So let’s switch gears a little to talk
some on sexual abuse of children.
It’s incredibly common for children to be
very reluctant to talk about sexual abuse.
They may be embarrassed.
They may have been coerced by their
perpetrator into not telling.
This may present with
just behavioral issues.
They may be excessively
using vulgar language
or acting out sexually with siblings
as a way of sort of mirroring
what’s been done to them.
So in those cases, we need to have
an elevated height of concern
over the potentiality
of sexual abuse.
It may be those infants and children have
signs of sexual abuse or neglect on them,
and so a thorough physical
exam is critically important
and we’ll give you
an example of those.
And last, usually the physical exam
outside of perhaps abusive
penetrative trauma may be normal.
And certainly if a rape kit for example
isn’t done within a 72-hour period,
that may be falsely
negative as well.
So it’s important to do a physical exam,
but understand that documentation of everything
that’s said as well is very important.
So for the GU exam in
sexual abuse victims,
it’s important to examine
within 72 hours of the event.
A rape kit is performed when
a patient has incurred rape.
This is at any age.
And this involves swabs, specimens
for DNA analysis, et cetera.
It’s a complicated thing to do
and requires experience with it.
Usually ER physicians are best trained
in this, child abuse physicians as well.
If you have someone in your
hospital who has experience,
it’s best for them
to do the rape kit.
For young girls, if you’re going to
examine them for signs of child abuse,
the best position is the frog-leg
position is the frog-leg position
or prone kneeling over and looking from
behind in the knee to chest position.
You can gently provide traction to
the labia majora outward and upward
so that you can visualize
It’s important to document hymen appearance
and presence of normal variants.
Remember, there can be hymens
that have unusually appearances
such as a septated hymen, which
is not necessarily pathologic.
So it’s important to take a picture
if you’re not familiar with what hymens may
look like and all the variations they’re in
so that you can document
it in the court of law.
Also, remember that just erythema may
not be a sign or symptom of abuse.
It could just be from irritation, say from
bubble bath or from some other cause,
so it’s important to document
more than just erythema.
You need to show evidence
of tears or bruising.
You need to test and look for signs
of sexually transmitted diseases.
Certainly, genital warts or herpes are
highly indicative of an abusive situation.
And also don’t forget to examine the
rectum for signs of tears or discharge.
So this is the hymen of a
young girl who was raped
and you can in the first picture the
scalloping of the introitus of the hymen
as well as the bloody excoriated area,
but that scalloped nature to
the entrance of the hymen
is pathologic for acute damage.
You can also see scarring and
this is the same patient.
A period later, you can see that there’s
been scarring of the ridge of that hymen.
That’s also pathognomonic
for an abusive situation.
So you can make delayed diagnosis
with scarring in hymens in girls.
This takes practice and experience
and the best thing to do is
consult a child abuse physician.
So how do we care for sexual abuse victims?
Well, of course, we’re going to do complete
STD testing and offering for treatment.
We will provide prophylaxis for
sexually transmitted diseases
including HIV within 72
hours of the assault.
It’s of course critically important
to report this to the police
and it’s critically important to
provide these patients psychosocial
referral and followup.
That’s so important because these patients
may often need lifelong mental health care.
There can be prolonged effects of
rape in children and adolescents
that children analysis
need to deal with
and manage as they proceed forward
and continue their lives.
So that’s my review of child
abuse and thanks for your time.