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