Meredith Gray and Eduardo Lara-Torre
History of present illness
A 13-year-old girl is brought to your office by her mother for evaluation of vulvar irritation. The mother reports seeing her daughter constantly touching and scratching her vulva. Her daughter has also been complaining of pain with urination and vaginal itching. The patient denies any vaginal discharge, but has had irregular bleeding and sometimes spotting between periods. She is currently having spotting. She also reports that it feels“raw down there,”and will not let her mother look at the area. She denies any local irritants or trauma. She has also been complaining of headaches and stomach aches for the past three months, and has difficulty falling asleep at night. The mother further expresses her concern by recounting recent changes in her daughter’s behavior. She describes her as secret- ive and withdrawn from her friends over the past three to four months. The patient used to enjoy going to her grandfather’s house on weekends, but recently has asked her mom if she can just stay at home. You ask her if you can take a look at her vulvar area, and she agrees but wants her mother present during the exam.
When you step out of the room to allow her to change, the mother finds you in the hall and reports that her daughter recently got in trouble at school for showing her genitalia to other children and using sexually explicit language. You ask the mother to please allow you to interview the patient in private. You reenter the room and gently ask the patient,
“I understand your mother is worried about you, can you tell me more about that?” The patient does not offer up any further information and becomes tearful.
Physical examination
General appearance:Normally developed teenaged girl in no acute distress, but tearful and nervous
Vital signs:
Temperature: 36.7°C Pulse: 98 beats/min
Blood pressure: 95/63 mmHg Respiratory rate: 20 breaths/min Height: 66 inches
Weight: 100 lb HEENT:Unremarkable Neck:Supple
Cardiovascular:Regular rate and rhythm without rubs, murmurs, or gallops
Lungs:Clear to auscultation bilaterally
Abdomen:Soft, nontender, nondistended, active bowel sounds present. No masses palpated. No bruising, cuts, or scars
Extremities:Unremarkable. No bruising
Genital examination (supine frog-leg position):Tanner stage III pubic hair development. Erythema of the labia and perineum is present. No warty lesions, abrasions, or scarring are present. Gentle traction to separate the labia reveals a hymenal laceration with a deep notch at 5 o’clock and evidence of recent bleeding. The full extension of the laceration is visualized. No other hymenal notches, bumps, or lacerations are appreciated. There are no anal lacerations.
The urethral meatus and clitoris appear normal Laboratory studies:
Urine pregnancy test: Negative
Wet mount preparation: No yeast, clue cells or trichomonads
Gonorrhea and chlamydia NAATs obtained on urine specimen
How would you manage this patient?
Child sexual abuse is suspected in this case. Thefindings of a posterior hymenal transection, deep notches, and perforations raise the suspicion for abuse, but are not diagnostic [1]. The differential diagnosis includes another type of genital injury, such as a straddle injury, which she denies; a congenital variation, which does not present with pain and bleeding;
and dermatologic conditions, which do not injure or transect the hymen. A transection of the hymen between 4 and 8 o’clock suggests penetration, but does not confirm sexual abuse [1]. Consensual intercourse between similarly aged adolescents must also be considered. This adolescent’s behav- ioral changes, in particular her sexualized actions and fear to interact with a male relative, are cause for concern and con- tribute to the suspicion of sexual abuse. Making sure the teen understands that is not her fault, asking her permission to involve her mom for assistance, and making sure she is ready to participate in the examination will allow for a less traumatic experience and facilitate the actual exam. Performing the nongenital examination componentsfirst will also allow you to establish a better rapport before performing the genital examination and addressing the affected areas. In this case, a complete description of the history and examinationfindings was documented including the child’s position during the Acute Care and Emergency Gynecology, ed. David Chelmow, Christine R. Isaacs and Ashley Carroll. Published by Cambridge University Press.
© Cambridge University Press 2015.
exam. The position used to perform the examination as well as a detailed description of thefindings will allow for standard- ization in case a second examination by a different practi- tioner is needed. The mother and the teen were informed of the concern for possible abuse in a nonaccusatory manner.
