Sexual Abuse

Abstract

There are many ways to sexually abuse a child or adolescent, and most leave no visible trace. No single sign or symptom, on its own, can be used to affirm that a child has been sexually abused; the suspicion is based on a combination of factors.

Dating based on clinical examination data is highly imprecise.

11.1 Definitions

As we begin this chapter on sexual abuse, we run immediately into the problem of definition . There are a number of expressions currently in use. “Sexual abuse” is the term most commonly used in the literature. “Sexual exploitation” refers to the use of human beings for profit—i.e., pornography and prostitution. “Sexual violence” emphasizes the violent or sadistic aspects of certain acts, and “incest” refers to intrafamilial abuse.

In a 1977 lecture to the American Academy of Pediatrics, Henry Kempe [1] defined sexual abuse as the “involvement of dependent, developmentally immature children and adolescents in sexual activities that they do not fully comprehend, to which they are unable to give informed consent, or that violate the social taboos.”

The National Center for Child Abuse and Neglect focuses on the position occupied by the abuser and defines sexual abuse as any contact or interaction between an adult and a child in which the child is used for sexual stimulation—whether that of the adult or some third party [2].

Krugman and Jones [3] discuss the criminological means and define sexual abuse as the participation of a child or adolescent minor in sexual activities that he is unable to understand, are inappropriate to his psychosexual development, are coerced through violence or seduction, or violate social taboos.

Making reference to age and developmental stage , the World Health Organization (WHO) defines sexual abuse as acts performed on a child by an adult or significantly older person for the purposes of sexual pleasure [4].

While there are several proposed definitions, each highlighting particular aspects, all of them frame sexual abuse as child abuse.

Sexual abuse includes direct physical contact (fondling or penetration) and acts that occur via visual, verbal, or psychological interaction (indecent exposure, the production of pornographic images of children, obscene telephone messages, masturbation requests, etc.).

It is important to distinguish sexual abuse from sexual play , which is common and concerns young children at the same developmental stage exploring their genitalia through mutual interest, with no coercion or sexual penetration [5].

11.2 Epidemiology

Sexual violence is endemic. According to a 2011 meta-analysis on prevalence, 12.5% of minors—or one in every eight children—are victims of sexual abuse, which reportedly affects 18% of girls and 7.6% of boys. Girls are two to three times more likely to be victims than are boys in Asia, Australia, Europe, North America, and a number of African countries [6]. Prevalence is lower in China, particularly among girls, and several protective factors have been proposed, including Confucian family values and how masculinity is defined [7].

Although sexual abuse occurs in all sociocultural contexts, it remains little-discussed by professionals due to difficulty in imagining such situations—especially in high-income settings.

Incest is characterized by repetition and progression from fondling to penetration.

Nearly all perpetrators are male and are known to the child in more than two thirds of cases.

Perpetrators may have been victims themselves, and the connection between abuse committed and abuse suffered should always be considered, particularly in adolescence.

11.3 Risk Factors

11.3.1 Risk Factors for Sexually Abusing a Child or Adolescent

The risk factors for sexually abusing a child are better known for men than for women.

On the individual level, sexual abusers are a heterogeneous group in terms of both criminology and psychopathology. Studies have, however, found some common characteristics:

• Poor emotional skills

• Identity construction based on an overvaluation of sexual performance

• Erroneous beliefs or cognitive distortions regarding child sexual abuse

• A history of physical, sexual, and/or psychological abuse [8]

On the relational and familial level , there are also some risk factors more specific to perpetrators of child sexual abuse:

• Difficulty with intimate relationships

• Social isolation

• Association with sexually delinquent peers

• A patriarchal family environment

Lastly, there are community and societal risk factors . These include:

• Social norms that support male superiority and the sexual rights of men over women

• Opinion makers who do not do enough to fight gender inequality

• A social construction of masculinity based on violence and sexual domination [9]

11.3.2 Risk Factors for Being Sexually Abused as a Child or Adolescent (0–18 Years)

On the individual level, anyone can be sexually abused at some time in life. For children and adolescents, however, there are certain characteristics that are found more often. Individual risk factors include:

• Being female

• Being between 6 and 11 years of age, but only for intrafamilial sexual abuse

• Being between 12 and 17 years of age, but only for extrafamilial sexual abuse

• Having previously suffered physical or sexual violence

• Having an intellectual impairment, a disability, a chronic illness, or a mental health problem [10]

On the relational and familial level, certain factors are associated with a higher risk of being sexually abused; the most frequently reported are as follows:

• Lack of parental supervision

• Parental alcohol or drug use

• Parents with mental health problems

• The presence of a stepfather in the household [11]

On the institutional level, sexual violence is more likely to develop in a rigid hierarchical system, a culture of silence that protects the reputation of the institution, whether educational or religious, and a lack of regulatory mechanisms—a lack of organizational policy and employee screening, nonavailability of a best practice standards, and a lack of reporting procedures.

