The diagnostic utility of sexual behavior problems in diagnosing sexual abuse in a forensic child abuse evaluation clinic.

OBJECTIVE: This study examined the utility of sexual behavior problems as a diagnostic indicator of sexual abuse. The hypothesis was that sexual behavior problems are multiply determined and consequently are variably related to sexual abuse in a clinical sample. METHOD: A sample of 247 children evaluated for sexual abuse at a multidisciplinary forensic child abuse evaluation clinic were included. Results from the Child Behavior Checklist (CBCL) and the Child Sexual Behavior Inventory (CSBI) were analyzed and compared to the results of a structured abuse assessment performed independent of these scores. RESULTS: The forensic team assessment found evidence of sexual abuse in 25% of cases, and no evidence in 61%. Children in this sample exhibited an elevated level of both sexual and nonsexual behavior problems. However, considerable variability was noted in sexual behavior problem scores. Thus, in this study a high score or a low score had no relationship to the diagnosis of sexual abuse. Indeed, nonsexually abused children were just as likely to have high CSBI scores as sexually abused children. CONCLUSIONS: This study found no significant relationship between a diagnosis of sexual abuse and the presence or absence of sexual behavior problems in a sample of children referred for sexual abuse evaluation. The finding suggests that community professionals should use caution in relying on sexual behavior problems as a diagnostic indicator of abuse.

Photographing the physically abused child. Principles and practice.

Photographic documentation of significant findings is an important part of any child abuse evaluation. High-quality photographs of significant physical findings may be important in helping courts to adjudicate whether child abuse has taken place. The physician evaluating abused children should ensure adequate photographic documentation of visible lesions. Physicians who care for abused children should be familiar with the basic principles and techniques of clinical photography. These include good equipment, adequate lighting, and planned composition. Equally important is a working knowledge of camera equipment, film procedure, and medicolegal implications. This review outlines for the practicing physician the basic concepts and techniques of photographing abused children.

Medical forensic photography of the sexually abused child.

The dramatic increase in reports of sexual abuse has resulted in increasing referrals to physicians for medical evaluation and has placed demands on physicians to adequately and expertly assess these children. High quality, close-up photographs of significant lesions can be an important part of this evaluation. Camera systems recommended vary from colposcopes to close-up 35-mm systems to instant cameras. Physicians who examine sexually abused children should have ready access to an adequate photographic system, as well as basic knowledge of camera operation, film procedures, and medicolegal implications. Case studies and discussion are used to review colposcopic and close-up 35-mm camera techniques available to the physician to photograph the sexual abuse victim.

Unexpected vaginal sperm in two sexual abuse victims.

A careful forensic examination of the sexually abused child may reveal evidence of male ejaculation if this had occurred in the recent past. Two cases of the unexpected presence of vaginal sperm in prepubertal children are presented. The techniques of sperm and acid phosphatase collection are discussed. Sperm and/or other seminal products should be sought in victims of recent assault, in preverbal or nonverbal children, in victims with signs or symptoms of recent penetration, or in any case where the recency of sexual contact is unknown or uncertain.

Child sexual abuse: the emergency department response.

Each child who presents with a suspicion of sexual abuse must have immediate access to a complete medical evaluation performed by a competent and knowledgeable examiner. This evaluation should include, at a minimum, a history, a complete physical examination with a detailed genital examination, treatment of identified medical problems, and collection of evidence. It is not appropriate to perform a cursory examination simply because there was a time delay between the abuse and the examination or because the history is suspect. Each sexual abuse workup must be medically and forensically complete. In addition, each child presenting with suggestive complaints should have sexual abuse strongly considered in the differential diagnosis. A report to the appropriate social and legal agencies is indicated even if the suspicion cannot be confirmed. If sexually abused children are to be examined in hospital emergency departments, a protocol should be developed to ensure rapid, thorough, uniform, and caring evaluation. With planning, preparation, and education, most current inadequacies in the emergency medical assessment of sexually abused children can be resolved so that child victims receive sensitive and comprehensive medical care.

Prostatic acid phosphatase and sperm in the post-coital vagina.

Sperm and prostatic acid phosphatase identified in vaginal fluid after an alleged sexual assault constitute important physical evidence useful in courts of law during rape trials. The purpose of this study was to define a normal and abnormal range for acid phosphatase in the post-coital vagina for our emergency department and to compare the sensitivity of acid phosphatase versus sperm in determining recent coitus. Vaginal swabs obtained from 90 patients were analyzed for acid phosphatase activity by the Sigma p-nitrophenyl phosphate technique. Swabs were stored in a bovine albumin preservative broth. Pap smears for sperm identification were also performed. Acid phosphatase values greater than 50, especially those greater than 138 Sigma units/cc, correlated with intercourse within the preceding 24 hours (P .005). Values greater than 20 but less than 50 correlated with intercourse within 48 hours (P .005). The presence or absence of sperm was found to be less sensitive, and correlated poorly with the time since intercourse [of 12 cases less than or equal to 24 hours, 11 were acid phosphatase-positive (91.7%) while seven were sperm-positive (58.4%)].

Ethanol-induced hypoglycemic coma in a child.

Reported is a case of ethanol-induced hypoglycemic coma in a 33-month-old boy after accidental ingestion of ethanol. Blood glucose was 10 mg% and blood ethanol was 71 mg%. He responded promptly to an IV bolus of 50% dextrose. The pathophysiology and clinical presentation of this not uncommon metabolic disorder are discussed. A plan for early recognition and management is presented.