Secondary sexual characteristics in boys: estimates from the national health and nutrition examination survey III, 1988-1994.

BACKGROUND: Descriptive data on pubertal stages for a representative population of racially and ethnically diverse boys in the United States have not been published to our knowledge. OBJECTIVE: To determine at what ages boys in the United States reach each of the 5 sexual maturity stages for genital and pubic hair growth. DESIGN AND SETTING: Cross-sectional survey from the National Health and Nutrition Examination Survey III (NHANES III), 1988-1994. PARTICIPANTS: A population-based sample of 2114 boys aged 8 to 19 years representing 16 575 753 boys according to NHANES III sampling strategies. The sample included white, African American, and Mexican American boys. MAIN OUTCOME MEASURES: Sexual maturity stages for genital maturation and pubic hair growth. RESULTS: The median (equivalent mean) ages at stage 2 for pubic hair development of white, African American, and Mexican American boys were 12.0 (95% confidence interval [CI], 11.7-12.3), 11.2 (95% CI, 10.9-11.4), and 12.3 (95% CI, 12.1-12.6) years, respectively, and at stage 2 for genital growth were 10.1 (95% CI, 9.6-10.6), 9.5 (95% CI, 8.9-10.0), and 10.4 (95% CI, 9.6-11.1) years, respectively. All 3 groups were significantly taller and heavier than boys in previous NHANES reports and showed earlier genital maturation and pubic hair growth than previous studies based on Tanner staging. Statistically significant differences among the 3 racial/ethnic groups were found in the median ages of onset of pubic hair growth and genital development at stage 5 with and without controlling for height and weight, indicating an earlier age of attainment for the African American boys. CONCLUSIONS: The median (mean) ages at the onset of genital and pubic hair growth were younger than in past studies. Additional studies are required to further evaluate these findings and to explore the public health implications.

Earlier onset of puberty in girls: relation to increased body mass index and race.

OBJECTIVE: A recent study conducted by the Pediatric Research in Office Settings network provided evidence that girls in the United States, especially black girls, are starting puberty at a younger age than earlier studies had found, but the reasons for this are not known. Because nutritional status is known to affect timing of puberty and there is a clear trend for increasing obesity in US children during the past 25 years, it was hypothesized that the earlier onset of puberty could be attributable to the increasing prevalence of obesity in young girls. Therefore, the objective of this study was to reexamine the Pediatric Research in Office Settings puberty data by comparing the age-normalized body mass index (BMI-ZS; a crude estimate of fatness) of girls who had breast or pubic hair development versus those who were still prepubertal, looking at the effects of age and race. RESULTS: For white girls, the BMI-ZS were markedly higher in pubertal versus prepubertal 6- to 9-year-olds; for black girls, a smaller difference was seen, which was significant only for 9-year-olds. Higher BMI-ZS also were found in girls who had pubic hair but no breast development versus girls who had neither pubic hair nor breast development. A multivariate analysis confirms that obesity (as measured by BMI) is significantly associated with early puberty in white girls and is associated with early puberty in black girls as well, but to a lesser extent. CONCLUSIONS: The results are consistent with obesity's being an important contributing factor to the earlier onset of puberty in girls. Factors other than obesity, however, perhaps genetic and/or environmental ones, are needed to explain the higher prevalence of early puberty in black versus white girls.

Is race or ethnicity a predictive factor in Shaken Baby Syndrome?

OBJECTIVE: Previous studies have concluded that shaken baby syndrome occurs more often among Whites than among Blacks. The purpose of this study was to determine whether race is a predictive factor in Shaken Baby Syndrome when population and referral patterns are considered. METHODS: A retrospective medical record review of closed head injuries due to child abuse during the time period January 1992 to July 1997 was conducted at three pediatric tertiary care medical centers in North Carolina. Patients included children, ages 0-4 years, identified from medical record reviews and child abuse databases. Only North Carolina residents were included. The specific rates of shaken baby syndrome in Whites versus non-Whites in the referral area were computed. RESULTS: The difference in the rate of shaken baby syndrome from the referral area was not statistically significant among Whites versus non-Whites (26.7/100,000 versus 38.6/100,000, p = .089) Most of the perpetrators were male (68%), and most victims (76%), lived with their mothers and biologic father or mother's boyfriend. CONCLUSION: Race was not a significant factor in predicting shaken baby syndrome in the referral area studied, and therefore is not a useful factor in targeting groups for intervention.

