Investigating Child Sexual Abuse

1. Investigating Child Sexual Abuse Christine E. Barron, MD Assistant Professor, Pediatrics Warren Alpert Medical School at Brown University

2. Objectives • National Data • Physical Examination • “Red Flag” Behaviors • Disclosures and Forensic Interviewing • Multidisciplinary Team • Prevention

3. 2008 National Data • ~ 3.3 million reports involving ~6 million children • 772,000 children were found to be victims of maltreatment • 70% Neglect • 15% Physical Abuse • <10% Sexual Abuse • <10% Psychological maltreatment • Child Maltreatment 2008

4. Sexual abuse is common • National survey of US adults • Childhood sexual abuse reported by • 27% of women • 16% of men1 • Each year ~1% of children are victims of CSA • Adolescents: highest rates for sexual assaults 1Finkelhor et al. Child Abuse & Neglect 1990;14:19-28.

5. Risk Factors • CSA occurs across all socioecomonic and ethnic groups • Race and ethnicity have NOT been identified as risk factors • Disabilities are a risk factor • Family Constellations • Putnam. J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 42:3, MARCH 2003

6. Myths of Sexual Abuse • Perpetrators are strangers • Perpetrators who touch boys don’t touch girls • Children tell about the abuse immediately • Children tell fantasies • Any child victim with penetration will have an abnormal examination • Disclosures in custody issues are all false allegations

7. Pedophiles • Can have normal peer sexual relationships • Can be sexually oriented only to children • Can be abuse reactive • Child-on-Child • Often someone family knows

8. Sexual abuse – RI laws Age <=13 14 15 16 17 >=18 Unable to consent <=13 Child molestation 14 Third degree 15 16 Consensual sex 17 >=18 Mark Massi

9. Physical Examinations • Evaluations for the Diagnosis & Treatment of Child Sexual Abuse

10. American Academy of Pediatrics • Developmentally appropriate interview • Complete examination to include growth, development, social, and emotional state • Directed genital examination for specific signs or physical indicators • Laboratory evaluation, cultures for STI’s -- as indicated by history or physical • Culture versus NAAT testing

11. Physical Examination • Provides reassurance • Examine for treatable conditions, STIs • Collect legal evidence • Chronic sequelae • Assists in the protection of the child

12. Triage • Nonurgent (within few weeks) • Urgent (within a few days) • Vaginal discharge, odor, possible pregnancy • Emergent (within 24 hours) • Vaginal, rectal bleeding • Psychological crisis • Safety concerns • Forensic Evidence Collection

13. Examination • When possible examinations should be completed by specially trained physicians to ensure that the examination is not more traumatizing then the incidences of abuse.

14. General Physical Examination Head to toe physical examination Attention to: Abdominal Exam Skin- appropriate UV light source Bruising Ligature/control marks Oral Sign of penetration Sexually transmitted diseases

15. Physical Examination Genitals • Completed in a non-traumatic manner • External inspection • A speculum is infrequently used in adolescents and rarely used in pre-pubertal children • Colposcope • Tool for magnification and photo-documentation • Does not see what is not there

16. Estrogen Effect on Hymen • Circulating maternal hormones causes estrogenization of hymen • Hormonal influences decrease in childhood • Hormonal influences become obvious once again during puberty • Estrogen- Thickened, redundant and pale.

17. Physical Signs and Symptoms • Bruises, scratches, bites • Abdominal pain • Genital bleeding – “blood on underwear” • Genital discharge, sexually transmitted disease • Genital or Anal Pain • Genital Skin Lesions • Genital/Urethral/Anal Trauma • Enuresis, Recurrent Urinary Tract Infections • Encopresis, Anal Fissures

18. Diagnosing Sexual Abuse Can the doctor tell? Can any doctor complete these evaluations?

19. Physicians • Not trained • Feel uncomfortable • Call normal findings abnormal • Call abnormal findings normal

20. Do Physician’s Recognize Sexual Abuse? • More than half could not recognize clear evidence of chronic sexual trauma • More than half of primary care physicians could not identify major parts of a female child’s genital anatomy • Ladson et al AJDC l987

21. Physical Examination Findings • Untrained physicians are more likely to over-diagnosis -- meaning calling normal variations evidence of abuse when they are not… • Or miss chronic findings of abuse and call the examination normal when it is not!

