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Clinical Summary

Child sexual abuse occurs when a dominant, more powerful person involves a depending, developmentally immature child or adolescent in sexual activities for his or her own or others’ sexual stimulation or gratification. This includes child pornography and prostitution, and ranges from nontouching abuses to direct genital, anal, or oral-genital contact. About 1% of children experience some form of sexual abuse each year. Perpetrators are usually male (75% to 90%) and usually involve adults or minors known to the child. Abuse by family members or known acquaintances often involves multiple episodes over weeks to years, whereas abuse by strangers tend to be a single episode. Most cases are detected when the child discloses the abuse. Sexually abused children may present with a variety of general and/or nonspecific symptoms and signs (eg, sleep disturbances, abdominal pain, enuresis, encopresis, phobias). Physical findings are often absent even when the perpetrator admits to penetration of the child’s genitalia. Many types of abuse leave no physical evidence, and injuries to the mucosa heal quickly and thus leave no physical evidence in most cases.

Figure 4.1 ▪ Condylomata Acuminata (Genital Warts Due to Sexual Abuse).

Lesions are seen in the perianal area of this 3-year-old male child who was abused by his maternal uncle. Genital warts are soft, flesh-colored, elongated lesions that develop around mucocutaneous junctions and intertriginous areas (eg, perianally, mucosae of female genitalia). Condylomata acuminata must be differentiated from condylomata lata as both occur in the same areas. (Photo contributor: Binita R. Shah, MD.)

Emergency Department Treatment and Disposition

Obtain a history in those older than age 3 years, and avoid leading and suggestive questions or showing strong emotions such as disbelief or shock in the absence of the parent so that their influence or distraction are minimized. Maintain a “tell me more” or “and then what happened approach.” Explain the physical examination to the child before conducting it and avoid any additional emotional trauma. Examination should be immediate if the patient presents within 72 hours of the alleged sexual abuse, and must include checking for acute injury or bleeding, vaginal discharge, possible presence of sexually transmitted infections (STIs) and the possibility of pregnancy in adolescent girls who have reached menarche. If more than 72 hours have passed since the alleged abuse, the exam can be scheduled at the earliest time that is comfortable for the child, the investigative team, and the physician. Perform a thorough physical examination, including mental and emotional status with special attention to areas that are involved in sexual activity. The supine frog-leg position is most often employed and well tolerated by prepubertal girls. It is important also to view the hymen in a second position if a concerning physical finding is seen. The prone knee-chest position often allows better visualization of the hymen, the fossa navicularis, and the posterior ...

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