Sexual Abuse

Sexual abuse and assault are major public health problems that affect many people from all walks of life, including people of all ages and genders, but it is more prevalent in women and girls, with reports of up to 1 in 3 experiencing sexual assault at some time in their life. In addition to psychological consequences, sexual assault can result in unintended pregnancy Pregnancy Pregnancy is the time period between fertilization of an oocyte and delivery of a fetus approximately 9 months later. The 1st sign of pregnancy is typically a missed menstrual period, after which, pregnancy should be confirmed clinically based on a positive β-hCG test (typically a qualitative urine test) and pelvic ultrasound. Pregnancy: Diagnosis, Maternal Physiology, and Routine Care, STIs, and physical injury. Management includes proper examination, testing, reporting, and psychological support.

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Overview

Definitions

  • Intimate partner violence is a pattern of assaultive and coercive behavior that may include physical injury, psychological abuse, reproductive coercion, and/or sexual assault.
  • Sexual assault is a crime of violence and aggression defined as attempted sexual touching of another person without their consent.
  • Sexual abuse of children is defined as sexual activity for which a child cannot give consent, is unprepared for developmentally, or cannot comprehend, including noncontact abuse.

Epidemiology

  • Affects all communities:
    • All genders
    • All ages
    • All sexual orientations
    • Children from all social, cultural, and economic backgrounds
  • Incidence is much higher in girls and women than in boys and men.
  • Prevalence is difficult to document accurately.
    • Worldwide estimate: 5%–25% of girls and 5%–9% of boys have been exposed to some type of sexual abuse.
    • Often unreported because of:
      • Fear of medical evaluation
      • Shame and embarrassment
      • Privacy concerns
  • Approximately 1 in 3 women have experienced sexual assault during their lifetime.
    • Approximately 1 in 5 women have experienced completed or attempted rape.
    • 33% state that the assault occurred before age 17 years and 12% before age 10 years.
    • 5% of girls who have been sexually assaulted have a STI STI Sexually transmitted infections (STIs) are infections that spread either by vaginal intercourse, anal sex, or oral sex. Symptoms and signs may include vaginal discharge, penile discharge, dysuria, skin lesions (e.g., warts, ulcers) on or around the genitals, and pelvic pain. Some infections can lead to infertility and chronic debilitating disease. Overview: Sexually Transmitted Infections.
    • Prevalence during pregnancy Pregnancy Pregnancy is the time period between fertilization of an oocyte and delivery of a fetus approximately 9 months later. The 1st sign of pregnancy is typically a missed menstrual period, after which, pregnancy should be confirmed clinically based on a positive β-hCG test (typically a qualitative urine test) and pelvic ultrasound. Pregnancy: Diagnosis, Maternal Physiology, and Routine Care is approximately 8%. 
  • Approximately 1 in 4 men have experienced sexual violence involving physical contact.
    • Approximately 1 in 38 men have experienced completed or attempted rape.
    • 25% state that the assault occurred before age 17 and 25% before age 10.
  • Perpetrators (according to the Rape, Abuse & Incest National Network):
    • Intimate partner: 33%
    • Acquaintance: 39%
    • Family member: 2.5%
    • Stranger: 19.5% 
  • Special populations at increased risk:
    • Developmentally delayed children
    • Elderly patients with cognitive decline
    • Patients institutionalized with mental health disorders
    • Sexual and gender minority adolescents (gay, lesbian, bisexual, and transgender)

Classification

  • Sexual abuse includes:
    • Sexual intercourse (rape)
    • Sodomy (oral–genital or anal–genital contact)
    • Nonpenetrating sexual contact (fondling)
  • Acquaintance rape/date rape: sexual assault committed by someone known to the victim
  • Statutory rape: consensual sexual intercourse with an individual younger than a specific legal age

Clinical Presentation and Diagnosis

The patient should be approached in a nonjudgmental and respectful manner. In addition to psychological consequences, sexual assault can be associated with unintended pregnancy Pregnancy Pregnancy is the time period between fertilization of an oocyte and delivery of a fetus approximately 9 months later. The 1st sign of pregnancy is typically a missed menstrual period, after which, pregnancy should be confirmed clinically based on a positive β-hCG test (typically a qualitative urine test) and pelvic ultrasound. Pregnancy: Diagnosis, Maternal Physiology, and Routine Care, STIs, and physical injury.

History

  • Reluctance to talk is common.
  • Children may present with behavioral changes (e.g., imitating sexual acts).
  • Document the location, timing, duration, and type of force.
  • Document other injuries or forms of abuse (e.g., physical abuse).
  • Assess current safety and the presence of an emergency plan.
  • Assess for suicidal ideation.

Physical examination

  • Children may or may not have signs of abuse on physical exam.
  • Vulvovaginitis Vulvovaginitis The term vulvovaginitis is used to describe an acute inflammation of the vulva and vagina. Vulvovaginitis can be caused by several infectious and non-infectious etiologies, and results from disruption of the normal vaginal environment. Common signs and symptoms include pain, pruritis, erythema, edema, vaginal discharge and dyspareunia. Vulvovaginitis in girls should elicit consideration for an evaluation of sexual abuse. 
  • May need photos for legal proceedings
  • Anoscopy and colposcopy may be useful for visualizing injuries.
  • Document findings:
    • Hymen trauma or scarring
    • Healed genital injuries (e.g., skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin tags or granulation tissue)
    • Ecchymoses
    • Abrasions
    • Vaginal or anal tears
    • Signs of STIs, such as vesicles or condylomatous lesions

Management

Patients who present with a report of sexual assault or abuse need proper examination, testing, and psychological support.

