Children who engaged in interpersonal problematic sexual behaviors.

BACKGROUND: Over one-third of inappropriate sexual contact experienced by children is initiated by other children. Many studies examined child initiators (CIs) of interpersonal problematic sexual behaviors (IPSBs). This study uniquely links CI information with types of sexual contact as described by children they engaged in IPSBs. OBJECTIVE: Describe CIs' characteristics and types of sexual acts they initiated. PARTICIPANTS/SETTING: Medical charts of CIs and children they engaged in IPSBs. Examinations occurred between 2002 and 2013. METHODS: Retrospective chart review. RESULTS: Most CIs were male (83%) and related to the child they engaged in IPSBs (75%); mean age was 10 years (range 4-17); 58% reported viewing sexually explicit media; 47% experienced sexual abuse. Most CIs (68%) engaged in multiple types of IPSBs. Children who experienced IPSBs initiated by males reported engagement in greater numbers of invasive acts (t(216) = 2.03, p = .043). Older CIs were more likely than younger CIs to report viewing sexually explicit media (χ2(1) = 7.81, p = .007) and those who did were more likely to initiate more invasive acts (t(169) = 2.52, p = .013) compared to CIs who did not. CONCLUSIONS: In this study, most CIs were young and experienced multiple adverse events; the most common types of IPSBs were invasive; and over half the CIs had been exposed to sexually explicit media, which was associated with initiating invasive sexual acts. These findings suggest aiming prevention efforts at young children to help them manage exposure to sexually explicit media and redress victimization experiences.

Urogenital symptoms after sexual abuse vs irritant contact in premenarchal girls.

OBJECTIVES: Sexually abused (SA) girls report urogenital symptoms temporally related to inappropriate genital contact. Since girls also experience symptoms following genital irritant exposure and mostly all girls are exposed to genital irritants, we describe overall symptoms reported by girls that disclosed SA compared to those that did not and we compare how girls describe symptoms following a specific episode of contact SA vs a genital irritant exposure. DESIGN: Cross-sectional study. Parents/girls interviewed; medical records reviewed. PARTICIPANTS: Five to 12-year-old premenarchal girls/parents. SETTING: An urban and a suburban pediatric practice; a regional treatment center for child abuse. OUTCOME MEASURES: Prevalence of histories of urogenital symptoms in SA girls compared to girls attending well-child exams (controls); girls' description of urogenital symptoms following specific episodes of contact SA compared to specific episodes of genital irritant exposure. RESULTS: More parents/girls in SA group reported prior urogenital symptoms. Most SA girls said past symptoms were caused by inappropriate genital touching; most control girls could not identify causes for prior symptoms. Girls' responses following specific irritant exposures: 76% SA vs 24% control girls used negative terms to describe how it felt, 69% SA vs 6% control girls said it bothered her body and her feelings, and 33% SA vs 12% control girls described experiencing dysuria afterwards (all ps < 0.05). CONCLUSIONS: Girls can relate urogenital symptoms to specific genital contacts; more SA girls reported unpleasant symptoms with an emotional component. A skilled medical history can help differentiate these conditions and diagnose sexual abuse with greater certainty.

Diagnostic accuracy in child sexual abuse medical evaluation: role of experience, training, and expert case review.

OBJECTIVES: (1) The purpose of this study was to assess the ability of clinicians who examine children for suspected sexual abuse to recognize and interpret normal and abnormal ano-genital findings in magnified photographs using an online survey format. (2) Determine which factors in education, clinical practice, and case review correlate with correct responses to the survey questions. METHODS: Between July and December 2007, medical professionals participated in a web-based survey. Participants answered questions regarding their professional background, education, clinical experience, and participation in case review. After viewing photographs and clinical information from 20 cases, participants answered 41 questions regarding diagnosis and medical knowledge. Answers chosen by an expert panel were used as the correct answers for the survey. RESULTS: The mean number of correct answers among the 141 first-time survey respondents was 31.6 (SD 5.9, range 15-41). Child Abuse Pediatricians (CAP) had mean total scores which were significantly higher than Pediatricians (Ped) (34.8 vs. 30.1, p<0.05) and Sexual Assault Nurse Examiners (SANE) (34.8 vs. 29.3, p<0.05). The mean total scores for Ped, SANE, and Advanced Practice Nurses (APN) who examine fewer than 5 children monthly for possible CSA were all below 30. Total score was directly correlated with the number of examinations performed monthly (p=0.003). In multivariable regression analysis, higher total score was associated with self-identification as a CAP, reading The Quarterly Update newsletter (p<0.0001), and with quarterly or more frequent expert case reviews using photo-documentation (p=0.0008). CONCLUSIONS: Child Abuse Pediatricians, examiners who perform many CSA examinations on a regular basis, examiners who regularly review cases with an expert, and examiners who keep up to date with current research have higher total scores in this survey, suggesting greater knowledge and competence in interpreting medical and laboratory findings in children with CSA. Review of cases with an expert in CSA medical evaluation and staying up to date with the CSA literature are encouraged for non-specialist clinicians who examine fewer than 5 children monthly for suspected sexual abuse.

