Children referred for possible sexual abuse: medical findings in 2384 children

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Abstract

Objective: The goal of this study was to compare rates of positive medical findings in a 5-year prospective study of 2384 children, referred for evaluation of possible sexual abuse, with two decades of research. The prospective study summarizes demographic information, clinical history, relationship of perpetrators, nature of abuse, and clinical findings. The study reports on the results by patterns of referral and the medical examination.

Results: There were 2384 children evaluated in a tertiary referral center between 1985 and 1990 for possible sexual abuse. Children were referred after they disclosed sexual abuse, because of behavioral changes or exposure to an abusive environment, and because of possible medical conditions. A total of 96.3% of all children referred for evaluation had a normal medical examination; 95.6% of children reporting abuse were normal, 99.8% who were referred for behavioral changes or exposure to abuse were also normal. Of the 182 children referred for evaluation of medical conditions, 92% were found to be normal at the time of examination by the Child Advocacy Center. The remaining 15/182 (8%) that were found to be abnormal were diagnosed with sexually transmitted diseases, acute or healed genital injuries, and were 17% (15/88) of the total cases found to have medical findings diagnostic of abuse. Interviews of the children indicated that 68% of the girls and 70% of the boys reported severe abuse, defined as penetration of vagina or anus. Penetration was associated with a higher percentage of abnormal findings in girls (6%) compared to 1% of the boys. The relationship of the abuser impacted on the severity of the abuse.

Conclusion: Research indicates that medical, social, and legal professionals have relied too heavily on the medical examination in diagnosing child sexual abuse. History from the child remains the single most important diagnostic feature in coming to the conclusion that a child has been sexually abused. Only 4% of all children referred for medical evaluation of sexual abuse have abnormal examinations at the time of evaluation. Even with a history of severe abuse such as vaginal or anal penetration, the rate of abnormal medical findings is only 5.5%. Biological parents are less likely to engage in severe abuse than parental substitutes, extended family members, or strangers.

Résumé

Objectif: Comparer les pourcentages de résultats médicaux positifs au cours d’une étude prospective qui a duré 5 ans sur une population de 2384 enfants adressés pour évaluation de la possibilité d’abus sexuels avec ceux obtenus durant vingt ans de recherche. L’étude prospective a récapitulé les données démographiques, l’histoire clinique, la relation avec les abuseurs, la nature des abus ainsi que les données cliniques. L’étude présente les résultats d’après les modèles selon lesquels les cas ont été adressés et d’après l’examen médical.

Résultats: On a évalué chez 2384 enfants la possibilité d’abus sexuels dans un center de référence tertiaire entre 1985 et 1990. Les enfants avaient été référés après révélation d’un abus sexuel, soit à cause de changements observés dans leur comportement, ou parce qu’ils avaient été exposés à un environnement dans lequel ils auraient pu être abusés, soit parce qu’il semblait possible que des constatations soient faites sous l’angle médical. Un total de 96.3% des enfants référés pour une évaluation ne présentaient pas d’anomalie à l’exament médical; 95.6% des enfants déclarant avoir été abusés étaient normaux, 99.8% de ceux qui avaient été adressés pour des changements de comportement étaient également normaux. Sur les 182 enfants adressés pour évaluation de leur état sous l’angle médical, 92% ont été considérés comme normaux au moment de leur examen au Center en faveur des Enfants. Les 15/182 (8%) restant qui avaient été identifiés comme anormaux avaient un diagnostic de maladie sexuellement transmissible, de blessures génitales aigües ou guéries et ils constituaient 17% (15/88) du total des cas présentant un diagnostic médical d’abus sexuel. Les entretiens avec les enfants ont révélé que 68% des filles et 70% des garçons avaient révélé des abus graves, comme la pénétration par le vagin ou l’anus. La pénétration était associée à un pourcentage plus élevé de constatations anormales chez les filles (6%) en comparaison avec les garçons (1%). La relation avec l’agresseur avait un impact sur la gravité de l’abus.

Conclusion: La recherche montre que les professionnels médicaux, sociaux et judiciaires se sont trop reposés sur l’exament médical pour diagnostiquer un abus sexuel. Ce que dit l’enfant demeure le seul élément diagnostique d’importance majeure pour en venir à la conclusion qu’un enfant a subi des abus sexuels. Seulement 4% des enfants adressés pour une évaluation médicale d’abus sexuel présentent une anomalie à l’examen au moment de l’évaluation. Même dans les cas où il y a eu sévice grave, c’est-à-dire avec pénétration vaginale ou anale, le pourcentage d’anomalies médicalement constatées est seulement de 5.5%. Les parents biologiques risquent moins que les parents substitutifs, les membres de la famille élargie ou les étrangers d’être à l’origine de sévices graves.

