Prepubertal Vagina Examination Sexual Abuse

Prepubertal Vagina Examination Sexual Abuse

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Affiliation

1 California Forensic Medical Training Center, Sacramento, CA, USA. Tnh1@earthlink.net

Theodore N Hariton .

Med Sci Law .

2012 Oct .

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Affiliation

1 California Forensic Medical Training Center, Sacramento, CA, USA. Tnh1@earthlink.net

Stirling J.
Stirling J.
Med Sci Law. 2013 Apr;53(2):112. doi: 10.1177/0025802413482829.
Med Sci Law. 2013.

PMID: 23761533

No abstract available.

Hariton TN.
Hariton TN.
Med Sci Law. 2013 Apr;53(2):113-4. doi: 10.1177/0025802413478861.
Med Sci Law. 2013.

PMID: 23761534

No abstract available.

Lopez AO.
Lopez AO.
Med Sci Law. 2013 Apr;53(2):115. doi: 10.1177/0025802413478860.
Med Sci Law. 2013.

PMID: 23761535

No abstract available.

Hariton TN.
Hariton TN.
Med Sci Law. 2013 Apr;53(2):116. doi: 10.1177/0025802413478859.
Med Sci Law. 2013.

PMID: 23761536

No abstract available.

Adams JA.
Adams JA.
Med Sci Law. 2013 Apr;53(2):117-8. doi: 10.1177/0025802413478858.
Med Sci Law. 2013.

PMID: 23761537

No abstract available.

Hariton TN.
Hariton TN.
Med Sci Law. 2013 Apr;53(2):119-20. doi: 10.1177/0025802413478856.
Med Sci Law. 2013.

PMID: 23761538

No abstract available.

McCann J, Miyamoto S, Boyle C, Rogers K.
McCann J, et al.
Pediatrics. 2007 Nov;120(5):1000-11. doi: 10.1542/peds.2006-0230.
Pediatrics. 2007.

PMID: 17974737

Pillai M.
Pillai M.
J Pediatr Adolesc Gynecol. 2008 Aug;21(4):177-85. doi: 10.1016/j.jpag.2007.08.005.
J Pediatr Adolesc Gynecol. 2008.

PMID: 18656071

Review.

McCann J, Miyamoto S, Boyle C, Rogers K.
McCann J, et al.
Pediatrics. 2007 May;119(5):e1094-106. doi: 10.1542/peds.2006-0964. Epub 2007 Apr 9.
Pediatrics. 2007.

PMID: 17420260

Boyle C, McCann J, Miyamoto S, Rogers K.
Boyle C, et al.
Child Abuse Negl. 2008 Feb;32(2):229-43. doi: 10.1016/j.chiabu.2007.06.004.
Child Abuse Negl. 2008.

PMID: 18329097

Berenson AB.
Berenson AB.
Curr Opin Obstet Gynecol. 1994 Dec;6(6):526-30.
Curr Opin Obstet Gynecol. 1994.

PMID: 7893957

Review.

Jina R, Jewkes R, Vetten L, Christofides N, Sigsworth R, Loots L.
Jina R, et al.
BMC Womens Health. 2015 Mar 27;15:29. doi: 10.1186/s12905-015-0187-0.
BMC Womens Health. 2015.

PMID: 25887051
Free PMC article.

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Study objective The purpose of this study is to evaluate the long-term effects of penile vaginal penetration in prepubertal girls. The specific emphasis is on whether there would be visible identifiable medical evidence of penetration on examinations done months or years after the event. Literature review The medical literature regarding this subject was reviewed specifically for defendable evidence supporting a statement that there would be no findings as well as those that suggested that there would be visible evidence of trauma. Specific definitions of sexual assault, visible anatomic change from trauma, and sexual penetration are established for clarity. The effect of the lack of estrogen on the genital tissue of prepubertal girls is reviewed in relationship to the potential effects of trauma. The average diameters of the hymenal opening in this age group and the diameter of the erect male penis were reviewed. Conclusion The result of the study both from review of the medical literature and an understanding of the anatomy and histology of the unestrogenized genitalia of the prepubertal girl makes it clear that if there has been forceful penile penetration of the hymen there will be both a history of pain and bleeding and healed evidence of this forceful penetration.

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Authors: Maria D. McColgan, MD , Assistant Professor of Emergency Medicine and Pediatrics, Drexel College of Medicine; Urgent Care Physician, St. Christopher’s Hospital for Children, Philadelphia; and Angelo P. Giardino, MD, PhD , Medical Director, Texas Children’s Health Plan, Inc.; Clinical Associate Professor of Pediatrics, Baylor College of Medicine, Houston

Peer Reviewer: Meta Carroll, MD , Pediatric Emergency Physician, Northwest Acute Care Specialists, PC; Emanuel Children's Hospital, Portland, Oregon and Salmon Creek Hospital, Vancouver, Washington, Legacy Health System

One of the most challenging evaluations that an emergency department (ED) physician is asked to perform is the examination of a child with potential child abuse. The majority of ED physicians feel overwhelmed, and although they would like to perform the "ideal" history and physical examination, they find themselves feeling inadequate in these situations. The authors comprehensively review the important aspects of the evaluation of a child with potential sexual abuse and highlight aspects that facilitate appropriate ED management.
The Editor

Child abuse and neglect is a major public health problem in the United States. In 2002, approximately 896,000 children were victims of child abuse. Of those, about 10%or almost 90,000 were cases of child sexual abuse (CSA) that were substantiated by child protective services. 1

The importance of the ED to the evaluation of sexual maltreatment is addressed in the Institute of Medicine’s landmark report, Emergency Medical Services for Children : 2

"Child abuse and sexual assault also should receive attention in the ED protocols. These cases require careful and systematic response to ensure that the child receives proper medical and psychosocial care and that appropriate legal and administrative steps are taken. The ED staff…must be alert to those cases in which the true nature of the problem is not reported to medical personnel, as may happen if a family member is the abuser."

