The management of the child with suspected sexual abuse involves both medical management and legal management. All cases of suspected sexual abuse in children are required by law to be reported to child protective services (CPS) and law enforcement. Often a hospital's social worker is involved and helps with reporting the suspected abuse to law enforcement and CPS. All children should have an immediate medical evaluation if the abuse was within the previous 72 hours or there is bleeding or concern of acute injury. Many communities have designated child sexual abuse teams utilizing specialized nurses, nurse practitioners, and/or physicians that can be a resource for these evaluations. Otherwise, if the child is safe and without symptoms, an appointment can be made at the next earliest convenience with the child's regular health care provider. A delay in examination should be considered if it means the child will be seen by someone skilled in the field of pediatric sexual abuse.17 In 2006, the American Board of Pediatrics added Child Abuse as a subspecialty in pediatrics. This reflects the depth of knowledge and skills that should be brought to the overall evaluation of this complex entity.17
The emergency department evaluation should begin with an interview of the adult accompanying the child. This interview should take place away from the child. Key information to obtain includes why abuse is suspected, to whom did the child disclose to, what the child said, the type of contact the child described, the timing of the last possible abuse, behavior changes, medical concerns, who lives at home with the child, who cares for the child, and anything the adult has witnessed.
Next, the child should be interviewed. If possible, it is recommended that children with a developmental age of 3 or older should be interviewed alone.18 Children are not likely to disclose information if they believe it will be upsetting to their caretaker. In general, children are more comfortable talking if their caregiver is not in the room.19 The interview of the child should take place in a child-friendly area that is free of distraction. Ideally the interviewer should use open-ended nonleading questions. “W” words (who, what, where, when, and how) are recommended. However, “why” questions should be avoided because they may imply blame on the child. If a skilled social worker has already obtained a detailed history from the child, the physician's interview can be abbreviated. Occasionally, further questioning of a child can be deleterious. The child may find repetitive questioning unpleasant or threatening, may infer that he or she is not believed, or may modify his or her history in response to repetitive questioning.3 The history taken from the child is often the most important part of the overall evaluation. The importance of taking a good history from the child cannot be emphasized enough. The results of a study by Hansen et al. suggests that the child's statement and not the physical findings were important for legal outcome.20 Great detail should be taken when documenting the history provided, with actual quotes from the child when possible. Upon finishing the interview, the child should be told that he or she did the right thing by telling.
Older children should be asked who they want to be in the room for the examination. This should be asked of the child without family members present. The examination should begin with a general physical examination. Prepubertal children should not have a speculum examination. A detailed external genital examination is sufficient. There are several examination techniques when performing a genital examination. Younger children may be more comfortable and cooperative if seated in a caregiver's lap. Children 3 years of age and older usually tolerate being placed on an examination table.21 The two most common examination techniques are the supine frog-leg position (the child lies with legs in full abduction and feet in apposition) and the prone knee–chest position (the child kneels on hands and knees and then places his or her head and chest on the examination table). In female patients, utilization of the labial separation and labial traction techniques allows complete visualization of the vulvar structures. This is done by gently grasping the labia majora and pulling the labia outward (toward the examiner) and laterally. Any abnormal finding noted in the supine position should be verified in the knee–chest position because the change in positioning can alter the appearance of the hymenal edge.21 Male patients can be examined in supine or prone positions. An examination of the perianal area is important in both female and male patients. This can be done in either the supine or lateral decubitus positions. The presence of stool in the vault or traction on the anus can cause the anus to dilate. Anal dilation of more than 2 cm without stool in the vault (this can be determined with direct visualization or less commonly a digital examination) may be concerning for possible abuse. As with the history, physical examination findings must be carefully and thoroughly documented in the medical record. Photographic documentation is strongly encouraged, particularly if the examination findings are thought to be abnormal.
In cases with suspected intravaginal injuries or active bleeding without an obvious external source, the internal vaginal examination should be performed only on prepubescent patients using general anesthesia and often requires consultation with a general surgeon who has expertise in examining and treating children.22
The AAP recommends forensic evidence collection if the evaluation is within 72 hours of the sexual abuse.18 However, the yield from such evidence collection significantly drops off after 24 hours. In a study done by Christian et al., no swabs taken from a child's body were positive for blood after 13 hours or sperm/semen after 9 hours.23 It is important that only medical providers who are experienced in the collection and preservation of forensic evidence perform a forensic evaluation. Part of a forensic evaluation requires that the child's clothing be collected and placed in a paper bag. DNA evidence may come from clothing. Evidence must be collected and stored properly as it may be used as evidence in legal proceedings.
Universal screening for STDs is not necessary because the incidence of STDs among children who have been sexually abused is low. Approximately 5% of sexually abused children contract an STD from abuse.24 The Centers for Disease Control and Prevention (CDC) recommend testing for STDs in the following situations: when the child has had symptoms or signs of an STD, when a suspected assailant is known to have an STD or to be at high risk for STDs, when a sibling or another child or adult in the household or child's immediate environment has an STD, when the patient or parent requests testing, or when evidence of genital, oral, or anal penetration or ejaculation is present.25 In nonacute evaluations, careful examinations without STD screening may be acceptable for asymptomatic, prepubertal children who lack clear history or physical examination findings indicative of penetrating sexual abuse.3
Enzyme-linked assays or DNA amplification tests, such as nucleic acid amplification tests (NAATs), for Chlamydia trachomatis and Neisseria gonorrhoeae can be utilized for noninvasive screening. NAATs have several advantages over culture, as noninvasive specimens can be used, they are more easily transported and processed, and they are highly sensitive and specific.26 However, the lack of sufficient clinical studies in prepubescent patients and the risk of false-positive test results limit the utility of these tests for forensic purposes. Routine bacterial and cell cultures remain the gold standard for diagnosis of bacterial STDs. Swabs taken from the external genitalia are sufficient in prepubertal female patients. In adolescent female patients with a history of rape, a speculum examination with cervical cultures is recommended. Again, while the only the minority of sexually abused children require STD screening, if cultures are warranted, cultures should also be taken from the throat and rectum. Blood tests for syphilis, HIV, hepatitis B and C should also be considered in high-risk cases.
Empiric treatment for STDs is usually not necessary. However, empiric treatment may be considered in cases of stranger assaults as well as in adolescent rape victims. Identified STDs should be treated with the appropriate regimens according to the published guidelines set by the CDC (see Chapter 88). Emergency contraception should be offered when female pubertal patients present within 72 hours of an assault that could result in pregnancy.27
Treatment should include a routine follow-up appointment/examination. In cases with positive examination findings, follow-up examination are helpful to assess healing of injuries. Follow-up appointments can also provide opportunity to assess the need for further screening for STDs, as some infections may not have had time to manifest symptoms at the time of initial assessment. Follow-up examinations by specialists affected the interpretation of trauma and detection of STDs in about 23% of pediatric patients undergoing sexual abuse patients in a retrospective study by Gavril et al.28 The follow-up with appointment can also ensure that the child and family are receiving any needed counseling services.
Colposcopy provides a noninvasive method for visualizing the anogenital structures. It provides magnification and a light source, both of which can be helpful in identifying injury. The colposcope also allows a video or still image to be recorded for documentation. Photodocumentation of the anogenital examination can provide a means for quality enhancement programs (peer review) and help limit unnecessary repeat examinations.
Alternative light sources can be used during forensic evidence collection to guide collection of possible body fluids on victims. Alternative light sources include the Blue Max 6000 or a Wood lamp. It is important to note though that material other than semen may also fluoresce with a Wood lamp.