At the societal level, risk factors include:

• The hypersexualization of youth

• Traditional norms regarding gender roles

• An ideology in which men have sexual rights over women

• A lack of consequences for committing child sexual abuse [12]

11.4 Clinical Presentation

11.4.1 Circumstances of Discovery

There are a variety of circumstances in which a doctor might encounter a child or adolescent sexual abuse victim. There are two possible basic scenarios.

In the first scenario, there is a clear request for help, and the doctor will have no major difficulties getting the history and managing the case. The child or adolescent reports, unsolicited, the sexual abuse she just experienced—usually in an extrafamilial context—or consults for something that happened in the past, an assault or incest situation from several months, or even years, earlier, that she just revealed to a loved one, who accompanies her. False allegations are extremely rare with such unsolicited disclosures, and what the child says should be listened to closely.

In the second scenario, the sexual abuse is not verbalized directly, and the doctor may have problems. The child expresses what happened to her via the somatic complaints or behavior problems that prompted the visit and need to be decoded. Running away and attempting suicide are two common ways in which adolescents reveal sexual abuse.

Numerous suggestive signs and symptoms have been reported in the literature. One cannot assert that a child has been sexually abused once or more based on a single symptom; what sets off alarm bells is a combination of multiple factors (Table 11.1).

Table 11.1 Symptoms of sexual abuse in children and adolescents

However, inappropriate sexualized behaviors are a good indicator of sexual abuse in young children.

To give a few examples, touching one’s own genitals and masturbation, attempting to see an adult or another child naked, and showing one’s genitals to another child are all considered normal in children between the ages of 2 and 5 years.

In that same age group, however, mimicking sexual movements, trying to put one’s tongue in someone’s mouth when kissing, or inserting objects into the genitals warrants an assessment [13].

11.4.2 Sexually Transmitted Infections

The discovery of a sexually transmitted infection (STI) can lead to a diagnosis of sexual abuse.

An STI in a prepubescent child should raise suspicion of sexual abuse and prompt testing for other STIs. After age 1, the likelihood that an STI was caused by sexual abuse is:

• Very high for Neisseria gonorrhoeae and Treponema pallidum infections. In these cases, sexual abuse is almost certain.

• High for Chlamydia trachomatis, Trichomonas vaginalis, and HSV2.

• Moderately high for HSV1 and Papillomavirus.

• Low for Candida albicans and nonspecific vulvovaginitis infections.

In practice, Neisseria gonorrhoeae, Chlamydia trachomatis, and Treponema pallidum are the leading cause of sexually transmitted infections in children. While Neisseria gonorrhoeae and Treponema pallidum infections—aside from the neonatal period and (the very rare) nonsexual vertical transmission—indicate sexual abuse, Chlamydia trachomatis is far less specific; because the pathogen can persist for 2–3 years, young children can develop the infection from mother-to-fetus transmission [14].

These infections—particularly those due to Chlamydia trachomatis—are often asymptomatic. Otherwise, they present as vulvovaginitis (not cervicitis, like in adults) and urethritis. Rectal or pharyngeal involvement is rare (Neisseria gonorrhoeae and Chlamydia trachomatis). The risk of developing an upper infection from a lower one has not been determined, but appears to be high for Neisseria gonorrhoeae and for Chlamydia trachomatis. Syphilis has the same presentation as in adults. The most common cause of leukorrhea is nonspecific bacterial vaginitis (due to Mycoplasma hominis, Gardnerella vaginalis, Ureaplasma urealyticum, Bacteroides spp., etc.). Some microorganisms, such as Mycoplasma hominis and Ureaplasma urealyticum, can be found in the normal vaginal flora at any age, and their presence does not in itself prove sexual transmission [15].

Sexually transmitted viral infections include papillomavirus, HIV, hepatitis B, and herpes virus (mainly HSV2). Papillomavirus infections are discussed in Sect. 11.6 below.

11.4.3 The Clinical Examination

11.4.3.1 Urgency of and Practical Conditions for the Examination

Sexual abuse requires a highly specialized clinical examination. If the doctor seeing the child is unaccustomed to performing such exams, it is better not to do so and to send the young victim to a specialist team quickly.

