Chapter 143: Sexual Abuse

High-Yield Facts

• Most sexual abuse examinations in children are normal even with known sexual abuse.

• The history is usually the most important piece of evidence in cases of suspected sexual abuse in children.

• All 50 states require reporting suspected child abuse including sexual abuse to a proper investigatory agency (child protective services and/orlaw enforcement).

• Sexually transmitted diseases (STDs) are extremely rare in cases of pediatric sexual abuse.

• Screening for and empiric treatment of STDs is not routinely recommended in cases of pediatric sexual abuse.

• Forensic evaluation is recommended by the American Academy of Pediatrics (AAP) when the abuse occurred within the previous 72 hours.

• Speculum examinations are not indicated in preadolescent female sexual abuse patients. A thorough external genital examination is sufficient.

Etiology

The National Center on Child Abuse and Neglect defines child sexual abuse as “contact or interaction between a child and an adult when a child is being used for the sexual stimulation of that adult or another person.” Child sexual abuse includes fondling the child's genitals, getting the child to fondle an adult's genitals, mouth to genital contact, rubbing an adult's genitals on the child, or actually penetrating the child's vagina or anus. Showing an adult's genitals to a child, showing the child pornographic material, or using the child as a model to make pornographic material are also forms of child sexual abuse.

Sexual abuse of children is a very real problem in our society. Children are most often abused by adults or older children who are known to them and who can exert power over them. The victim knows the offender in 8 out of 10 reported cases.¹ The offender is more frequently male.² The offender is frequently someone that the child trusts and will often persuade the child with bribes, tricks, or coercion to engage in sex or sexual acts. This can be followed by threats to the child if he or she tells.

Increased risk for sexual abuse of children is not related to socioeconomic status or race.³

Epidemiology

Sexual abuse affects approximately 100,000 children each year in the United States.⁴ Most abuse goes unreported during childhood. However, it is estimated that 20% of girls and 9% of boys are the victims of sexual abuse during childhood.^1,3 Children of all ages are the victims of sexual abuse, but are most likely to be abused sexually during preadolescence, that is, from ages 8 to 12 years.³

Pathogenesis

The vast majority of children who are the victims of sexual abuse will have normal examinations without findings of injury. Studies have found that both normal-appearing genital tissues and nonspecific findings are seen in children known to be sexually abused.^5–7 Kellogg et al. found that of 36 adolescents who were pregnant at the ...