The number of cases of CSA seen by a particular ED may vary depending upon available community resources such as a regional child abuse center or availability of local child abuse experts. In addition, families often come to the ED prior to contacting their primary care physician. In one study, 46% of children were first evaluated in the ED. 3 Also, a higher percentage of victims of CSA are uninsured or insured by publicly funded insurance than for other pediatric complaints presenting to the ED. 4,5

The emergency physician needs to be prepared to conduct a thorough examination in a sensitive and nonthreatening manner to prevent further victimization of the patient. Several studies have indicated a need for continued training in the area of CSA. In a four-year study of ED patients, 46 children were diagnosed with nonacute genital trauma indicative of sexual abuse. 6 However, when these patients were re-examined within 2 weeks by physicians with training in child abuse, only eight (17%) had clear evidence of abuse on examination, and four had nonspecific changes; normal findings were found in 32 children (70%). 6 In a statewide survey of physicians in Arizona, emergency physicians estimated that physical examinations of victims of CSA would yield physical findings 34% of the time (answers ranged from 2% to 95%). 7 However, as will be discussed below, recent studies indicate that positive findings occur less than 10% of the time. 8

Of the 896,000 children who were determined to be victims of child abuse in 2002, more than 60% were neglected, about 20% were physically abused, and 10% were sexually abused. 1 Child sexual abuse is defined as involvement of a child or adolescent in sexual activity by a dominant or more powerful person for the purpose of sexual stimulation, or for the gratification of other persons (e.g., child pornography or prostitution). The sexual activities include exhibitionism, inappropriate viewing of the child, allowing the child to view inappropriate sexual material, taking sexually related photographs of the child, sexualized kissing, fondling, masturbation, digital or object penetration of the vagina or anus, and oral-genital, genital-genital, and anal-genital contact. These sexual activities are imposed on the child victim, who is unable to provide consent because of age or developmental stage. 9,10

Health Care Evaluation vs Investigation

In the ED, the multidisciplinary team that handles cases of sexual abuse is often composed of the physician, nurse, and social worker, who then relay information to law enforcement and child protective services workers. The evaluation completed by the ED team is contributory, but distinct from the police and child protective services investigation. 11 The information obtained during the ED evaluation is critical to the investigation process and focuses on the initial disclosure or symptoms that prompted the visit, the child’s health status and need for treatment, important medical and psychological follow-up, and development of a safety plan. The ED evaluation of suspected CSA includes a history, physical examination, and observations of the interaction between the patient and his/her caretaker. Laboratory studies (e.g., culture testing for sexually transmitted diseases [STDs]) and forensic evidence collection also may be indicated in the ED. By contrast, personnel in child protective services and law enforcement investigate allegations of CSA under legal mandate. The police determine whether a crime has been committed and begin appropriate legal action. 12 Child protective services work with the police to ensure the safety of the victim, evaluating a caretaker’s ability to protect the child, and provide support services required by families that may include alternative living arrangements for children deemed unsafe in their homes. 13

The health care environment can be a source of stress for children who may fear painful procedures and feel uncomfortable in the technical, adult-oriented environment. 14 The child who has been sexually abused may be distressed and/or embarrassed about having painful injuries examined. 15-17 Studies of the response to the genital examination in prepubertal children and adolescents show that fear associated with the CSA examination is greater than that associated with a routine doctor visit, but that the examination is less traumatic when performed in a controlled setting by experienced and psychologically supportive clinicians. 18,19 The emergency physician can use a variety of strategies to reduce patient anxiety ( See Table 1 ). 20

Recent studies have shown that the diagnosis of sexual abuse typically relies upon the history given by the child and parent, and that the rates of physical evidence and trauma in sexual abuse are low. 8,21 In fact, the history from the child typically provides the most valuable component of the medical evaluation and may be the only diagnostic information uncovered. In 1992, U.S. Supreme Court Chief Justice Rehnquist ruled that excited utterances and statements made in the course of procuring a medical examination might carry more weight than statements made in court. 22

In contrast to the interview done by law enforcement, the history should be geared toward information that will help to guide the clinician in diagnosis and treatment of potential medical issues. A medical history, in other words, is not a forensic interview. The history should be viewed as a multistep process: 1) introduction, 2) interview of caretaker, 3) interview of child (if medically necessary), and 4) wrap-up of the history and preparation for the examination.

Begin with a private interview of the adult accompanying the child. If there is more than one adult, each should be interviewed separately to identify corroborationand inconsistenciesin their histories. All caretaker interviews should be conducted without the child present. 23 Often the adult can provide enough pertinent information for the clinician to decide upon medical treatment and the need for emergency evaluation versus deferral to a subspecialty setting. In many cases, it is unnecessaryand discouraged by law enforcement and child advocates to obtain a history of the abuse from the child.

When interviewing the adult caretaker in a quiet, private room, answers to the following questions will assist medical decision making: 24, 25

Next, proceed with a thorough review of systems, staying alert to symptoms associated with abuse (e.g., painful urination or defecation, pelvic or abdominal pain, constipation, bleeding, discharge, changes in sleep or dietary habits, and developmental regression). 26 In addition to the child’s account of events, the parents’ account of the behavioral history can reveal behaviors inappropriate for the child’s developmental level. 27 These i
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Prepubertal Vagina Examination Sexual Abuse

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