If it has been less than 3 days since the sexual assault, it is considered a medicolegal emergency. At that point it is still possible to find recent, unhealed lesions and collect samples for evidentiary purposes (to look for semen and touch DNA and take toxicology samples). If the abuse is less recent, it is up to the doctor to decide on the urgency of the clinical examination based on the context and his or her experience. It is always preferable to perform an in-depth clinical exam, however—not just to look for suspicious semi-recent or healing lesions, but also to reassure the child and her family.

To avoid further trauma, the examination should be done in a calm setting, taking as much time as necessary. A properly conducted examination is reassuring, provided the doctor gains the patient’s trust, explains the examination process, and pays careful attention to her psychological state. It is also important to pay attention to the family, whose emotional reactions can in large part determine the child’s.

11.4.3.2 The Interview

The first phase of the clinical examination is the interview with the child. If possible, the child should be seen without the parents. Having a neutral, reassuring third person (nurse, social worker, etc.) present can be extremely helpful. The interview is done in successive stages, in order to be as non-leading as possible. After being introduced to the child, the doctor explains his or her mission. The goal of the first part of the interview is to gain the child’s trust. This is facilitated by talking to the child about her life in general (family composition, rank among siblings, home environment, etc.) and her activities (school, nonschool activities, social life and relationships, etc.). During this step, the doctor assesses the child’s psychological state and developmental level. She also determines the child’s orientation in time and space.

The second part of the interview deals with the sexual assault itself, allowing the child to describe it in her own words, completely freely, even if she contradicts herself or hesitates. At most, the doctor can repeat her last words back to her to try to get things going again if the child stops talking. It is not until the next part that the doctor asks specific, open questions aimed at clarifying certain points while continuing to use the child’s vocabulary.

By the end of the interview, the following should have been ascertained:

• The date, time, location, and circumstances of the assault

• Whether it was a one-time or repeated assault

• The nature of the assault (fondling, penetration, ejaculation, condom use)

• Whether there were any threats or violence

• The relationship between the victim and perpetrator—emotional ties or authority relationship

11.4.3.3 The General Physical Examination

The general physical examination looks for signs of violence (ecchymoses, hematomas, bite marks, etc.), which are described in detail (size, color, and location) and drawn on a diagram or photographed. Ecchymosis on the inner thighs is highly suggestive of sexual abuse (Fig. 11.1). Describing the functional impact of the lesions is helpful in determining total work disability.

Fig. 11.1

Ecchymoses on the inner thighs . Postpubescent adolescent girl in lithotomy position. Allegations of penile vaginal penetration the previous day. Two bluish ecchymoses on the upper third on the right inner thigh, suggesting that she was gripped by a hand

If there are blood or semen spots on the child’s clothing, the latter must be stored in a paper (not plastic) bag for possible analysis later by a crime laboratory.

11.4.3.4 The Gynecological Examination

The entire vulva should be examined: the labia majora and minora, the posterior labial commissure, the clitoris, the urinary meatus, and the hymen. Colposcopy photos preserve the findings and reduce the number of repeat exams.

The “frog-leg” position (patient on her back, knees bent, and soles of the feet together) should be used for young girls. Under good lighting, the hymen is exposed by simply separating the labia majora (labial traction). Adolescent girls should be examined in lithotomy position; good visualization of the hymen often requires the use of a cuffed tube or Foley catheter (Fig. 11.2). The configuration of the hymen (Figs. 11.3, 11.4, and 11.5), the appearance of its free edge, and its compliance should be described (Figs. 11.6, 11.7, and 11.8). The hymen is sometimes imperforate (Fig. 11.9). For medicolegal purposes, defloration is defined as a complete break in the hymenal tissue up to the vaginal wall (Fig. 11.10). Ecchymosis can sometimes be seen (Fig. 11.11). For most adolescent girls, the hymen is flexible and elastic enough to allow full sexual intercourse without injury, making it impossible for the examiner to either confirm or rule out previous complete penile penetration. In prepubescent girls, however, vaginal penetration always causes a traumatic tear of the hymen, accompanied in some cases by injuries to the vaginal wall.

