Childhood Sexual Abuse

1. Childhood Sexual Abuse • Andrea Clark • Sexual Health Scholars Program, 2010-2011

2. The numbers. • Childhood sexual abuse is very common. • Most of us will encounter abused children in med school or later in practice. • How common is it? • 24% of girls • 8-10% of boys

3. But, I’m just a med student... • Now is the time to develop your own patterns of thought and communication with patients. • What do YOU value? Make sure you build it into your own patterns. • We can make space to consider issues other than the biomedical diseases in front of us.

4. Barriers for Physicians • Unsure what questions to ask • Unsure what to do with the answers • Concern about further endangering the patient • Don’t let fear take control!

5. Mandatory reporting • In many states, any person who suspects child abuse or neglect is required to report. • Check the following site for your local requirements. • HTTP://www.childwelfare.gov/systemwide/laws_policies/statutes/manda.cfm

6. Child abuse reporting hotlines • Follow this link to find the appropriate reporting phone numbers. • http://www.childwelfare.gov/pubs/reslist/rl_dsp.cfm?rs_id=5&rate_chno=11-11172

7. Definition of sexual abuse • Any sexual activity a child cannot comprehend or consent to...or that violates law. • Specific behaviors: • fondling, any combination of oral, anal and/or genital contact, exhibitionism, voyeurism, exposure to pornography.

8. When to consider abuse? • Sexually acting out or sexual knowledge beyond what the child should know.  • There is a long list of behavior changes that can occur but can also occur with other stressors. • 95% of exams are normal but it’s still worth looking.

9. Behavior changes that should give you pause. • Sexual acting out (the most specific indicator) • Aggression • Problems in school • Regression (e.g. thumb sucking, use of a security blanket) • Sleep disturbances • Depression • Eating disturbances • Substance use

10. Age-appropriate sexual behavior • Birth - 2 yrs. • Explore all body parts, including genitals • Begin to notice differences in their body from others

11. Age-appropriate sexual behavior • 3-4 years old • Curious about babies • Play doctor with friends / siblings close in age • More exploration of genitals as part of potty training • May increase genital touching as soothing behavior

12. Age-appropriate sexual behavior • 5-7 years old • Learn about sexuality from peers • Understand touching genitals is private • Questions about sexuality • May try out new sexuality-related words

13. Sexual abuse must be differentiated from “sexual play” or age-appropriate behavior. • Sexual play: • Developmental level of participants is similar • Activity occurs without coercion.

14. Resources on Sexual Development • For parents: • http://www.pcaiowa.org/documents/newsletters/Part-1.pdf • http://www.pcaiowa.org/documents/newsletters/Part-2.pdf • http://www.siecus.org/_data/global/images/FAT_Newsletter_V3N4.pdf • For providers: • http://www.iowaepsdt.org/EPSDTNews/2003/sum03/Talk_Sexual_Abuse.htm

15. Concerning medical problems • Anogenital trauma • Bleeding, irritation or discharge in genital region • Dysuria • Frequent urinary tract infections • Encopresis • Enuresis (especially after continence has been achieved) • Oral trauma • Somatic complaints such as recurrent abdominal pain or frequent headaches resulting from psychologic stress

16. Note: • Pregnancy or diagnosis of a sexually transmitted disease in a minor are diagnostic of sexual abuse.

17. What are the Risk Factors for Childhood Sexual Abuse?

18. Risk Factors • Inappropriate expectations placed on the child • Substance abuse in caregivers • Young parents • Impulsive parents • Mental illness in parents • Punitive disciplining techniques • Parent was abused as a child

19. Risk Factors Cont’d • Isolation / lack of support system • Family / domestic violence • Poverty / unemployment • Single parent

20. History and Physical Exam

21. Remember! • In 80% of legally confirmed cases of child sexual abuse, there are NO diagnostic physical findings! • The child’s story is the most important evidence.

22. How to get the story. • Interview the child alone if at all possible. • Document precisely (record verbatim!). • Open-ended questions (“Has anyone ever touched you in a way that you didn’t like or that made you feel uncomfortable?”)

23. When “In” is really “In” • Often prepubertal girls don’t understand what “in” the vagina means. • So, make sure to clarify this for the record: between thighs, labia, buttocks, or actually in the vagina.