Urogenital symptoms in premenarchal girls: parents' and girls' perceptions and associations with irritants.

OBJECTIVES: Premenarchal girls commonly seek care for urogenital symptoms, yet little is published about parents' and girls' perceived causes of symptoms or associations with irritant exposures. We sought to describe urogenital symptoms, perceived causes, and associations between symptoms and genital irritant exposures. DESIGN: Descriptive study. Parents/girls interviewed; medical records reviewed. PARTICIPANTS: Five- to 12-year-old well, premenarchal girls and their parents. SETTING: One urban and 1 suburban pediatric practice. OUTCOME MEASURES: Prevalence of histories of urogenital symptoms and perceived causes; association between symptoms and exposure to genital irritants in a well population. RESULTS: Of 191 parent/girl dyads, 33% of parents and 48% of girls reported girls' histories of urogenital symptoms not attributed to urinary tract infections or trauma. Perceived causes: poor hygiene (29% of parents vs 14% of girls); soap products (20% of parents and girls); none identified (24% of parents vs 53% of girls). Analysis of symptoms versus irritant exposures demonstrated these associations: dysuria and genital soreness with poor genital hygiene, tight garments, or exposure to soap products; genital pruritus with poor hygiene (all P < .05). No symptoms were associated with nylon underwear, tights, or bike or horseback riding. Vaginal discharge was not associated with any irritants. CONCLUSION: Almost half the girls had histories of urogenital symptoms. Poor hygiene and soap exposure were perceived causes of most symptoms. When no cause for urogenital symptoms is identified, treatment should be focused on hygiene, soap exposure, and tight-fitting clothes, not on bike or horseback riding or wearing nylon underwear or tights. Vaginal discharge warrants further evaluation.

Putting it all together.

The most available form of evidence in child sexual abuse cases is what the child has to say about his or her alleged experience. The most difficult skill for clinicians to develop is the "how tos" of talking to children in a developmentally appropriate, nonjudgmental, facilitative, and empathetic manner. This manuscript provides insight into obtaining historical details about a child's experience and guidance regarding how to incorporate those details when formulating a balanced and defensible opinion. The consultative report should be an instrument to explain the presence or absence of physical findings, the significance of symptoms temporally related to sexual contact, and discrepancies between a child's perception of an experience and physical findings.

Conducting the medical history.

A key portion of the medical evaluation of child sexual abuse is the medical history. This differs from interviews or histories obtained by other professionals in that it is focuses more on the health and well-being of the child. Careful questions should be asked about all aspects of the child's medical history by a skilled, compassionate, nonjudgmental, and objective clinician. Often the diagnosis of sexual abuse is based only on the medical history. The history can be further understood by knowledge of how children are abused and their reactions to it. By addressing the child's and parent's concerns, reassurance can also be provided about what is normal and abnormal with the child's body.

Girls who disclose sexual abuse: urogenital symptoms and signs after genital contact.

BACKGROUND: Little information is available about idiosyncratic historical details provided by sexually abused girls, yet this information can help medical professionals diagnose sexual abuse. OBJECTIVES: Our goals were to describe types and frequencies of urogenital symptoms/signs reported by girls who disclosed direct genital contact and to explore factors associated with this reporting. METHODS: We reviewed 161 medical charts of 3- to 18-year-old girls who disclosed sexual abuse by direct genital contact for urogenital symptoms/signs, type of genital contact (oral, object, digital, or genital), time interval between last perpetrator contact and physical examination, age and sexual maturity at the time of last perpetrator contact, genital findings, and other medical diagnoses. Regression analyses were performed to determine factors that were most predictive of symptom/sign reporting. RESULTS: Many of the girls reported multiple types of genital contact; 33% reported oral/object-genital contact, 72% reported digital-genital contact, and 55% reported genital-genital contact. Sixty percent of the girls reported experiencing >or=1 symptom/sign; 53% of the total sample had genital pain, 37% had dysuria, and 11% had genital bleeding. Symptoms/signs were highly associated with genital-genital contact: 48% of the girls reporting genital-genital contact had dysuria compared with 25% of girls not reporting genital-genital contact, 72% had genital pain/soreness compared with 32% not reporting genital-genital contact, and 16% had bleeding compared with 4% of those not reporting genital-genital contact. Using regression analysis, the strongest factor predictive of symptom reporting by the girls was genital-genital contact. CONCLUSIONS: Sexually abused girls who experienced direct genital contact frequently reported symptoms related to the abusive episode. These symptoms were reported most frequently with genital-to-genital contact. This information sheds some light on the mechanism of injury leading to symptom reporting and can be used to further study symptoms/signs reported by sexually abused girls compared with the general population.

