Child Abuse Sexual

I. Problem. A 6-year-old girl is brought to the physician after telling her mother that her uncle touches her "privates" with his hand and his "privates."

Immediate Questions

A. Does hospital, county, or state have specific protocols or evaluation centers for suspected sexual abuse or sexual assault? Multidisciplinary evaluation programs for suspected chronic sexual abuse and acute sexual assault best serve many child and adolescent victims.

B. How should the history be obtained? It is essential to understand what happened, when it happened, and what symptoms are present. Initial history should be obtained from adults who accompany child, preferably without child present, including past medical history, review of systems, and content and context of child's disclosure. Some direct history from child is appropriate and should be obtained in a relaxed manner, preferably with child's caretaker out of the room. Questioning should be open-ended and nonleading. A general inquiry such as "why are you here to see the doctor?" or "has anything happened to you that hurt, scared, or confused you?" or instruction to "tell me what happened" is a good place to start. Use phrases such as "tell me more," or "how did that happen," or "what happened next" to continue the interview. Do not start by saying "your mother told me your uncle touched your privates—is that true?" Document the history carefully, indicating which portion is from caretaker and which from child. Indicate direct quotations by using quotation marks.

C. When did last sexual contact occur? Disclosure of abuse is often a social and emotional, but not a medical, emergency. If sexual abuse occurred within the last 72 hours and type of sexual contact suggests body fluids from abuser might be recovered, perform immediate evaluation at a facility capable of forensic evidence collection. Most cases of child sexual abuse do not fit these criteria.

D. What symptoms are present? Does child have genital pain, discharge, bleeding, sores, or itching? Urinary burning or frequency? Anal pain, bleeding, or itching? Although these symptoms are nonspecific, prompt evaluation is indicated when acute symptoms are present. Were anogenital symptoms present at time of abuse incident or at any other time in the past? Have there been other physical symptoms or changes in child's behavior?

Differential Diagnosis. Sexually abused children present for medical care in three ways: disclosure of sexual abuse, behavioral symptoms, and signs and symptoms of anogenital problems.

A. Child Sexual Abuse. Most common presentation is a complaint or disclosure of sexual contact. Abuse is primary reason that child makes a disclosure. History of sexual abuse provided by child is also the most important and frequently present evidence.

B. Behavioral Conditions. Presenting symptoms of sexual abuse may be very general in nature and include changes in child's behavior, emotional responses, and activity. These behaviors are nonspecific and may be indicators of physical, emotional, or other nonabuse-related stresses. Sexually "acting out" behavior should raise concern about abuse but is not diagnostic.

C. Dermatologic Conditions. Genital signs and symptoms are commonly associated with improper hygiene, irritant or contact dermatitis, atopic dermatitis, or seborrhea. Lichen sclerosus et atrophicus may present with hemorrhagic, bruised, or abraded appearance in anogenital area.

D. Congenital Conditions. Congenital variations of anal and genital structures are common. Midline fusion abnormalities suggesting injury may involve either genital or anal openings.

E. Urethral Disorders. Painless genital spotting or bleeding is associated with urethral prolapse, most often found in prepubertal African-American girls.

F. Anal Conditions. Midline perianal tags are common normal variations. Anal fissures and bleeding may be associated with constipation. Perianal lesions may accompany inflammatory bowel disease.

G. Nonsexual Trauma. Straddle injuries can be associated with pain, bruising, bleeding, and lacerations. Injuries are often anterior, typically involve the external genitalia (not the hymen), and are asymmetric.

H. Infectious Conditions. Perianal streptococcal infection can produce painful defecation and intense redness with fissuring and bleeding of perianal tissues. Streptococcal vaginitis may produce intense genital pain and redness with purulent or bloody discharge. Other nasopharyngeal or respiratory pathogens can produce purulent vaginitis. Shigella infection may produce bloody vaginal discharge. Genital lesions can be associated with varicella and molluscum contagiosum. Pinworms are associated with either genital or anal pain, itching, and excoriation.

I. Other Conditions. Intravaginal foreign bodies are associated with purulent or bloody discharge. Normal physiologic leukorrhea in pubertal girls may be misinterpreted as infections. Labial adhesions or agglutination often result from an irritant or infectious process.

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