Fig. 11.2

Foley catheter allowing more sensitive analysis of the hymen

Fig. 11.3

Normal annular hymens with different-size openings. Examination done in frog-leg position. The free edge of the hymen is regular, and there are no injuries meeting the medicolegal definition of defloration. (a) Four-year-old girl. (b) Nine-year-old girl, wide vaginal opening. (c) Five-year-old girl, very narrow punctiform opening

Fig. 11.4

Normal semilunar (or crescentic) hymen . Two-year-old girl examined in frog-leg position. No allegation of sexual abuse. Examination motivated by recent change in behavior. Semilunar hymen with a highly regular free edge

Fig. 11.5

Normal semilunar (or crescentic) hymen . Eleven-year-old girl examined in lithotomy position. Allegations of sexual fondling. Semilunar hymen with a highly regular free edge

Fig. 11.6

Advantages of using a Foley catheter for examining the hymen. Fifteen-year-old girl in lithotomy position. Allegations of digital vaginal penetration 2 weeks prior to examination. (a) Without the catheter, the hymen cannot be explored using labial traction. (b) With the catheter, a normal semilunar hymen can be seen. The left edge of the hymen is readily visible. There is no injury meeting the medicolegal definition of defloration

Fig. 11.7

Normal denticulate or fringed hymen . Twelve-year-old girl in lithotomy position. Allegations of digital vaginal penetration 3 days prior to the examination. Denticulate hymen whose right edge is fully displayed against the catheter balloon. There is no injury meeting the medicolegal definition of defloration

Fig. 11.8

Normal septate hymen . Fifteen-year-old girl in lithotomy position. Allegations of sexual fondling without penetration. Septate hymen with a band extending from the 12 o’clock to 6 o’clock position. There is no injury meeting the medicolegal definition of defloration

Fig. 11.9

Imperforate hymen . Five-year-old girl in frog-leg position. No allegation of sexual abuse. Examination motivated by the child’s sexualized talk

Fig. 11.10

Medicolegal defloration . Sixteen-year-old girl in lithotomy position. Allegations of vaginal penetration less than 24 h earlier. Medicolegal defloration with torn hymen (arrow)

Fig. 11.11

Hymenal ecchymosis . Fourteen-year-old girl in lithotomy position. Allegations of vaginal penetration 24–36 h earlier. Hymenal ecchymosis (arrows)

11.4.3.5 The Anal Examination

In children, the proctological examination is also done in the “frog-leg” position; in adolescents, it is done in supine position with the knees bent. The knee-chest position allows a good view of the anus. The skin, external genitals, and anus are inspected; digital rectal examination is not recommended. The doctor inspects the skin for irritation, wounds, abrasions, and/or hematomas and the anus for fissures, ulceration, skin tags, and/or flattening of the skinfolds radiating from the anal orifice (Figs. 11.12 and 11.13). Perineal anatomy is a bit different in children than in adults, and it is not uncommon to observe “physiological” anal gaping if there is stool in the rectal ampulla or the examination position favors it (Fig. 11.14).

Fig. 11.12

Anal fissures . Sixteen-year-old boy in knee-chest position, allegations of anal penetration less than 24 h earlier, bouquet of superficial anal fissures between the 4 o’clock and 8 o’clock positions

Fig. 11.13

Anal wound. Fifteen-year-old boy in knee-chest position; allegations of anal penetration less than 24 h earlier. Anal wound at the 12 o’clock position

Fig. 11.14

Anal gaping in a 5-year-old child. Allegations of anal gaping and suspected incest by the mother, in the midst of a divorce. Imputability difficult to determine

11.4.3.6 Limitations of the Examination

Over the past 20 years, the recommendations on medical examination of children suspected of being sexually abused have changed substantially. In the 1980s and 1990s, there was a great deal of data published on the genital and anal findings from examinations of children who had not been victims of sexual violence. Performed systematically on thousands of children, those examinations yielded a better understanding of normal variations [16, 17]. The data has been updated numerous times, most recently in 2011 [18].

Though the examination is normal in the majority of cases, that does not rule out the possibility of sexual abuse [19,20,21,22,23]. Indeed, discovery often comes long after the events, and most young victims are examined several days, if not months, after the assault, when any traumatic injuries have already disappeared. Moreover, some sexual assaults leave no visible marks on the child’s body—for example, fondling without penetration or penetration in an already sexually active adolescent girl. Hence, listening to the child is of the utmost importance.

Some injuries are nonspecific and can be difficult to interpret. A large prospective study from the United States, published in 2002, analyzed a sample of 2384 children referred for sexual abuse; it found that the clinical features were nonspecific in more than 96% of cases [21].

Rarely, the findings suggest sexual abuse or sexual contact in an adolescent girl [24]. The prevalence of traumatic injuries in girls who were penetrated vaginally is on the order of 4–6%, depending on the study [25].

