6: Emergency Department Evaluation of Sexual Abuse

OVERVIEW OF SEXUAL ABUSE

DIAGNOSTIC EVALUATION

A patient who has been sexually abused commonly presents to the emergency department for the following:

1. Medical and forensic management of suspected reported acute sexual assault

2. Evaluation after disclosure of sexual abuse

3. Injury or examination finding; for example, bleeding that prompts a differential diagnosis including sexual assault

4. Genital discharge or evidence of sexually transmitted disease (STD)

The history is often the most important part of the diagnosis of sexual abuse. A disclosure of abuse may come during an emergency department physician’s history and physical examination. Disclosures should be met with calm and nonjudgmental responses and leading questions should be avoided. The emergency department physician may ask questions about possible sexual assault or abuse if necessary for the medical and forensic evaluation of the patient including

• Nature of the sexual assault and type of contact

• Time interval between assault and arrival at the emergency department

However, forensic interviews should be performed by professionals who are trained in interviewing children for possible sexual abuse. When children with a concern of sexual abuse present to the emergency department, a social worker (in-house or on call) should be notified.

Children who are sexually abused warrant a physical examination; however, the type and urgency of the examination is dictated by the history and temporal relationship to the most recent abusive event. A child who is asymptomatic and discloses a remote history of sexual abuse (>3 days since last contact) may need only a general medical examination in the emergency department, and the genital examination deferred to an outpatient child advocacy center (if available) or to a practitioner trained in child abuse pediatric medicine.

A genital examination is warranted when the child describes genital symptoms (pain, discharge, dysuria, bleeding) or describes sexual abuse involving genital contact that occurred within the last 72 hours. An anxious child will usually cooperate fully with the examination (and evidence collection) if a parent or other support person is present during the examination. Reassurance and distraction techniques are helpful and consultation with a child life specialist (when available) can be useful. Sedation is rarely needed and can be ineffective. An examination should never be forced upon an unwilling child. When an examination is deemed medically necessary; for example, vaginal bleeding without a known source and uncooperative patient, examination under anesthesia should be considered. When a genital examination is performed, a chaperone (hospital personnel) should be present.

A pubertal girl can be examined in the supine position with feet in stirrups. A prepubertal girl should be examined in the supine frog-leg position (hips and knees bent; soles of feet touching). Gentle, even labial traction with gloved hands will allow visualization of the vulva and the hymen (Figures 6–1 and 6–2). Special attention should be given to the hymen, posterior fourchette, ...