Child Sexual Abuse

1
Child Sexual Abuse

• Robert Allan Shapiro, MD
• Childrens Hospital Medical Center
• Cincinnati, Ohio
• 513-636-7966

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Sexual Abuse Definition

• Activities by an older or mature person that
  expose a child to sexual stimulation
  inappropriate to the childs age, role in the
  family, and developmental status.
• Can be violent assault or non-violent coercion.

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Sexual Abuse Definition

• Includes vaginal and anal penetration,
  oral-genital contact, genital fondling,
  commercial exploration of the children in
  pornography, and incest.

4
National Studies on Prevalence

• 20 of adult woman in the U.S. have experienced
  sexual abuse. 20 retrospective studies
• Male sexual abuse is estimated at 7. Finklehor
  estimate
• Of the 63 million children in the U.S.,8 ½
  million are sexually abused.
• 500,000 children/year are abused.

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Unknown Unproven Abuse

• In 1993, 330,000 reports of sexual abuse.
• However, only 150,000 were substantiated.
• The prevalence was probably 500,000.
• 350,000 children/year remain unprotected.

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Adolescent Perpetrators

• 60-80 of offenders began deviant sexual
  interests during adolescents.
• 1/3 of offenses occur within the family.
• 2/3 of offenses occur while they baby-sit.
• Most are reenacting own abuse.
• Average of 8 victims before arrest.

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Presenting signs of sexual abuse

• Behavior changes
• new fears
• depression
• acting out
• night terrors, nightmares
• runaway
• suicide attempt

• Physical symptoms
• discharge
• genital injury
• bleeding
• STD
• pregnancy

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Issues of Abused Boys

• Stigma of homosexuality
• Loss of freedom
• Expected male role
• deal with problems alone
• dont be so sensitive
• be strong
• allegiance

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Medical Findings

• Normal findings are common
• Abuse occurs without causing injury
• Transmission of infection uncommon
• Many exam findings are non-specific
• Injuries will heal making recognition difficult

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Different exam techniques
Graphic removed for public display. To request
the original presentation, contact Robert Allan
Shapiro, M.D., 513-636-7966.
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Size of the hymenal opening
Cantwell (1983) 74 girls with gt 4mm were abused
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Frequency of Abnormal Exams
Review of 21 studies
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Healing of the hymen
Graphic removed for public display. To request
the original presentation, contact Robert Allan
Shapiro, M.D., 513-636-7966.
14
Healed tears
Graphic removed for public display. To request
the original presentation, contact Robert Allan
Shapiro, M.D., 513-636-7966.
15
Adams, Joyce Knudson, Sandra Genital Findings
in Adolescent Girls Referred for Suspected Sexual
Abuse. Arch Pediatr Adolesc Med 1996
150850-857.

• Retrospective review of 204 charts
• adolescents reported penile-vaginal penetration
• medical records, colposcopic photos
• Abnormal findings 32 (suspicious, suggestive,
  evidence)
• higher incidence
• in girls reporting bleeding at time of assault
• seen within 72 hours of assault

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Sexually Transmitted Diseases
17
Muram, D. Speck, P.M. Dockter, M. Child
Sexual Abuse Is There a Need for Routine
Screening for N. Gonorrhoeae? J Pediatr Adolesc
Gynecol 1966979-80.

• Examined prevalence of GC
• 865 prepubertal girls
• 2743 women
• Prepubertal 12 girls w/ GC infections
• 12 girls infected (1.4)
• all had vulvovaginitis
• Older females 5.6

18
Ingram, David et. al. Vaginal Gonococcal
Cultures in Sexual Abuse Evaluations Evaluation
of Selective Criteria for Pre-teenage Girls.
Pediatrics 1997 99(6)

• 2731 GC cultures in girls under age 12
• 84 girls had GC infections
• 80 had a vaginal discharge
• 4 without discharge
• 2 had contact with perpetrator known to have GC
• 1 GC isolated from urine culture
• 1 had a sister (lt 12y/o) with GC infection

http/www.pediatrics.org/cgi/content/full/99/6/e8
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Clinical infections chlamydia

• Children
• sites include vagina, urethra, and rectum
• asymptomatic infection from birth may last up
  until 3 years old (or longer)
• Hammerschlag 1994 Ped Ann 23349-353.
• 2-13 prevalence of infection from sexual abuse
• Hammershlag, et al. 1983 Ped Inf Dis. 3100-104.
• Ingram, et al. 1984 Ped Inf Dis. 397-99.
• Ingram, et al. 1986 Ped Inf Dis. 5226-229.

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Cell culture chlamydia

• This is the current Gold Standard
• specificity approaches 100
• only acceptable test in suspected abuse/assault
• Sensitivity is 70-85 compared to PCR
• Cold, fast transport of specimen is critical
• Technique
• specimens are inoculated onto cell culture
• within 48-72 hr., fluorescein-labeled antibodies
  bind to chlamydia lipopolysaccharide or major
  outer membrane protein

21
Embree, et al. Acceptability and usefulness of
vaginal washes in premenarcheal girls as a
diagnostic procedure for STDs. PID
199615662-7.

• 138 girls, alleged abuse
• Age 2-13, Tanner I-III
• Obtained samples of
• vaginal swabs
• vaginal washes
• Cultured compared samples for
• chlamydia GC
• Performed PCR
• 29 vaginal washes

• Culture from swabs
• 1 GC
• 2 chlamydia
• Culture from washes
• 2 GC
• 2 chlamydia
• PCR
• 2 GC
• 4 chlamydia