24. Physical exam • Have a chaperone. • Explain everything in advance to patient and caretaker. Document that you’ve done so. • Look over whole body for any lacerations, ecchymoses, petechiae.

25. Why is the exam normal? • Most cases involve oral-genital contact or fondling. • Delay in disclosure. • Offender usually known to the child and has “groomed” the child over time. • Genital injuries heal quickly. • Takes a lot of experience to do a good exam.

26. What about STIs? • If you are concerned about sexual abuse, it’s important to consider STIs. • Here is a link to specific treatment guidelines: http://www.cdc.gov/std/treatment/2010/sexual-assault.htm • Very detailed information on what to do and when. • The gist: don’t treat presumptively for STDs. Wait for results!

27. Physical Exam Overview • As a medical student, you will most likely not be doing this exam yourself.

28. Physical Exam • Don’t forget to examine oral cavity and anus for evidence of forced penetration. • IF THE PATIENT PRESENTS WITHIN 72 HOURS • Obtain a rape kit from the ETC • It’s a good idea to call your local child advocacy center to get their advice on how to use this.

29. Equipment. • Magnification and illumination are key. • Otoscopes can work for this, but a culposcope is best because it allows you to take photos.

30. How to examine prepubertal female genitalia. • Gently retract labia majora with thumb and forefinger pressing down and out. Iatrogenic tears can occur, so be careful!

31. Hymenology, cont’d • Apart from some children with ambiguous genitalia, all girls have a hymen. • Hymens change with exposure to estrogen. • Hymens heal quickly. • The hymen of a prepubertal girl is very sensitive and will hurt if touched.

32. Hymenology, cont’d. • Sex does not necessarily injure the hymen. • Tampons do not injure the hymen. • If post-pubertal, examine the folds. • Use q-tip to gently examine. • Use foley: insert, inflate, gently pull out until very light traction is felt.

33. Findings suggestive of abuse • Genital warts or herpes with no other history • Trauma (bruising, tears, bleeding, transection of hymen) • Absence of hymen tissue • Positive gonorrhea culture outside neonatal period • HIV + without perinatal transmission • Trichomonal vaginalis after 1yr. • Pos Chlamydia if older than 3 • Syphilis when prenatal transmission is ruled out

34. Diagnostic of Abuse • Pregnancy • Sperm on child’s body

35. Documentation • Examine the hymen from the 3 to 9 o’clock position. This is most common location for injuries. • The 9 to 3 o’clock area has many more variants. • Draw a picture in your note. Include the position of the child.

36. Examination of boys • Sitting, supine or standing • Look for bite marks, abrasions, ecchymosis (from suction) • Anal exam with gentle traction of gluteal folds.

37. For more information • This is a very helpful, comprehensive paper. • Lahoti SL, McClain N, Giardet R, McNeese M, Cheung K. Evaluating the child for sexual abuse. American Family Physician. 2001 Mar 1;63(5):883-893. • http://www.aafp.org/afp/2001/0301/p883.html

38. More References • Local hotlines: http://www.childwelfare.gov/pubs/reslist/rl_dsp.cfm?rs_id=5&rate_chno=11-11172 • Mandatory reporting info: http://www.childwelfare.gov/systemwide/laws_policies/statutes/manda.cfm • www.nationalchildrensalliance.org • http://www.iowaepsdt.org/EPSDTNews/2003/sum03/Talk_Sexual_Abuse.htm • STI treatment: http://www.cdc.gov/std/treatment/2010/sexual-assault.htm • 5-part guide: http://www.pcaiowa.org/preventing_child_sexual_abuse.html

39. Resources on Sexual Development • For parents: • http://www.pcaiowa.org/documents/newsletters/Part-1.pdf • http://www.pcaiowa.org/documents/newsletters/Part-2.pdf • http://www.siecus.org/_data/global/images/FAT_Newsletter_V3N4.pdf • For providers: • http://www.iowaepsdt.org/EPSDTNews/2003/sum03/Talk_Sexual_Abuse.htm

40. Acknowledgements • I would like to thank Dr. Regina Butteris at St. Luke’s Child Protective Center in Hiawatha, IA for her support and guidance in putting this project together.