Underascertainment of child abuse mortality in the United States.

CONTEXT: Mortality figures in the United States are believed to underestimate the incidence of fatal child abuse. OBJECTIVES: To describe the true incidence of fatal child abuse, determine the proportion of child abuse deaths missed by the vital records system, and provide estimates of the extent of abuse homicides in young children. DESIGN AND SETTING: Retrospective descriptive study of child abuse homicides that occurred over a 10-year period in North Carolina from 1985-1994. CASES: The Medical Examiner Information System was searched for all cases of children younger than 11 years classified with International Classification of Diseases, Ninth Revision codes E960 to E969 as the underlying cause of death and homicide as the manner of death. A total of 273 cases were identified in the search and 259 cases were reviewed after exclusion of fetal deaths and deaths of children who were not residents of North Carolina. MAIN OUTCOME MEASURE: Child abuse homicide. RESULTS: Of the 259 homicides, 220 (84.9%) were due to child abuse, 22 (8.5%) were not related to abuse, and the status of 17 (6.6%) could not be determined. The rate of child abuse homicide increased from 1.5 per 100000 person-years in 1985 to 2.8 in 1994. Of all 259 child homicides, the state vital records system underrecorded the coding of those due to battering or abuse by 58.7%. Black children were killed at 3 times the rate of white children (4.3 per 100000 vs 1.3 per 100000). Males made up 65.5% (133/203) of the known probable assailants. Biological parents accounted for 63% of the perpetrators of fatal child abuse. From 1985 through 1996, 9467 homicides among US children younger than 11 years were estimated to be due to abuse rather than the 2973 reported. The ICD-9 cause of death coding underascertained abuse homicides by an estimated 61.6%. CONCLUSIONS: Using medical examiner data, we found that significant underascertainment of child abuse homicides in vital records systems persists despite greater societal attention to abuse fatalities. Improved recording of such incidences should be a priority so that prevention strategies can be appropriately targeted and outcomes monitored, especially in light of the increasing rates.

The epidemiology of adolescent homicide in North Carolina from 1990 to 1995.

BACKGROUND: Rates of homicides by adolescents under age 18 years tripled from 1984 to 1994. Most studies report data on urban adolescents and young adults as a single age group (age 15-24 years), but homicide characteristics among adolescents, especially those younger than 15 years, may differ from those of young adults. OBJECTIVE: To describe the homicide characteristics among adolescents age 11 to 18 years in North Carolina from 1990 to 1995. METHODS: A retrospective, descriptive analysis of adolescent homicides using the medical examiner database. Police interviews provided additional information for cases from 1993 to 1995. RESULTS: There were 419 victims from 1990 to 1995 (average annual rate: 9.7 per 100000 adolescents; 9.9 in urban counties, 7.1 in rural). Victims were mostly ages 15 to 18 years (85%), male (79%), and black (76%); 48% lagged behind in school, and, by police report, 40% had a criminal record. Only 23% of the identified perpetrators were strangers. Firearms (59% were handguns) were used in 83% of homicides. Proportionally more younger adolescents (age 11-14 years) were killed by means other than firearms than 15- to 18-year-olds (chi2 = 24.2, P = .007). Drug-related motives (23%) were most common, followed by non-drug-related altercations (20%) and retaliations (17%). CONCLUSIONS: Proportionally more North Carolina adolescents than urban young adults (ages 15-24 years) were killed by firearms (83% vs. 75%). Proportionally fewer adolescents were killed by police, strangers, or intimate partners. Interventions should include reducing access to firearms and drugs, and helping adolescents develop nonviolent strategies to resolve disputes. Efforts should be focused on adolescents who lag behind in school and have criminal records.

