Sexual Abuse

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Sexual abuse of a child is very different from the violent isolated acts of adult rape. Rather, children become victims to chronic secretive abuse which may range from inappropriate touching to anal or vaginal penetration. Rarely, children may be victims of child pornography. Both victim and perpetrator may be either male or female although most commonly the victim is female and the perpetrator male. The perpetrator of child sexual abuse is often known to the child and in a position of authority which might be exploited through the use of threats to the child to maintain secrecy. Very young children may not even realize that the behavior of this trusted adult is abnormal. Over 90% of child abuse victims will show no physical evidence of the abuse. It may be years before sexual abuse is discovered or disclosed.

Although uncommon, sexual abuse may present as sexually transmitted ocular disease. Gonorrhea or chlamydial conjunctivitis, human papilloma virus of the conjunctiva, pubic lice of the eyelashes, periocular infection with mollus-cum or herpes simplex, or ocular involvement with HIV or syphilis may all occur in sexually abused children. However, there is evidence that some infections, such as gonorrhea [18], may be transmitted to the eye nonsexually. This is contrary to the well-documented exclusivity of sexual transmission for gonorrhea to the oropharynx, vagina, rectum and male urethra. There may be unique factors about the externalized conjunctival mucosa that allow for this nonsexual transmission to occur. Infections such as molluscum and herpes simplex are so frequently transmitted nonsexually that consideration of sexual abuse seems almost misdirected in the absence of other concerning findings. Nonsexual transmission of syphilis to children does not occur. But like virtually all sexually transmitted diseases, infection via the birth canal is an important consideration and some infections, particularly Chlamydia, may have very long latent periods. Consultation with child abuse and infectious disease specialists may be helpful. In teenagers, one must also consider the possibility of consensual sexual activity with peers as the source of infection. At the very least, sexually transmitted diseases with ocular manifestations should lead the ophthalmologist to place sexual abuse in the differential diagnosis, and communicate this concern to the child's primary care physician or a child abuse pediatrician, to consider further evaluation.

There is also important literature to suggest that covert sexual abuse, and perhaps other forms of abuse, may lead to functional visual loss in children [4,30].Although it would not be appropriate to question every child with functional visual loss regarding possible covert abuse, it is recommended that the evaluation of functional symptoms include consideration of possible stressors in the child's life.

• Sexual abuse of a child is a chronic covert act that may escape detection or report by the child for years and is most often not associated with physical injury to the victim

• Ocular manifestations of sexually transmitted disease may be a sign of sexual abuse

• The ophthalmologist must consider the possibility of nonsexual transmission of sexually transmitted diseases to the conjunctiva, but when there is a suspicion of sexual abuse, the ophthalmologist should refer to expert professionals

• Infection via the birth canal, and, in teenagers, via voluntary sexual activity, must be considered

• Functional visual loss and other symptoms may be a sign of covert abuse

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