Gynecologically, however, we have to distinguish between prepubescent children and adolescents. Penile vaginal penetration invariably causes hymenal injury in prepubescent girls, most often inferiorly. Vaginal bleeding will be immediate.

Regarding the anal region, the injuries that do occur disappear quickly and often completely. Anal injuries are even less common than injuries to the vulva and hymen [26, 27]. This highlights the importance of routine sample collection to look for semen after sexual abuse with penetration, even when the examination appears absolutely normal.

In some cases, examination long after the alleged events reveals lesions suggestive of sexual abuse. Bruni [28] reviewed the clinical examinations of 50 children in whom the perpetrator admitted anal penetration and found that anal scars and skin tags (either single or multiple) were very common (84% and 32% of cases, respectively).

Some perineal injuries are caused not by sexual abuse, but by intentional or unintentional ill-treatment (e.g., penile hair tourniquet and poultices, respectively). The circumstances behind these injuries must be elucidated via careful, in-depth investigation.

Lastly, it is important to be alert to situations in which there is more than one form of abuse. At one British center, the percentage of battered children that were also sexually abused ranged from 7 to 24% [29].

The French National Authority for Health recently proposed a system for classifying medicolegal findings according to whether they are definitely or not definitely related to sexual abuse [30]. There are more detailed classification schemes available indicating normal variations examiners are likely to encounter [31].

Findings Suggestive of Sexual Abuse

• Lacerations of the labia, posterior labial commissure, penis, scrotum, perineal tissues, or perineum (may also be caused by accidental injury)

• Partial or complete tear of the hymen, hymenal ecchymosis, and vaginal laceration

• Deep perianal laceration involving the external anal sphincter

• A break in the hymenal ring with no visible tissue to the base, in the posterior (inferior) half of the hymen, confirmed in knee-chest position

• Neisseria gonorrhoeae-positive genital, anal, or pharyngeal culture outside the neonatal period

• Confirmed syphilis, aside from perinatal transmission

• Pregnancy

• Semen inside or on the child’s body

Because child victims have no sexual experience, they often lack even the words to describe what happened to them. They might honestly mistake vestibular penetration—that is, between the rolls formed by the labia majora but not past the hymen—for hymenal penetration . In that case, a report of sexual penetration is not deceitful, but due simply to the child’s lack of experience. This is why it is useful to try to reconstruct with the child what the abuser did, on the exam table, and note her feelings, to get the best possible idea of what happened.

11.5 Additional Tests

The examiner decides which additional tests should be done based on the child’s account. The decision should consider the child’s age, the type of assault, how long it has been since the last assault, any signs and symptoms suggesting a possible STI, the perpetrator’s serological status (if known), the prevalence of STIs in the child’s community, and the fears expressed by the child and her family. Adolescent girls are recommended to have a complete workup for pregnancy and sexually transmitted infections (see below).

The victim and her parents should be given the results at a follow-up visit.

11.5.1 Testing for Sperm

The only absolute proof of recent sexual contact is the presence of spermatozoa . It is essential to look for sperm if the latest assault was recent and included sexual penetration. Samples are taken, based on the history, at every site that might contain semen, even if there is no traumatic injury [32]. Cytological testing for sperm involves swabbing and smearing on a slide, with no cover slip or fixative. The recommendations are to do four swabs and three slides per site and store the swabs in the freezer. The first swab is left intact (not smeared), so that it can be used for later testing should the slides be negative.

Spermatozoa can be found up to 48 h after the assault in the vagina and up to 5 days at the cervix. The time interval is shorter in prepubescent girls due to the lack of cervical mucus. Sperm can be detected for 24 h in the rectum if the victim has not defecated and for 6 h in the mouth if she has not eaten or brushed her teeth [33].

11.5.2 Forensic Samples

In cases of recent sexual assault with sexual penetration, samples are collected for possible genetic identification of the perpetrator; the swabs used for cytological testing and the control swab for the victim should be frozen immediately at −20 °C and kept available to the legal authorities.

It is now possible to identify an assailant using what is called “touch DNA,” where the assailant’s cells are recovered from the child’s body—in particular, skin cells, from the areas where she was held, or cells from his saliva, from areas where she was licked or sucked. This is done by soaking a cotton swab in sterile water or normal saline and pressing it against the skin surface to take the sample. That swab, placed back in its sleeve, should also be frozen immediately.

The person collecting the samples must follow strict rules that to avoid contaminating the samples with his own DNA; these include wearing a gown, cap, shoe covers, and a mask and using new gloves for each sample site.

