Urgent medical assessment after child sexual abuse
Introduction
The medical diagnosis of child sexual abuse (CSA) rests primarily on the history and may be supported by physical evidence such as positive physical examination findings, detection of sexually transmitted infections (STI) or isolation of forensic trace evidence (Committee on Child Abuse and Neglect, 1991, Committee on Child Abuse and Neglect, 1999). Children who have been sexually abused have been noted to have specific patterns of disclosure, physical examination and forensic findings which may assist in the identification and prosecution of alleged perpetrators and assure protection from further abuse (Adams, Harper, & Knudson, 1992; Berenson et al., 2000; Berenson, Heger, Hayes, Bailey, & Emans, 1992; Heger, Ticson, Velasquez, & Bernier, 2002; McCann, Voris, & Simon 1992; Palusci et al., 1999).
While the history obtained from the child is paramount, the diagnosis of CSA is augmented by physical findings or other forensic evidence in a small but important number of cases and is affected by the child's age, gender and stage of sexual development (Adams, 1997, Christian et al., 2000; Enos, Conrath, & Byer, 1986; Heger et al., 2002). Differences in examination findings among children, adolescents and adults have been noted after sexual assault, and guidelines for the timing of examination are based primarily on evidence regarding the isolation of spermatozoa from adult female genital tracts (Jones, Rossman, Wynn, Dunnuck, & Schwartz, 2003; Silverman & Silverman, 1978; Soules, Pollard, Brown, & Verma, 1978). Older children, females, those with genital-genital contact with older males, and those seen within shorter periods of time are believed to have a greater likelihood of disclosure, positive physical examination findings or identifiable trace evidence (Christian et al., 2000, Enos et al., 1986, Heger et al., 2002). In a retrospective review of forensic tests of 273 children less than 10 years of age, Christian noted that 25% had positive forensic evidence obtained during emergency department visits, 64% of which was on clothing or bedding, and only one child in this Philadelphia case series had body evidence (a pubic hair) when seen after 24 hours or more after an assault (Christian et al., 2000).
Recent or acute sexual contact is generally defined to have occurred when children are brought for medical evaluation within 72 hours of contact (Committee on Child Abuse and Neglect, 1999). While the American Academy of Pediatrics has recommended immediate medical examination for children after recent sexual contact, the immediate need for such evaluation may preclude the use of child-friendly settings such as the child's medical home or specialized programs, such as child advocacy centers or sexual assault clinics, which may use techniques such as videocolposcopy to reduce further trauma to the child (Palusci & Cyrus, 2001). It is unclear whether young or prepubertal children seen within 72 hours of sexual contact have rates of disclosure, positive physical findings, sexually transmitted infections or forensic evidence differing from those seen non-urgently. There may be certain subgroups of children who benefit more from immediate medical evaluation, and, conversely, there may be others for whom the evaluation could be modified or delayed to minimize further trauma while preserving important physical evidence and maximizing the potential therapeutic effect of the physical examination (Palusci et al., 1999).
We hypothesized that: (1) young children seen for concerns of sexual abuse within 72 hours of alleged contact have higher rates of disclosure and positive physical examination findings during assessment than children seen non-urgently; (2) there are specific event, child or perpetrator characteristics (such as child age, gender and bathing) associated with increased likelihood of identifying forensic evidence; and (3) there are differences in disclosure, physical examination and laboratory findings within the 72-hour period after alleged sexual contact.
Section snippets
Methods
We retrospectively collected information about all patients seen at a community child advocacy center for the medical evaluation of child sexual abuse or assault. The center houses child protective services (CPS) workers, police personnel, and counselors assigned to sexual abuse cases in a county of over 600,000 people. There is a medical unit that provides non-urgent assessments for over 95% of the children referred for CSA from these agencies and physicians in this county. The medical unit
Results
Among the 955 children referred for evaluation of sexual abuse or assault to the Children's Assessment Center in Grand Rapids, Michigan, there were 191 children under the age of 13 years referred for evaluation within 72 hours of alleged contact. One did not allow physical examination, leaving 190 available for analysis. There were 586 children under the age of 13 years who were seen non-urgently (Figure 1). Most were young girls who disclosed sexual contact during the medical assessment. Fewer
Discussion
We found that children seen urgently were younger and had less frequent CPS involvement, more disclosures, more positive physical examinations and had contact with older perpetrators than those seen non-urgently. Most children seen urgently, however, had normal or non-specific physical examinations, no sexually transmitted infection, and no forensic evidence identified. This absence of positive examination findings may reflect less violent types of sexual contact (Heppenstall-Heger, McConnell,
Conclusions
Children seen within 72 hours of alleged sexual contact have higher rates of disclosure and positive physical examination findings than children seen non-urgently, and there are specific event, child or perpetrator characteristics that appear to allow for better scheduling for evaluation. Females and older children are more likely to have positive examination findings. Those having positive exams are more physically developed and more likely to disclose genital contact or ejaculation. They are
Acknowledgments
We would like to thank Jeffrey Jones, MD for his review of the manuscript, Judie Chorman, LPN, N. Debra Simms, MD and Susan Wakefield, MD for their assistance with data collection, and DeVos Children's Hospital, Susan Heartwell, MPA, the Children's Assessment Center, and the DeVos Children's Hospital Foundation for their support.
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