Resumen

Objetivo: Comparar las tasas de los hallazgos médicos positivos en un estudio prospectivo de 5 años a 2384 niños derivados para evaluación por posible abuso sexual en dos décadas de investigación. El estudio prospectivo resumió información demográfica, historia clı́nica, relación de los perpetradores, naturaleza del abuso, y hallazgos clı́nicos. Este estudio informa de resultados por patrones de derivación y examen médico.

Resultados: Se evaluaron a 2384 niños en un centro de derivación terciario entre 1985 y 1990 por posible abuso sexual. Los niños fueron derivados por haber revelado el abuso sexual, por cambios de conducta o exposición a un ambiente maltratante y por posibles condiciones médicas. Un total de 96.3% de todos los niños derivados para evaluación tuvieron un examen médico normal; el 95.6% de los niños que notificaron el abuso fueron normales, el 99.8% de los derivados por cambios de conducta o exposición al abuso fueron también normales. De los 182 niños derivados para evaluación por condiciones médicas, el 92% se encontró como normal en el momento del examen por el Centro de Protección Infantil. En el 8% restante, que se encontró como anormal, se observaron diagnósticos de enfermedades de transmisión sexual, heridas agudas o cicatrizadas en los genitales. En un 17% del total de casos se encontraron hallazgos de diagnóstico médico de abuso. Las entrevistas de los niños indicaron que el 68% de las niñas y el 70% de los niños notificaron abuso severo, definido como penetración vaginal o anal. La penetración se asoció con un porcentaje mayor de hallazgos anormales en niñas (6%) comparado con un 1% en los niños. La relación con el abusador impacto en la severidad del abuso.

Conclusión: La investigación indica que los profesionales médicos, sociales, y legales han confiado en el examen médico para diagnosticar el abuso sexual infantil. La historia del niño sigue siendo el único dato diagnostico que permite concluir si un niño está siendo abusado sexualmente. Solamente el 4% de todos los niños derivados para evaluación médica de abuso sexual tienen exámenes anormales en el momento de la evaluación. Incluso con una historia de abuso severo, por ejemplo, penetración vaginal o anal, la tasa de hallazgos médicos anormales es solamente de 5.5%. Los padres biológicos son menos propensos a implicarse en abuso severo que los padres sustitutos, miembros de la familia extensa o extraños.

Introduction

In 1988, Richard Krugman waved the “yellow flag” in the race to diagnose child sexual abuse (Krugman, 1988). This caution flag was raised in the midst of the wave of research published in response to escalating rates of child sexual abuse reports. Dr. Krugman called on medical professionals to pause and remember that “the initial goal of the race was to protect abused children.” However, the dramatic rise in reports of child sexual abuse and an enhanced investment in criminal prosecution overwhelmed the job of protection. He asked that all legal, social, and medical professionals commit adequate resources to unravel the complexity of the job that joins protection with criminal investigation to understand better the process and to investigate more thoroughly the science. With this knowledge we could then measure outcomes and assess the impact of intervention and investigation on the child.

Over the past 20 years, there has been a growing body of medical literature on the diagnosis of sexual abuse of children. Research included studies of genital anatomy in children selected for nonabuse Berenson et al 1991, Berenson et al 1992, Gardner 1992, Heger et al in press, McCann et al 1989, McCann et al 1990, Pokorny 1987 and reports on anatomical variations in children referred for possible sexual abuse (Adams, Harper, Knudson, & Revilla, 1994; Berenson, 2000; Bowen and Aldous 1999, Cantwell 1983, Emans et al 1987, Dubowitz et al 1992, Hobbs and Wynne 1987, Kellogg et al 1998, Orr and Prietto 1979; Palusci, 1999; Pugno 1999, Rimsza and Niggermann 1982, Teixeira 1982). In addition, there have been a few reports of healing trauma Finkel 1989, Heger et al 2000, McCann et al 1992. Based on these studies, recommendations for diagnostic criteria or standards as well as classification schemes have been developed Adams 2001, Adams et al 1992, American Academy of Pediatrics: Committee on Child Abuse and Neglect 1999, American Professional Society on the Abuse of Children 1998, Muram 1989.