11.5.3 Bacteriology and Virology Samples

A local sample should be collected to look for gonococci if the child exhibits local signs of infection or if the examination is done long after the assault, given that the incubation period is about 1 week.

Serological testing should include TPHA-VDRL, HIV serology, hepatitis B serology (if the child was not vaccinated previously), and hepatitis C serology. These indicate the victim’s serological status at the time of the assault and should be repeated at 1 month and at 3 months (or 4 months, if antiretroviral therapy is prescribed).

Chlamydia trachomatis testing requires a urine sample for PCR (polymerase chain reaction)-based identification .

11.5.4 Pregnancy Testing

A beta hCG (β-hCG) pregnancy test should be administered to all adolescent girls past puberty who suffered vaginal penetration. If the initial result is negative but the victim’s menstrual period is late, a second test should be offered. If the initial result is positive, the hCG level can be used to date the pregnancy and determine whether it is linked to the assault.

11.5.5 Other Samples

If there is suspicion of drug-facilitated sexual assault —that is, administration of psychoactive substances without the victim’s knowledge—blood and urine samples should be collected. The reader is invited to consult the chapter devoted specifically to this topic.

The clothes worn by the child at the time of the assault may contain traces of the assailant and should be stored in paper (not plastic) bags to avoid altering potential DNA until the legal authorities take them.

11.6 Differential Diagnosis

11.6.1 False Allegations of Sexual Assault

All professionals dread false allegations of child sexual abuse. That should not, however, blind us to the fact that the majority of children and adolescents who claim, unsolicited, that they were sexually abused are sincere. They may nevertheless try to conceal the actual perpetrator’s identity when they are caught in a “loyalty conflict,” that is, faced with the dilemma of having to accuse someone they love or respect—especially a parent.

Most false allegations come from very young children (ages 2–6 years), unconsciously influenced or manipulated by a parent during an acrimonious divorce or separation. In that context, the signs of distress exhibited by the child are misinterpreted as symptoms of abuse. From there it is only a short step to where a complaint or report sets the legal machinery in motion. The child then has to deal with questioning, medical examinations, and expert evaluations that may ultimately create doubt in her mind about whether the abuse really happened. Hence false allegations have consequences that are comparable to those of a real assault, in the sense that both require a specialized approach [34].

In addition, some adolescent girls use false allegations as a way to explain a pregnancy or as an excuse for being away from the family home. These situations, which are not uncommon, primarily involve girls who are caught in the act, and in addition to giving a vague account of the assault, they often claim “amnesia .”

11.6.2 Accidents

Because an accident is often the initial excuse used to explain a pelvic injury in a young child, accidental mechanisms are especially important to look at.

In straddle injuries, which are usually caused by a child falling onto the crossbar of a bicycle, the soft tissues are compressed against the pelvic bones. The injuries in boys—lacerations and/or ecchymosis—are to the scrotum and/or penis. The injuries in girls—lacerations or abrasions—are to the labia minora or majora, but not the hymen. Vaginal and hymenal lesions can only be caused by a straddle injury involving a penetrating object or by sexual assault.

11.6.3 Condylomata Acuminata (Anogenital Warts)

The viruses most often responsible for sexually transmitted infections are the human papillomaviruses (HPVs) [35]. The infection may be entirely latent or manifest clinically as vulvar, perianal, periurethral, perineal, or cervical condylomata acuminata—or even as cervical dysplasia. Condylomata acuminata present as raised, verrucous lesions less than 5 mm in diameter that grow in larger clusters (Fig. 11.15). The warts are usually painless and uncomplicated, but occasionally bleed or become painful or itchy, especially when they are scrubbed during bathing. Because transmission in adults is primarily sexual, anal warts in children and adolescents often raise suspicion of sexual abuse. There are, however, non-venereal modes of transmission. Auto- and heteroinoculation from verrucae vulgaris (common warts) is also possible. That transmission mode was deduced from the fact that a given individual can have identical HPV 2 and 4 subtypes in both common and anogenital warts. Nonsexual transmission via fomites has also been described [36,37,38,39]. As HPV has been reported in the amniotic fluid of over 60% of asymptomatic HPV-infected pregnant women, vertical transmission should be the first thing investigated when a child under 2 years of age shows clinical signs of papillomavirus infection [40].

