Due to the large number of children who have been and/or will be sexually abused, it is important for all medical practitioners caring for children to be well informed with regard to child sexual abuse. More specifically, some children who have been sexually abused may manifest this abuse with urologic conditions, such as incontinence. Moreover, children may be referred for concerns of child sexual abuse for a non-abuse urologic condition, such as urethral prolapse. In addition, in the process of examining a child’s genitalia for a urologic condition unfamiliar findings may be revealed; therefore, it is important to understand the normal and potentially abnormal findings of the genital exam.
A. The 2006 World Report on Violence against Children provided estimates that in 2002 approximately 150 million girls and 73 million boys were subject to child sexual abuse worldwide, including 1.2 million trafficked children and 1.8 million exploited through prostitution or pornography.
B. In the United States, a population-based sample of face-to-face interviews with more than 34,000 adults found that 10% of respondents reported experiencing child sexual abuse before age 18 years, 25% of whom were men.
C. One meta-analysis of global prevalence studies included 65 articles involving 37 male and 63 female samples across 22 countries, totaling more than 10,000 individuals. The investigators reported a combined mean prevalence of child sexual abuse in 7.9% of males and 19.7% of females.
Another meta-analysis included data from 331 studies representing nearly 10 million individuals. In this analysis, the total combined
prevalence was 11.8%, with 7.6% of males and 18% of females reporting experiences of child sexual abuse.
E. Children are more frequently abused by males; however, women may be perpetrators, especially in day care settings.
F. Most perpetrators of sexual abuse are trusted adult acquaintances of the child, who often target children lacking close adult supervision and craving adult attention.
IV. RISK FACTORS
A. Presence of other forms of abuse or neglect
B. Family environments with low family support and/or high stress, such as high poverty, low parental education, absent or single parenting, parental substance abuse, domestic violence, or low caregiver warmth.
C. Children who are impulsive, emotionally needy, and who have learning or physical disabilities, mental health problems, or substance use
D. The risk of child sexual abuse appears to increase in adolescence.
E. Out-of-home youth may be particularly at risk
F. Children in conflict with the law may be at risk of abuse by authorities both on the street and in detention
G. Children living in conflict and post conflict environments
A. Children who are sexually abused are generally coerced into secrecy, therefore a high index of suspicion is required to recognize the problem.
B. Children who have been sexually abused may present in a variety of ways.
b. A parent may communicate concerns that the child has been sexually abused.
c. The child may actually make an initial disclosure of sexual contact at a medical visit (rare).
TABLE 29-1 Possible Medical Indicators of Sexual Abuse
Genital, anal, or urethral trauma
Genital or anal bleeding or itching
Genital infection or discharge
Chronic constipation, painful defecation
Vulvitis or vulvovaginitis
Foreign body in the vagina or rectum
Chronic genital or anal pain
Bruises to hard or soft palate, torn frenulum
Sexually transmitted disease
Bite marks on nipples/breasts
Scratch marks or bruises on hips/buttocks
d. Behavioral and emotional problems may raise concern, although it is important to keep in mind that these are nonspecific and may be related to many other causes.
2. Physical examination
a. During examination of the genitalia, suspicious findings may be observed.
VII. PHYSICAL EXAMINATION
A. General Examination
1. A more general physical examination should be done prior to the genital examination. Always discuss the genital examination prior to initiating. Older children should be given the choice of whether they would like their parent to be present or not. Provide for privacy. After the routine physical examinations, the genital examination should be prefaced with a (age-appropriate) statement such as, “I am now going to examine the hole where the pee comes out, it is ok for me to do this because your caregiver is in the room and I am a medical professional at a medical office/hospital, otherwise no one should look or touch your private area.” If sexual abuse is a concern, finish this statement with, “Has anyone ever tried to touch you here before.” Making the first statement every time one examines a child’s genitalia allows the statement to feel very comfortable and normal for a child, and when the second statement is needed, it will also feel more comfortable. A certain level of comfort and confidence is important for the genital examination. Although a child might not answer honestly initially, if all medical professionals ask these questions, eventually we hope they might. Try to use distraction and relaxation during the examination. Note the child’s behavior during the examination. No child thought to have been sexually abused should ever be forcibly restrained and examined against his/her will; arrangements should be made for an examination under anesthesia.
2. Examination findings change depending on the position of the child (supine, knee chest, lateral), degree of relaxation, amount of labial traction (gentle, moderate), and time of performing the examination. All these variables will influence the size of the orifice and the exposure of the hymen and the internal structures. The more relaxed the child is, the more visible the hymenal edges and the more dilated the introitus diameter; therefore, it is very important to view findings using varying traction and varying positions.
FIG. 29-1 Anatomy of prepubertal female genitalia.
FIG. 29-2 Supine frog-leg position.
In females, the genital examination should include inspection of the medial aspects of the thighs, labia majora, labia minora, clitoris, urethra, periurethral tissue, hymen, hymenal opening, fossa navicularis, and posterior fourchette/posterior commissure (Fig. 29-1
). In male children, the urethral meatus, thighs, penis, and scrotum should be examined.
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