Clinician agreement on physical findings in child sexual abuse cases.

OBJECTIVE: To measure agreement among experienced clinicians regarding the interpretation of physical findings in child sexual abuse cases and to determine whether knowledge of clinical history affects the interpretation of the physical findings. DESIGN: Experienced clinicians rated colposcopic photographs on a scale of 1 to 5 with 1 being normal and 5 being clear evidence of penetrating injury. To answer an additional study question of whether clinical history affected interpretation, 4 clinicians rated 69 cases in which they were blinded to the patients' histories and 70 cases in which the patients' histories were available. The other 3 clinicians then rated the same cases with the presence or absence of history reversed. SETTING: All clinicians involved perform child sexual abuse examinations at tertiary care centers. PATIENTS: A total of 139 girls with Tanner stage 1 or 2 genitalia who were referred to a general pediatric clinic at an academic medical center for examination of possible sexual abuse. RESULTS: Half of the photographs were interpreted as indicating little or no evidence of abuse. Of those photographic sets that both readers could interpret, 39% were in perfect agreement and 77% disagreed by 1 category or less. Perfect agreement across all possible pairs of readers was 34.5%. Agreement was better when the patient's clinical history was unknown (29.3% vs 38.9%, P = .005). The kappa, a measure of interrater reliability, indicated poor agreement among clinicians. The combined kappa for the first group of clinicians was 0.22 without knowledge of clinical history and 0.11 with knowledge of clinical history. For the second group of clinicians, the kappa was 0.31 without knowledge of clinical history and 0.15 with knowledge of clinical history. The overall kappa across all 7 clinicians disregarding clinical history was 0.20. Agreement was best for categories 1 (normal, kappa = 0.28) and 5 (clear evidence of a penetrating injury, kappa = 0.39). CONCLUSIONS: Clinicians educated and experienced in assessing child sexual abuse do not agree perfectly on the interpretation of photographs of genital findings in girls with Tanner stage 1 or 2 genitalia. Clinicians agree less when a patient's clinical history is available. Efforts should be directed at standardizing physical findings and avoiding overemphasis on physical findings in child sexual abuse cases.

Secondary sexual characteristics and menses in young girls seen in office practice: a study from the Pediatric Research in Office Settings network.

OBJECTIVE: To determine the current prevalence and mean ages of onset of pubertal characteristics in young girls seen in pediatric practices in the United States. METHODS: A cross-sectional study was conducted by 225 clinicians in pediatric practices belonging to Pediatric Research in Office Settings, a practice-based research network. After standardized training in the assessment of pubertal maturation, practitioners rated the level of sexual maturation on girls 3 through 12 years who were undergoing complete physical examinations. RESULTS: Data were analyzed for 17,077 girls, of whom 9.6% were African-American and 90.4% white. At age 3, 3% of African-American girls and 1% of white girls showed breast and/or pubic hair development, with proportions increasing to 27.2% and 6.7%, respectively, at 7 years of age. At age 8, 48.3% of African-American girls and 14.7% of white girls had begun development. At every age for each characteristic, African-American girls were more advanced than white girls. The mean ages of onset of breast development for African-American and white girls were 8.87 years (SD, 1.93) and 9.96 years (SD, 1.82), respectively; and for pubic hair development, 8.78 years (SD, 2.00) and 10.51 years (SD, 1.67), respectively. Menses occurred at 12.16 years (SD, 1.21) in African-American girls and 12.88 years (SD, 1.20) of age in white girls. CONCLUSIONS: These data suggest that girls seen in a sample of pediatric practices from across the United States are developing pubertal characteristics at younger ages than currently used norms. Practitioners may need to revise their criteria for referral of girls with precocious puberty, with attention to racial differences.

Vaginal foreign bodies and child sexual abuse.