Fig. 11.15

Papillomavirus condylomata of the anus . Ten-year-old child. Sexual abuse possible but not certain, because mucosal HPV types can be found with this type of lesion

Children with anal or genital warts should have a thorough skin examination to look for common warts, and close family members should be checked to see if they are carriers. The estimated frequency of HPV transmission in sexual abuse situations has declined from 30% in the 2000s to less than 10% today [41,42,43]. Those data are especially important to keep in mind, given that HPV transmission may have occurred months, or even years, before the warts became clinically apparent.

11.6.4 Other Skin Conditions

There are many skin conditions that can be mistaken for sexual assault-related injuries:

• Hyperpigmentation of the anal margin due to hyperkeratinization.

• Scratches due to nocturnal itching; look for pinworm infection.

• Langerhans cell histiocytosis , in which perianal lesions are sometimes seen. The primary lesion is an infiltrated, occasionally crusted, papule. The lesions have a predilection for the body folds, scalp, and the area behind the ears, in particular. Biopsy confirms the diagnosis.

• Perineal blisters from congenital epidermolysis bullosa and bullous pemphigoid, in particular. Biopsy confirms the diagnosis.

• Behçet’s disease , which typically has two foci: oral and genital ulcers.

• Lichen sclerosus , which is more common in females and can cause vulvar bleeding. Examination reveals pinkish papules that grow together in a figure-of-eight pattern around the anogenital region. Here again, biopsy confirms the diagnosis [44].

• Incontinentia pigmenti , an X-linked disorder. A mother with cicatricial alopecia and dental abnormalities (conoid incisors) helps confirm the diagnosis.

• Psoriasis .

• Dermatitis on an infant’s bottom, including diaper (napkin) rash, caused by maceration in a child who is not changed often enough.

• Seborrheic dermatitis, which appears between the first and third month of life. It has two foci: on the scalp and around the mouth and in the perianal region, where it tends to form large patches.

• Contact dermatitis, caused by exposure to allergens and irritants like bathing products such as foam or bubble baths, soaps, etc.

11.6.5 Infectious Diseases

• Streptococcal anitis, with its classic perianal erythema (the throat culture is positive in more than half of cases); perianal staphylococcus causes much more desquamation and tends to recur.

• Ecthyma gangrenosum [45].

• Lower urinary tract infections, whose symptoms (burning on urination and pollakiuria) may be misinterpreted as the result of sexual abuse, especially in little girls.

• Perianal candidiasis.

• Varicella and herpes.

11.6.6 Inflammatory Diseases

Crohn’s disease : Consider this disease if there are anal fistulas, deep anal fissures , and skin tags, particularly when there is also delayed growth, diarrhea, or abdominal pain. Crohn’s disease lesions can sometimes be misleading, for example, a deep fistula opening mimicking a deep wound in an adolescent (Fig. 11.16) or a gaping, ulcerated anus in an adolescent (Fig. 11.17). Vulvar sites are also possible.

Fig. 11.16

Differential diagnosis : Crohn’s disease. Deep fistula opening mimicking a deep wound in a 16-year-old boy

Fig. 11.17

Differential diagnosis: Crohn’s disease . Gaping anus, ulcerated with a deep rhagade in a 17-year-old boy. A biopsy of the lesion showed a granuloma, confirming the diagnosis

11.6.7 Urethral Conditions

Urethral polyps and prolapse can cause genital bleeding, thus highlighting how important it is to consider these whenever genital bleeding is found in little girls of African or West Indian origin.

11.6.8 Congenital Abnormalities

Congenital malformations and abnormalities are sometimes discovered late in infants and young children; these include epispadias, hemangiomas of the hymen and vagina, perianal lymphangiomas, and perianal pyramidal protrusion (Fig. 11.18).

Fig. 11.18

Differential diagnosis : perianal pyramidal protrusion. Benign lesion in a young girl, age 12 years here, which resolved on its own in a few months

11.7 Dating (of Injuries)

If dating injuries is imprecise, dating events is even more so. Acute superficial injuries usually heal quickly—within 48–72 h—and so an examination done some time after the event may be completely normal, showing no sequelae [46]. Deeper lesions may leave scars that can be seen and photographed long after the assault. In medicolegal defloration that causes bleeding, the lesions tend to be located in the inferior (posterior) half of the hymen, and a scar may persist. If there has been recent anal penetration, a bleeding fissure, blood coming out of the anus, or painful anal spasms may be seen. Residual anal gaping is more suggestive of past anal penetration.

11.8 Treatment Principles

Genital wounds : After collecting local samples (semen testing, forensic samples, and gonorrhea testing), wounds should be disinfected with soapy water and then with an antiseptic.

