Medical Evaluation for Child Sexual Abuse
Sexual abuse is a problem of epidemic proportions. Pediatric nurse practitioners (PNPs) will most likely encounter sexually abused children in their practice, both those who have been previously diagnosed and others who are undiagnosed and require identification by the PNP. This continuing education article will discuss the medical evaluation of children with concerns of suspected sexual abuse. Acute and non-acute sexual abuse/assault examinations will be discussed. Physical findings and sexually transmitted infections concerning for sexual abuse/assault will also be discussed.
Sexual abuse is a problem of epidemic proportions. According to the U.S. Department of Health & Human Services (2010), more than 70,000 children were victims of sexual abuse in 2008. Twenty-five percent of girls and 16% of boys in the United States experience sexual abuse before the age of 18 years (Matkins & Jordan, 2009). Studies have suggested that approximately 1% of children experience some form of sexual abuse every year (Kellogg, 2005). Sexual abuse perpetrators are most often someone the child knows, trusts, and even loves. Compared with women, men are much more frequently identified as sexual abuse perpetrators; however, women also sexually abuse children. Adolescents are perpetrators in at least 20% of sexual abuse cases (Kellogg, 2005).
Pediatric nurse practitioners (PNPs) will most likely encounter sexually abused children in their practice, both those who have been previously diagnosed and others who are undiagnosed and require identification by the PNP. A competent medical evaluation for child sexual abuse requires a specific skill set and knowledge. Knowledge of normal ano-genital anatomy is a fundamental essential (see Figure 1). It is vital for PNPs to recognize physical findings of sexual abuse, abnormal sexual behaviors, victim disclosures of sexual abuse, and infections that raise concern for sexual abuse. The medical evaluation for child sexual abuse includes obtaining the history of abuse from the child and/or non-offending parent/guardian; identifying and documenting injury or infection; treating medical conditions arising from the abuse; providing reassurance to the child and parent; assessing the child's emotional and physical well-being and making appropriate referrals; reporting concerns of sexual abuse to Child Protective Services (CPS); and documenting findings accurately and thoroughly (Adams et al., 2007). The PNP completing a medical evaluation for suspected sexual abuse may be required to testify in court regarding statements made by the child, physical examination findings, and related documentation.
(Enlarge Image)
Figure 1.
Normal ano-genital anatomy. This figure is available in color online at www.jpedhc.org.
Children and adolescents with a concern of suspected sexual abuse may present to their PNP in a variety of ways. They may have made a verbal disclosure to a caregiver or had a caregiver witness an incident of sexual abuse. The caregiver may have suspicions of sexual abuse based on behaviors exhibited by the child or other factors. The child may present with an ano-genital physical finding or a sexually transmitted infection (STI) that raises concerns about sexual abuse, or the child may disclose sexual activity at the time of the health care visit.
The PNP must consider the possibility of sexual abuse when a child or adolescent presents with a behavioral or psychiatric disorder (Putnam, 2003). A child presenting with depression, suicidal ideation, substance abuse, post-traumatic stress disorder, or attention deficit hyperactivity disorder should be asked a few sexual abuse screening questions to explore the possibility of sexual abuse. Children, especially young children, presenting with age-inappropriate knowledge of sex should be assessed for possible sexual abuse or exposure to sexually explicit behaviors (Hornor, 2004). All well-child visits should include a few developmentally appropriate screening questions for sexual abuse because spontaneous disclosure of sexual abuse may not be offered (Hornor, 2010). Parents and children should be separated for questioning if possible. Box 1 provides appropriate screening questions. Children often are reluctant to disclose sexual abuse for a variety of reasons including fear, guilt, embarrassment, threats, family loyalty, and concern regarding consequences of disclosure. Many children never disclose their sexual abuse or disclose weeks, months, or even years after the latest incident.
Abstract and Introduction
Abstract
Sexual abuse is a problem of epidemic proportions. Pediatric nurse practitioners (PNPs) will most likely encounter sexually abused children in their practice, both those who have been previously diagnosed and others who are undiagnosed and require identification by the PNP. This continuing education article will discuss the medical evaluation of children with concerns of suspected sexual abuse. Acute and non-acute sexual abuse/assault examinations will be discussed. Physical findings and sexually transmitted infections concerning for sexual abuse/assault will also be discussed.
Introduction
Sexual abuse is a problem of epidemic proportions. According to the U.S. Department of Health & Human Services (2010), more than 70,000 children were victims of sexual abuse in 2008. Twenty-five percent of girls and 16% of boys in the United States experience sexual abuse before the age of 18 years (Matkins & Jordan, 2009). Studies have suggested that approximately 1% of children experience some form of sexual abuse every year (Kellogg, 2005). Sexual abuse perpetrators are most often someone the child knows, trusts, and even loves. Compared with women, men are much more frequently identified as sexual abuse perpetrators; however, women also sexually abuse children. Adolescents are perpetrators in at least 20% of sexual abuse cases (Kellogg, 2005).
Pediatric nurse practitioners (PNPs) will most likely encounter sexually abused children in their practice, both those who have been previously diagnosed and others who are undiagnosed and require identification by the PNP. A competent medical evaluation for child sexual abuse requires a specific skill set and knowledge. Knowledge of normal ano-genital anatomy is a fundamental essential (see Figure 1). It is vital for PNPs to recognize physical findings of sexual abuse, abnormal sexual behaviors, victim disclosures of sexual abuse, and infections that raise concern for sexual abuse. The medical evaluation for child sexual abuse includes obtaining the history of abuse from the child and/or non-offending parent/guardian; identifying and documenting injury or infection; treating medical conditions arising from the abuse; providing reassurance to the child and parent; assessing the child's emotional and physical well-being and making appropriate referrals; reporting concerns of sexual abuse to Child Protective Services (CPS); and documenting findings accurately and thoroughly (Adams et al., 2007). The PNP completing a medical evaluation for suspected sexual abuse may be required to testify in court regarding statements made by the child, physical examination findings, and related documentation.
(Enlarge Image)
Figure 1.
Normal ano-genital anatomy. This figure is available in color online at www.jpedhc.org.
Children and adolescents with a concern of suspected sexual abuse may present to their PNP in a variety of ways. They may have made a verbal disclosure to a caregiver or had a caregiver witness an incident of sexual abuse. The caregiver may have suspicions of sexual abuse based on behaviors exhibited by the child or other factors. The child may present with an ano-genital physical finding or a sexually transmitted infection (STI) that raises concerns about sexual abuse, or the child may disclose sexual activity at the time of the health care visit.
The PNP must consider the possibility of sexual abuse when a child or adolescent presents with a behavioral or psychiatric disorder (Putnam, 2003). A child presenting with depression, suicidal ideation, substance abuse, post-traumatic stress disorder, or attention deficit hyperactivity disorder should be asked a few sexual abuse screening questions to explore the possibility of sexual abuse. Children, especially young children, presenting with age-inappropriate knowledge of sex should be assessed for possible sexual abuse or exposure to sexually explicit behaviors (Hornor, 2004). All well-child visits should include a few developmentally appropriate screening questions for sexual abuse because spontaneous disclosure of sexual abuse may not be offered (Hornor, 2010). Parents and children should be separated for questioning if possible. Box 1 provides appropriate screening questions. Children often are reluctant to disclose sexual abuse for a variety of reasons including fear, guilt, embarrassment, threats, family loyalty, and concern regarding consequences of disclosure. Many children never disclose their sexual abuse or disclose weeks, months, or even years after the latest incident.