
external genitalia may be diagnosed as sexual abuse when they are really the
result of poor hygiene, diaper irritation, scratching, or bubble baths.
Physical indicators and sexual abuse
Health
care providers are working to standardize the terms that describe the physical
indicators of sexual abuse. These indicators can be categorized as:
Category
1 -
Normal
Category
2 -
Non-specific
- Redness, inflammation
- Labial adhesions
- Small fissures, bruises or lacerations in
the genital or perianal region
- Vaginal discharge
Physical findings that should raise concerns
of sexual abuse
Category
3 -
Specific
- Unexplained vaginal or perianal injuries or
bleeding
- Unexplained recurrent pain in the genital
or perianal area
- Recurrent vaginal or urinary tract
infections
- Healed lacerations of the hymen or vaginal
mucosa
- Enlarged hymeneal opening
- Venereal disease (confirmed by lab),
sexually transmitted infections
Category
4 -
Definitive
Colposcopy
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A
colposcope is a special microscope that is used to examine cervical and vaginal
tissue. It looks like a pair of binoculars mounted on a stand, and has its own
light source. A still or video camera can be used with it during an
examination. Use of a colposcope requires training and experience or
misdiagnosis may occur.
Colposcopy
is very effective for examinations related to sexual abuse. It is non-invasive,
and can be used to document injuries in a way that permits later review by
peers, as well as by the examiner prior to court proceedings. It can also
eliminate the need for additional examinations of an already distressed child. |
A clear discussion of diagnostic issues, with
colposcopic photographs, can be found online in Evaluating the Child for
Sexual Abuse (American Academy of Family Physicians.
Protocols for the physical examination of child
sexual assault victims should be followed to gather biological trace evidence
such as epithelial cells, semen, and blood; and to maintain a chain of evidence
(see Care of the Adolescent Sexual Assault Victim, American Academy of
Pediatrics.
The forensic interview
| Diagnosing sexual abuse requires both knowledge
and experience. A primary care provider is often wise to arrange to have a
trained professional carry out a forensic interview of a child who may have
been sexually abused. To arrange for a forensic interview, contact:
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Forensic interview goals:
- Talk with a child in a sensitive and developmentally appropriate
manner
- Obtain and fully document accurate information that will enable
health care, criminal justice, and child welfare systems to act in the best
interests of the child
A professional forensic interviewer will tailor
the interview to the age and developmental level of the child. They will ask
open-ended questions, will not lead the child, and will accurately record the
conversation. Interviews will usually be videotaped so the child does not have
to repeat the interview over and over.
If the child’s history and physical examination
support a diagnosis of sexual abuse, discuss the referral process with the
parent and child in a calm non-threatening manner. Lack of cooperation can lead
to problematic evaluations and follow-up, and to increased difficulties for the
child and family. The law requires you to orally report child sexual abuse to
the Department of Human Services within 24 hours of noticing it. If the child
may be in danger, you must also report the suspected abuse to law enforcement.
The oral report to DHS must be followed-up with a written report within 48
hours.
It
is also important that children and families who have experienced sexual abuse
be referred for psychological counseling. Children who have been sexually
abused may experience guilt, humiliation, a sense of helplessness, anger. Adult offenders are motivated to deny or
minimize their behavior for fear of losing family, home, jobs, freedom, and
reputation. Non-offending spouses feel shock, betrayal, anger, guilt, and
self-blame. For this child and this family, emotional and mental health care is
essential. Your regional child protection center can direct you to counseling services.
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