Over the past two decades, most research has reported on the medical evaluation of children referred for possible sexual abuse. These children were referred after disclosure of abuse or exposure to an abusive environment or because a genital examination by a primary care medical professional needed further clarification. Research starting in 1979 (Orr, 1979) reported on rates of abnormal genital findings in the child that range from >80% Cantwell 1983, Hobbs and Wynne 1987 in the late 1980s to <3% in 2000 (Berenson, 2000) (see Table 1).

The first decade of research on child sexual abuse covered a wide range of clinical findings but lacked a consistency in terminology, methods, and results. Since 1989 most of the published research has relied on photodocumentation first described in 1986 (Woodling & Heger, 1986). Photodocumentation enhanced the potential for consistency and peer review. The evolution of peer review improved the understanding of normal anatomy and nonspecific findings, and many of the anatomical findings that were reported as abnormal in the early studies are now considered by clinicians and researchers to be nonspecific genital variations. These nonspecific anatomical variations include enlarged hymenal diameter, narrowing of the hymenal edge, partial notching or clefts of the posterior hymenal rim, erythema or swelling, bumps or irregularities, and changes in tone or rugal patterns of the anus.

With the improved access to emergency evaluations of sexual assault, a better understanding of the importance of acute injuries has developed. Following these injuries to healing provided the basis for longitudinal studies that identified the more significant findings to be acute trauma, hymenal transections, and genital scarring. Sexually transmitted diseases and positive forensics continued to provide critical diagnostic evidence.

Photodocumentation and consensus on terminology also created a more consistent level of research and contributed to the development of classification schemes (Adams, 1992; Muram, 1989), as well as consensus papers American Academy of Pediatrics: Committee on Child Abuse and Neglect 1999, American Professional Society on the Abuse of Children 1998. Standardization was also enhanced by the adoption of state protocols for interviewing children and documenting medical findings.

The standardization of terminology and development of classification schemes is reflected in the research of the 1990s. Four papers published between 1994 and 1999 (Adams et al 1994, Bowen and Aldous 1999, Kellogg et al 1998; Palusci, 1999) more closely replicated rates for normal and abnormal anatomy. Mirroring this growing collection of research and knowledge, classification schemes (see Table 2) evolved and changed Adams 2001, Adams et al 1992, Muram 1989.

Diagnosis of child sexual abuse is dynamic, and the research continues to provide necessary data on the accurate diagnosis of child sexual abuse (Adams, 2001; Berenson, 2000; Heger, Emans, & Muram, 2000). This study was undertaken to evaluate a large group of children referred for possible sexual abuse and to determine the rates of medical findings by history and/or reason for the referral.

Section snippets

Patients and methods

Over 5 years, 2742 children were referred for possible sexual abuse to a pediatric emergency department and the hospital-based Child Advocacy Center. Of the 2742 children of all ages, 358 were evaluated by medical professionals in the emergency room and are excluded from this study; 2384 children were referred to the Child Advocacy Center and were included in a prospective database that recorded demographic information, clinical history, details of disclosure, relationship of perpetrators,

Results

Of the 2384 children evaluated by the Child Advocacy Center, 1652 (69.2%) were referred after disclosing abuse, 732 (30.8%) had not disclosed abuse but were referred because of behavioral changes or exposure to an abusive environment (550), or because of anatomical variations or medical conditions (182) (see Table 3). Behaviors included sexually acting out, masturbation, regression, and fear or anger. Potentially abusive environments were defined as the disclosure of abuse by a sibling, family

Discussion

The most startling result of this study was to find that such a small percentage of children did have genital findings diagnostic of prior trauma from sexual abuse. We were encouraged to see that an increasing number of children were referred to this Child Advocacy Center for expert, multidisciplinary evaluations. Referrals came from a broad range of professionals who were mandated reporters of child abuse and from primary physicians after routine examinations. Two decades ago, most primary

Conclusions

The medical examination plays an important role in the healing of the child and the reassurance of the child and family. An appropriate, multidisciplinary evaluation by the medical professional may be the determining factor in the outcomes for the child, the family, and society. The primary goal of the medical professional is always safety and healing, but caution should be used to prevent the focus from shifting from the child to the presence or absence of medical findings diagnostic of

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