Preventing pregnancy : If an adolescent girl is examined within 72 h of sexual abuse with vaginal penetration, she should be offered a contraceptive drug or the so-called “morning-after” pill. Side effects can include nausea and vomiting, asthenia, abdominal pain, and menorrhagia.

Preventing bacterial infections : Given the low prevalence of sexually transmitted infections in children and the lack of a single antibiotic effective against all offending bacteria, antibiotics are not recommended.

Preventing HIV infection : The aim in instituting antiretroviral therapy after sexual exposure is to reduce the risk of seroconversion. Its indications are well-codified [47]. Accurate risk assessment involves analyzing several factors: the assailant’s HIV status (often unknown, in practice), the time elapsed since the abuse, the type of abuse, whether the victim had an infection or lesions with breaks in the genital or oral mucosa, whether there was bleeding during intercourse, etc.

If it is determined that there is indeed a risk of infection, prophylactic therapy should be started as soon as possible. In practice, a combination of two nucleoside reverse-transcriptase inhibitors (NRTIs) and one protease inhibitor (PI) are administered as soon as possible, and no later than 48 h after the assault. The treatment, taken twice daily, should continue for 4 weeks if the assailant’s HIV status turns out to be positive or remains unknown. Clinical and laboratory monitoring is recommended.

Side effects are common and varied, including nausea, vomiting, asthenia, abdominal pain, diarrhea, and muscle aches. They should be made explicit to patients and treated, so that patients do not stop taking their medications.

Should the presumed assailant be brought in for questioning, the investigators are encouraged to demand an evaluation of his serological status in terms of sexually transmitted infections—HIV, in particular—as soon as possible.

Postexposure prophylaxis for hepatitis B : May be administered within 48 h of the assault if the victim is not already vaccinated and the presumed perpetrator’s serological status is not yet known. It consists of serovaccination, which involves injecting hepatitis B immune globulin in one arm and a dose of vaccine in the other.

Hospitalization: The need for hospitalization should be evaluated on a case-by-case basis. It may be essential in cases where the abuser and the victim live under the same roof and no measures have yet been taken to protect the child or adolescent. The offer of hospitalization may also address other needs, in particular when the emotional reactions of the victim or her family make an immediate return home impossible. It may also be medically warranted in certain circumstances—for example, when the victim needs surgery, turns out to be pregnant, or shows signs of infection.

Follow-Up— Management : If the child is not hospitalized at the end of the medical examination, it is important to clearly explain the aims of outpatient follow-up and be sufficiently convincing as to its necessity. Beyond the strictly medical aspects, there should always be follow-up to evaluate how the child is handling the aftermath of the assault and its disclosure. There is no one-size-fits-all emotional reaction after a sexual assault. Referral to a psychotherapist will depend on the individual situation, but is required if there are signs of psychological distress. The medical team should reassess the victim’s psychological state at each new contact, and in particular when they evaluate her treatment tolerance and recheck her serological status.

Sequelae: The sequelae of sexual abuse have been well-documented in adults. Their likelihood increases when child or adolescent sexual abuse goes untreated. There is a significant association between childhood sexual abuse and anxiety, depression, eating disorders like bulimia and anorexia/bulimia, a variety of psychosocial problems, addiction, high-risk behaviors—sexual, in particular—and post-traumatic stress disorder [48,49,50,51,52].

Psychosomatic disorders like fibromyalgia, chronic pain, functional gastrointestinal disorders, and chronic fatigue are classic [53,54,55]. A study of encopresis in children ages 4–12 years followed for sexual abuse or psychiatric problems, compared to a control group, showed the same rate of encopresis was as common in the children who had been sexually abused as in those with psychiatric disorders and much more common than in the control group, highlighting the fact that encopresis appears to be more a reflection of psychological distress than an indicator of sexual abuse [56].

Key Points

• There are many ways to sexually abuse a child or adolescent, and most leave no visible trace.

• No single sign or symptom, on its own, can be used to affirm that a child has been sexually abused; the suspicion is based on a combination of factors.

• After age 1, discovery of a Neisseria gonorrhoeae or Treponema pallidum infection in a prepubescent child is almost certainly an indication of sexual abuse.

• Clinical examination is usually normal; that does not rule out sexual abuse.

• Testing for sperm is imperative if the last assault was recent and involved penile penetration, even when there are no visible lesions.

• Hymenal injuries are highly suggestive of sexual penetration at any age.

• Anogenital warts can be spread in a variety of ways, in addition to sexual transmission.

• Dating based on clinical examination data is highly imprecise.