  • Forensic evidence collection (rape kit) should be done within 72 hours.
    • May be falsely positive if delayed
    • Should always be done if there is bleeding or acute injury
    • Specimens obtained for DNA DNA The molecule DNA is the repository of heritable genetic information. In humans, DNA is contained in 23 chromosome pairs within the nucleus. The molecule provides the basic template for replication of genetic information, RNA transcription, and protein biosynthesis to promote cellular function and survival. DNA Types and Structure analysis
  • Report to police
  • Offer emergency contraception, if indicated.
  • Consider prophylactic STI STI Sexually transmitted infections (STIs) are infections that spread either by vaginal intercourse, anal sex, or oral sex. Symptoms and signs may include vaginal discharge, penile discharge, dysuria, skin lesions (e.g., warts, ulcers) on or around the genitals, and pelvic pain. Some infections can lead to infertility and chronic debilitating disease. Overview: Sexually Transmitted Infections treatment.
  • Recommended lab tests:
    • Chlamydia Chlamydia Chlamydiae are obligate intracellular gram-negative bacteria. They lack a peptidoglycan layer and are best visualized using Giemsa stain. The family of Chlamydiaceae comprises 3 pathogens that can infect humans: Chlamydia trachomatis, Chlamydia psittaci, and Chlamydia pneumoniae. Chlamydia testing of the vagina Vagina The vagina is the female genital canal, extending from the vulva externally to the cervix uteri internally. The structures have sexual, reproductive, and urinary functions and a rich blood supply, mainly arising from the internal iliac artery. Vagina, Vulva, and Pelvic Floor and anus
    • Gonorrhea Gonorrhea Gonorrhea is a sexually transmitted infection (STI) caused by the gram-negative bacteria Neisseria gonorrhoeae (N. gonorrhoeae). Gonorrhea may be asymptomatic but commonly manifests as cervicitis or urethritis with less common presentations such as proctitis, conjunctivitis, or pharyngitis. Gonorrhea testing of the pharynx Pharynx The pharynx is a component of the digestive system that lies posterior to the nasal cavity, oral cavity, and larynx. The pharynx can be divided into the oropharynx, nasopharynx, and laryngopharynx. Pharyngeal muscles play an integral role in vital processes such as breathing, swallowing, and speaking. Pharynx, vagina Vagina The vagina is the female genital canal, extending from the vulva externally to the cervix uteri internally. The structures have sexual, reproductive, and urinary functions and a rich blood supply, mainly arising from the internal iliac artery. Vagina, Vulva, and Pelvic Floor, and anus
    • Viral testing of lesions suspicious for herpes simplex
    • Trichomonas and bacterial vaginosis testing
    • HIV serology
    • Hepatitis B Hepatitis B Hepatitis B virus (HBV) is a partially double-stranded DNA virus, which belongs to the Orthohepadnavirus genus and the Hepadnaviridae family. Most individuals with acute HBV infection are asymptomatic or have mild, self-limiting symptoms. Chronic infection can be asymptomatic or create hepatic inflammation, leading to liver cirrhosis and hepatocellular carcinoma (HCC). Hepatitis B Virus and C
    • Syphilis Syphilis Syphilis is a bacterial infection caused by the spirochete Treponema pallidum pallidum (T. p. pallidum), which is usually spread through sexual contact. Syphilis has 4 clinical stages: primary, secondary, latent, and tertiary. Syphilis testing (rapid plasma reagin test)
  • Evaluate psychosocial support system and refer as needed.
  • Survivors of sexual abuse may need lifelong mental health care for: 
    • Substance abuse
    • PTSD PTSD Posttraumatic stress disorder is a psychiatric illness characterized by overwhelming stress and anxiety experienced after exposure to a life-threatening event. Symptoms last more than 1 month and involve re-experiencing the event as flashbacks or nightmares, avoiding reminders of the event, irritability, hyperarousal, and poor memory and concentration. Posttraumatic Stress Disorder (PTSD)
    • Major depressive disorder Major depressive disorder Major depressive disorder (MDD), commonly called depression, is a unipolar mood disorder characterized by persistent low mood and loss of interest in association with somatic symptoms for a duration of ≥ 2 weeks. Major depressive disorder has the highest lifetime prevalence among all psychiatric disorders. Major Depressive Disorder 
    • Suicidality
    • Distorted self-perception
    • Panic disorder Panic disorder Panic disorder is a condition marked by recurrent and episodic panic attacks that occur abruptly and without a trigger. These episodes are time-limited and present with cardiorespiratory (palpitations, shortness of breath, choking), GI (nausea, abdominal distress), and neurologic (paresthesias, lightheadedness) symptoms. Panic Disorder

References

  1. Bechtel, K., Bennett, B.L. (2021). Evaluation of sexual abuse in children and adolescents. UpToDate. Retrieved June 7, 2021, from https://www.uptodate.com/contents/evaluation-of-sexual-abuse-in-children-and-adolescents
  2. Sexual Assault Awareness. (2021). Centers for Disease Control and Prevention, Retrieved June 7, 2021, from https://www.cdc.gov/violenceprevention/sexualviolence/index.html
  3. Miller, E., Wiemann, C.M. (2020). Adolescent relationship abuse including physical and sexual teen dating violence. UpToDate. Retrieved June 7, 2021, from https://www.uptodate.com/contents/adolescent-relationship-abuse-including-physical-and-sexual-teen-dating-violence
  4. Rape, Abuse & Incest National Network (n.d.). Perpetrators of sexual violence: Statistics. Retrieved June 10, 2021, from https://www.rainn.org/statistics/perpetrators-sexual-violence
  5. Sackey, M., Murphy-Lavoie, H. (2018). Sexual assault. In Schlamovitz, G.Z. (Ed.), Medscape. Retrieved June 10, 2021, from https://emedicine.medscape.com/article/806120-overview

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