The patient was referred to a child forensic nurse examiner, where further documentation and evidence collection took place. She was also enrolled into the local Child Advocacy Center for counseling and follow-up. The suspected abuse was reported to Child Protective Services and the local Police, as required by law.
Child sexual abuse
Child sexual abuse is any sexual activity with someone under the age of 18 years old in which he or she cannot comprehend, give consent, or that violates the laws and norms of society.
The US Department of Health and Human Services reports that more than 60 000 children are sexually abused annually, which translates into approximately 1% of children experien- cing some form of sexual abuse [2].
Most cases of child abuse are detected when a child dis- closes that he or she has been abused [3]. The diagnosis of abuse is often based on the child’s history alone. Pediatric providers are obligated to screen for abuse (including physical and sexual abuse) at each visit. Screening is generally accomplished by looking for signs of abuse during the general examination such as burns or bruising, as well as by direct questioning to the child or adolescent when suspicion is pre- sent. In teens, spending time alone to confidentially address mental health, substance abuse and sexuality is part of the routine visit and is used to directly ask questions regarding abuse. Simple questions such as“Has anyone touched you in a way that made you feel uncomfortable?”should be used, and the use of complex medical language should be avoided as adolescents and children tend to not respond well to its use.
In our case, the physical examination findings are highly suggestive of abuse; however, rarely are such clear examination findings such as an acute hymen tear present. Many types of abuse (fondling, exhibitionism, voyeurism, or pornography) are less physically intrusive and leave no physical evidence. For this reason, a careful history and a high index for suspicion from the medical provider are the most important parts of the evaluation.
The history should be obtained with and without the parent or guardian present when possible and without leading questions or strong shows of emotion. The history taken by the medical professional has weight in the legal system and can be used in court as part of the evidence to reach a verdict [4].
Therefore, careful descriptions of the victims’answers, includ- ing quotations, should be documented. Expert interviewers often use audiotape or videotape during the interview in accordance with state guidelines.
Victims of abuse struggle with fear, guilt, shame, and embarrassment. These feelings can result in behavioral
changes. Most complaints that are possible indicators of sexual abuse are nonspecific. Indirect evidence of sexual abuse can include sleep problems, changes in appetite (increased or decreased), behavioral changes, abdominal pain, anxiety and depression, use of sexual language or behaviors unexpected at the child’s chronological age, bladder or bowel control prob- lems, or changes in school performance [5]. Teenagers may turn to substance abuse, running away, or promiscuity.
The physical examination should not result in more emo- tional trauma to the victim. All actions should be explained to the patient before the examination is performed. It is helpful to have the parent or adult not suspected of abuse present for the exam. A child or adolescent should be examined by a healthcare provider with appropriate training and experience;
someone who can interpret normal anatomy, nonspecificfind- ings, and findings associated with healed or new trauma.
Special training and certification is required to become a forensic examiner. Although residency programs in Obstetrics and Gynecology as well as Emergency Medicine may train physicians to perform these types of assessments, certified forensic nurse examiners undergo specialized training through postgraduate courses on evidence collection, identification of injuries, documentation guidelines, and post-abuse referrals.
Those dealing with children undergo even further training as the approach to children with abuse requires different skills to be able to deal with both patients, and their parents. An immediate evaluation of assault is required if the patient is symptomatic with complaints such as active bleeding from a genital injury, vaginal discharge, vulvar/vaginal pain, or if the abuse has been suspected to have occurred within 72 hours [4].
Otherwise, the examination should be deferred until an experi- enced clinician or sexual abuse center can be involved. The use of standardized techniques for the interview and exam, as those provided by a pediatric forensic nurse examiner, pro- vides a more reliable source of information to use in court and should be used when available.
A thorough physical examination should be performed looking for signs of physical abuse, neglect, or self-inflicted injuries. The examination should be meticulously documented in writing and with drawings or photography. For children and early adolescents the genital and anal structures can be visualized with the patient in frog-legged or knee-chest prone position. Gentle traction on the labia allows the examiner to inspect the outer vagina and hymen without the need for an internal exam. A bimanual or speculum examination when needed should be targeted to the age of the patient and the clinical presentation. An examination under anesthesia is sug- gested on those prepubertal children with acute injuries and may include the use of vaginoscopy when the injuries affect the internal genitalia. In adolescents, the use of a speculum smaller than the traditional Graves or Petterson, such as the Huffman speculum (1/2 inches wide × 4 inches long), could facilitate the internal exam, without adding significant discomfort.