OBJECTIVE: To determine whether vaginal foreign bodies (VFBs) in prepubertal girls are associated with sexual abuse and whether evidence exists in earlier reports for such an association. DESIGN: Retrospective case review. SETTING: General pediatric clinic at Duke University Medical Center, Durham, NC. PARTICIPANTS: All 12 girls 10 years of age and under who, between 1985 and 1988, were seen in the general clinic and subsequently found to have VFBs. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: Clinic protocol required referral of all children with vaginal bleeding, unusual discharge, or VFBs to the Child Protection Team at the medical center, which also served as a pediatric gynecology consultation service. Records for the 12 girls, whose mean age was 6.3 years, showed 19 visits for single, multiple, or recurrent VFBs. Two girls had concurrent sexually transmitted diseases. Eight met diagnostic criteria for confirmed sexual abuse; three, for suspected abuse; and in one, abuse status was unknown. CONCLUSIONS: Vaginal foreign bodies in young girls may be a previously unrecognized indicator of sexual abuse. Girls with VFBs should be evaluated for possible sexual abuse. Prospective studies on the suggested association between VFBs and sexual abuse need to be conducted.

Pediatric acquired immunodeficiency syndrome. Barriers to recognizing the role of child sexual abuse.

The only reportable exposure categories for human immunodeficiency virus (HIV) infection of children are vertical transmission from an HIV-infected mother or receipt of infected blood or blood products. Although sexual transmission of HIV among adults is the subject of intense concern, sexual transmission of HIV to children during child sexual abuse has received almost no investigative attention. This review discusses factors contributing to the exclusion of sexual transmission of HIV to children from studies of the epidemiology of HIV infection. Difficulties occur in screening and confirming abuse in nonselected populations of children, perceived and real barriers exist to the evaluation for HIV of sexually abused children, and problems occur in the assessment for child sexual abuse of HIV-infected children. Impediments to the understanding of the relationship between sexual abuse and HIV infection in sexually abused, HIV-infected children are considered, and measures that can allow these barriers to be overcome are discussed.

Transmission of human genital papillomavirus disease: comparison of data from adults and children.

A substantial body of evidence has demonstrated that the primary means of transmission of genital warts in sexually active adults is through sexual contact. However, the epidemiology and social significance of anal-genital warts in prepubertal children is controversial. Debate continues regarding the frequency with which these lesions have resulted from sexual abuse or transmission by other means. An accurate understanding of the dominant means of transmission of anal-genital warts in children is of particular importance because that understanding influences the extent to which child protective services may become involved following a diagnosis. This paper reviews the evolution of the data on the means of transmission of human papilloma virus disease of the genital tract of adults and compares those data with the information available concerning the transmission of anal-genital human papillomavirus-related disease in children. Methods for the diagnosis of child sexual abuse that have developed in the past decade form one of the bases for the evaluation of studies of the transmission of anal-genital human papillomavirus-related diseases to children.

Children's perceptions of genital examinations during sexual abuse evaluations.

Children's reactions to the medical evaluation of sexual abuse and the methods that enhance their coping ability have not been well addressed in the literature. For many children, a genital examination can be highly stressful, and may even trigger memories of the sexual abuse itself. Stress can be reduced by preparing the child for the examination, by giving the child greater control, and by debriefing the child (and parents) afterward. Research is needed to develop the most effective techniques for reducing children's stress during a genital examination.

Sexual abuse of human immunodeficiency virus-positive children. Outcomes for perpetrators and evaluation of other household children.