22. “Genital Examinations for Alleged Sexual Abuse of Prepubertal Girls: Findings by Pediatric Emergency Medicine Physicians Compared With Child Abuse Trained Physicians” • ER Physician: Diagnosed patients with non-acute genital findingsindicative of sexual abuse • Child Abuse Physicians: • 32 (70%) normal • 4 (9%) nonspecific • 2 (4%) concerning Makoroff et al Child Abuse Negl 2002

23. Physical Exam • Adams approach to interpretation of medical findings in suspected child sexual abuse • Adams et al. Guidelines for medical care of children evaluated for suspected sexual abuse: an update for 2008. Current opinion in obstetrics and gynecology 2008;20(5):435 -441

24. Physical Exam • Findings commonly seen in non abused children • Ex: periurethral bands • Findings commonly caused by other medical conditions • Ex: erythema of the vestibule • Indeterminate findings(conflicting data from research, requires further evaluation to determine significance) • ex: deep notch in hymen

25. Physical Exam • Findings diagnostic of trauma and/or sexual contact • Examples: • Lacerations or bruising • Hymenal transection (area of hymen torn through or nearly through the base) • Infection such as chlamydia > 3years old • Pregnancy • Sperm on sample taken from child’s body

26. Examination Techniques

27. Physical Findings • 5-10% of children have physical findings • Genital (female) • Bruising • Transections • Absent hymenal tissue • Abrasions • Sexually Transmitted Diseases

28. Physical Findings • Genital (Male) • Penile Abrasions • Bites, Bruises • Urethral/Anal Discharge • Sexually Transmitted Infections • Scars

29. “It’s normal to be normal.” Joyce Adams, MD

30. “Genital Anatomy in Pregnant Adolescents: “Normal” Does Not Mean “Nothing Happened”; • 36 pregnant adolescents seen for sexual abuse evaluations • 2/36 (6%) had definitive findings of penetration (cleft to base of hymen) • 4/36 (8%) had suggestive findings of penetration (deep notches or clearly visible scars) Kellogg N et al Pediatrics 2004

31. Repetitive Penetration • Study 506 girls 5-17 with reported penile-vaginal penetration • 85% of victims reporting > 10 penetrative events had no definitive findings on exam • This was true even if this occurred over a long period of time. • Anderst Pediatrics 2009: 124-;e403-e409

32. Physical Exam • A normal exam does not exclude the possibility of sexual abuse or prior penetration

33. “The genital examination of the abused child rarely differs from that of the nonabused child. Thus legal experts should focus on the child’s history as the primary evidence of abuse.” Berenson, A. Am J. OB/Gyn 2000

34. “Children Referred for Possible Sexual Abuse: Medical Findings in 2384 Children” • Referrals based on disclosure, behavior changes, medical findings • Overall 96% had normal exams • 5.5% abnormal when disclosed penetration • 1.7% abnormal without history penetration • 8% exams abnormal when had medical findings • STIs, acute genital trauma, healed hymenal trauma, transections Heger et al Child Abuse & Neglect 2000

35. Why are exams normal? • Nature of assault may not be damaging • Perception of “penetration” • Disclosures often delayed • Complete healing can occur • The hymen changes with puberty

36. Physical Exam • 2 year old female living in home with father after 9 year old half sister disclosed sexual abuse by him. • brought 2 year old to the pediatrician for a genital “rash” but did not report history of half-siblings disclosure. When the pediatrician said everything “looked fine” mother concluded that 2 year old was not sexually abused and could continue living with father

37. Evidence based medicine, experience and reason support that a normal exam does not rule out sexual abuse or prior penetration • This may contradict beliefs of families (and jurors, some law enforcement workers) • Try to understand families’ perceptions and explain significance of exam findings

38. Additional Exam Findings

39. Stay Moral, Go Oral Adolescents do not consider oral sex to be sexual activity. Need to ask if anything has been in the mouth!

40. Mimickers of Sexual Abuse • Medical Conditions • Accidental Trauma

41. Vaginal Bleeding

42. Case

43. Physiologic Endometrial Shedding • Vaginal bleeding is occasionally observed in female infants during the first few weeks of life. • The condition results from the reduction in high level of placentally acquired maternal estrogens that takes place after birth. • The bleeding occurs as the stimulated endometrial lining is shed, usually ceases within 7-10 days.

44. Prepubertal Vaginal Bleeding • Endometrial Shedding • Endocrine- • Hypothyroidism • Liver Cirrhosis • Coagulopathy • Precocious puberty • McCune-Albright Syndrome • Ovarian Cyst

45. Case # 2

46. Urethral Prolapse • Exam- annular mass from urethral meatus • Urethral mucosa is friable- • bleeding, pain and dysuria. • Prolapse can be more pronounced with Valsalva maneuver • Not associated with child abuse • More prevalent in African-American females • Tx: Nonsurgical unless • Urinary retention, or lesion is necrotic

47. Case

48. Lichen Sclerosus et Atrophicus • Hypopigmented, well-circumscribed areas of atrophic skin around genital and/or anus. • “Figure-of-eight” • Subepithelial hemorrhages • Frequently mistaken for bruising or bleeding caused by trauma from SA

49. Straddle Injuries • Site of impact often anterior • External to hymen • Unilateral • Painful • Bleeding may be significant • Occasional penetrating trauma to hymen with external to internal injury

50. Case