Sexual Abuse of Children

00:01 So let’s switch gears a little to talk some on sexual abuse of children.

00:07 It’s incredibly common for children to be very reluctant to talk about sexual abuse.

00:13 They may be embarrassed.

00:14 They may have been coerced by their perpetrator into not telling.

00:19 This may present with just behavioral issues.

00:22 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.

00:33 So in those cases, we need to have an elevated height of concern over the potentiality of sexual abuse.

00:40 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.

00:53 And last, usually the physical exam outside of perhaps abusive penetrative trauma may be normal.

01:03 And certainly if a rape kit for example isn’t done within a 72-hour period, that may be falsely negative as well.

01:10 So it’s important to do a physical exam, but understand that documentation of everything that’s said as well is very important.

01:18 So for the GU exam in sexual abuse victims, it’s important to examine within 72 hours of the event.

01:26 A rape kit is performed when a patient has incurred rape.

01:31 This is at any age.

01:32 And this involves swabs, specimens for DNA analysis, et cetera.

01:38 It’s a complicated thing to do and requires experience with it.

01:42 Usually ER physicians are best trained in this, child abuse physicians as well.

01:47 If you have someone in your hospital who has experience, it’s best for them to do the rape kit.

01:53 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.

02:06 You can gently provide traction to the labia majora outward and upward so that you can visualize the introitus.

02:14 It’s important to document hymen appearance and presence of normal variants.

02:19 Remember, there can be hymens that have unusually appearances such as a septated hymen, which is not necessarily pathologic.

02:29 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.

02:39 Also, remember that just erythema may not be a sign or symptom of abuse.

02:45 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.

02:54 You need to show evidence of tears or bruising.

02:58 You need to test and look for signs of sexually transmitted diseases.

03:02 Certainly, genital warts or herpes are highly indicative of an abusive situation.

03:08 And also don’t forget to examine the rectum for signs of tears or discharge.

03:14 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.

03:31 You can also see scarring and this is the same patient.

03:35 A period later, you can see that there’s been scarring of the ridge of that hymen.

03:39 That’s also pathognomonic for an abusive situation.

03:43 So you can make delayed diagnosis with scarring in hymens in girls.

03:49 This takes practice and experience and the best thing to do is consult a child abuse physician.

03:55 So how do we care for sexual abuse victims? Well, of course, we’re going to do complete STD testing and offering for treatment.

04:03 We will provide prophylaxis for sexually transmitted diseases including HIV within 72 hours of the assault.

04:10 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.

04:20 That’s so important because these patients may often need lifelong mental health care.

04:26 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.

04:39 So that’s my review of child abuse and thanks for your time.