OBJECTIVE: To obtain the following data that pertain to programs for the prevention of sexual abuse and sexual transmission of human immunodeficiency virus (HIV) to children: (1) to determine the prevalence of sexual abuse among siblings and other children cohabiting with sexually abused HIV-positive children, and (2) to determine if programs designed to restrain identified perpetrators from further acts of child sexual abuse were instituted. DESIGN: Case series. SETTING: Households of previously described sexually abused HIV-infected children. PATIENTS AND OTHER PARTICIPANTS: Twenty-two siblings or other children who lived in the homes of 14 previously described HIV-infected sexually abused children. Eight perpetrators of the abuse were identified. MAIN OUTCOME MEASURES: Sexual abuse of cohabiting children was confirmed with disclosure interviews, witness by other persons, diagnosis of another sexually transmitted disease, or an abnormal physical examination result that was highly suggestive of sexual abuse. Telephone contact with the Department of Social Services, county sheriff or police, and district attorney provided data regarding reports, criminal indictments, trials, convictions, and plea-bargain arrangements for the identified perpetrators. RESULTS: Eleven (50%) of the 22 cohabiting children were confirmed to have been sexually abused and four (18%) were suspected of having been sexually abused. Seven (32%) of the cohabiting children could not be examined and it was not known if they had been sexually abused. No assailant was tried for a criminal offense, required to participate in offender therapy, or prohibited from unsupervised visitation of children. CONCLUSION: Programs for the prevention of sexual abuse and sexual transmission of HIV to children require means of ensuring the safety of children exposed to perpetrators and require adequate supervision of perpetrators and their adherence to therapy.

Evaluation of sexually abused and nonabused young girls for intravaginal human papillomavirus infection.

OBJECTIVE: The objective of this study was to compare the prevalence of intravaginal human papillomavirus-associated disease in two groups of girls to develop information regarding the means of transmission of anal-genital human papillomavirus disease. DESIGN: A pair of parallel studies of prevalence of human papillomavirus infections in two populations of prospectively enrolled girls. PATIENTS: Index patients consisted of 15 consecutive girls aged 11 years or younger who were confirmed to have been sexually abused, had signs or symptoms of vaginal disease, and required generalized anesthesia for evaluation. Selection of nonabused control patients was based on negative findings from screening evaluations and physical examinations. MAIN OUTCOME MEASURES: Prevalences of cervical-vaginal human papillomavirus infections in the two populations were compared. Vaginal wash samples from index and control patients were assayed for human papillomavirus 1, 2, 4, 6, 11, and 16 by reverse-blot and Southern transfer hybridization methods. Papanicolaou smears were examined from index patients. RESULTS: Vaginal wash samples from five (33%) of 15 index patients were positive for human papillomavirus 6, 11, or 16, compared with none of 17 controls. The presence or absence of external anal-genital warts was not correlated with results from the assay of intravaginal samples. Blinded readings of vaginal exfoliative cytologic findings of the index patients showed koilocytosis, atypia, or inflammatory reactions in four of five human papillomavirus-positive girls, and normal cytologic findings in one human papillomavirus-positive girl. CONCLUSION: These findings support other studies that indicate that sexual contact is a major route in the transmission of anal-genital human papillomavirus-related disease in children. Evaluation of intravaginal specimens was required to identify human papillomavirus-infected girls since the results of the wash samples were not correlated with the presence or absence of external anal-genital warts.

Human immunodeficiency virus transmission by child sexual abuse.

During 1987-1989, 14 (14.6%) of the 96 children who tested positive for the human immunodeficiency virus (HIV) and were followed up by the Duke University (Durham, NC) pediatric acquired immunodeficiency syndrome team were confirmed to have been sexually abused. Every sexually abused child was evaluated for each of five modes of HIV transmission, and in nine children the pathway was identified. Four of the study children acquired HIV from child sexual abuse and in six, abuse was a possible source. Transmission by child sexual abuse was the most frequent of the proven modes of acquisition of HIV in this population. The other proven modes of acquisition were vertical transmission (n = 3) and HIV-contaminated blood transfusion (n = 2). Twelve males were identified (n = 8) or suspected (n = 4) of being perpetrators. Three knew themselves to have HIV at the time of an assault and eight were aware that the child had HIV at the time of an assault. There was no indication from any child that "safe sex" precautions had been observed. Children with HIV infection had multiple risk factors for abuse or neglect. The sociological descriptors of the lives of the 14 abused children showed multiple known risk factors for sexual abuse that also overlapped with known risk factors for or sequelae of the acquisition of HIV infection. These included drug abuse and alcoholism in the home, prostitution of a parent, lack of parenting, poverty, and chronic illness of the child. Prevention efforts should recognize that children as well as adults are at risk for sexually transmitted HIV infection.