Table 79.1 listsfindings during an examination that are con- cerning for abuse.
Approximately 5% of victims acquire a sexually transmit- ted disease from their abuser [6,7]. Postpubertal patients should be tested for sexually transmitted diseases (STDs) and pregnancy, as well as offered emergency contraception if applicable. However, more selective criteria can be used for prepubertal children based on the type of abuse, the age of the child, the examination findings, and the prevalence of the diseases in the area. For the most up-to-date recommendations on the screening and treatment of children and adolescents suspected of sexual abuse refer to the Centers for Disease Control and Prevention (CDC) guidelines [7].
All healthcare providers in the United States are required by law to report suspected or confirmed cases of child sexual abuse. Local requirements may vary by state or even by juris- diction, and providers should check their local agencies such as the Attorney General’s office or the local Child Protective Services (CPS) office for details. In most counties a call to the local police department and CPS complies with the require- ment. The CPS office is generally staffed by social workers and specialists in child abuse that can guide the provider on the
next steps after the initial report. The CPS office will facilitate referrals for the multidisciplinary needs of the patients includ- ing medical care, social work, short- and long-term psycho- logical therapy, as well as assist the victims and their caregivers in navigating the legal implications of the abuse. First and foremost our goal is to protect the child and provide healing and safety for our patients.
Key teaching points
Child sexual abuse should be considered by any
practitioner who takes care of a pediatric population when new behavior problems exist and/or physical complaints arise without a clear etiology.
The evaluation of sexual abuse requires careful questioning and a detailed physical examination with detailed
documentation. Such evaluations are best performed by a trained professional, such as a Pediatric Forensic Nurse examiner whenever possible.
Behavioral changes, abdominal pain, bowel and bladder control problems, sexually advanced language or behavior, substance abuse, or changes in school performance are potential indirect evidence of abuse.
Posterior hymeneal transections, deep notches, and perforations arefindings suspicious for abuse, but are not diagnostic.
All physicians in the United States are required by law to report suspected as well as known cases of child abuse.
Patient history and provider suspicion of abuse are the most important components in the diagnosis.
References
1. BerkoffMC, Zolotor AJ, MakoroffAL, et al. Has this prepubertal girl been sexually abused?JAMA2008;300:
2779–92.
2. Children’s Bureau.Child Maltreatment 2010. Available athttp://www.acf.hhs.
gov/programs/cb/pubs/cm10/cm10.pdf.
3. Adams J. Approach to the interpretation of medical and laboratoryfindings in suspected child
sexual abuse: A 2005 revision.APSAC Advisor2005;Summer:7–13
4. Adams JA, Kaplan RA, Starling SP, et al. Guidelines for medical care of children who may have been sexually abused.J Pediatr Adolesc Gynecol 2007;20:163–72.
5. National Institute for Health and Clinical Excellence.When to Suspect Child Maltreatment. Clinical Guidelines CG89, July 2009. Available athttp://
www.nice.org.uk/CG89.
6. American Academy of Pediatrics.
Sexually transmitted diseases in adolescents and children. In Pickering LK, ed.Red Book: 2012 Report of the Committee on Infectious Diseases, 29th edn. Elk Grove Village, IL, American Academy of Pediatrics, 2006, p. 166.
7. Centers for Disease Control and Prevention.Sexually Transmitted Diseases. Treatment Guidelines, 2010.
Available athttp://www.cdc.gov/std/
treatment/2010/sexual-assault.htm.
Table 79.1 Findings suspicious for sexual abuse*
Abrasions or bruising of genitalia
Acute or healed tear in the posterior hymen extending to the base of the hymen
Markedly decreased or absent posterior hymenal tissue Injury to or scarring of the posterior fourchette Anal bruising or lacerations
Vaginal discharge in the prepubertal patient
* From Adams [3].
Case 79: A 13-year-old girl with vulvar irritation and new-onset behavioral problems