Guidelines for medical care of children who may have been sexually abused.

BACKGROUND: Children who may have been sexually abused are examined in many different settings by medical providers with variable levels of education and experience in this special area of practice. Therefore, there is a need for a consistent evidence-based approach that is agreed upon by medical experts. OBJECTIVES: To develop and provide guidelines and recommendations for performing and interpreting findings of the medical evaluation of children referred for sexual abuse medical evaluations, and to provide guidelines for the education, oversight, and peer review process for clinicians who provide assessments for suspected child sexual abuse. METHODS: Participation from medical providers was solicited through postings on the Internet list-serves administered by Cornell University (Special Interest Group in Child Abuse), and by the Ray E. Helfer Society, an honorary society for physician specialists in child abuse diagnosis and treatment. The guidelines were developed through review and critique of published research studies, discussions in focus group meetings at child abuse medical conferences, and ongoing communication leading to revision of draft documents. RESULTS: Groups of 10 to 40 physician experts met at child abuse conferences between January 2002 and January 2005 to revise the table summarizing the interpretation of physical and laboratory findings in suspected child sexual abuse and to develop guidelines for medical care for sexually abused children. Between January and December 2005, the guidelines were expanded and revised. CONCLUSIONS: The guidelines presented here reflect the current knowledge, recommended clinical approaches, and required competencies in the field of child sexual abuse medical evaluation.

Funding of child abuse evaluations: survey of child abuse evaluation programs.

This article delineates the current fiscal management and reimbursement for child abuse examinations. These financial issues are high priority for child abuse programs because most programs lack the revenues to meet the demands for service, education, advocacy and research. Programs may share medical protocols and standards but have yet to share management solutions. The authors present the administrative details of 75 child abuse evaluation programs and highlight innovative approaches to increase funding and stabilize the funding for the programs. They present information on billing, contracts, costs of care, and state-based initiatives that can be reproduced by other programs and states.

Evaluating child sexual abuse.

We have learned much about the medical evaluation of suspected child sexual abuse during the past 2 decades. The physical examination still holds an important place in the evaluation but is secondary to a well-performed history. As the evolving literature increases our understanding, the relevance of various anatomic appearances of the prepubertal and pubertal genital examination will certainly become even clearer. The physical examination rarely is diagnostic by itself, with more than 92% of cases failing to demonstrate either acute or chronic signs of injury. Thus, the 1994 quote by Adams and colleagues, "It's normal to be normal," continues to ring true, now supported by a growing body of pediatric literature.

Adolescents' responses to sexual abuse evaluation including the use of video colposcopy.

PURPOSE: To examine adolescents' responses to a medical examination, which included the use of video colposcopy, conducted during an investigation of possible child sexual abuse. METHODS: Girls aged 11 to 18 years, referred for evaluation and treatment of sexual abuse at an academic medical center were eligible to participate. Demographic data and information regarding the alleged sexual abuse event(s) were obtained by medical record review. Prior to the medi- cal examination subjects were assessed regarding: anticipations of the medical examination; level of state anxiety using the State-Trait Anxiety Inventory (STAI); response to stressful situations along the dimensions of information-seeking or information-avoiding using the Miller Behavioral Style Scale (MBSS); and knowledge of reproduction and genital anatomy. Subsequently, a medical examination, which included the use of video colposcopy with a monitor for subject viewing, was completed. The examining physician provided a standardized educational intervention regarding genital anatomy and a discussion about abuse issues and sexually transmitted infections. An exit interview assessed perceptions of the medical examination and video colposcopy and reassessed anxiety using the state portion of the STAI. Follow-up interviews occurred 3 months later during which knowledge of reproduction and genital anatomy was reassessed. Measures were evaluated using paired Student's t-tests, McNemar tests for correlated proportions, correlations and independent Student's t-tests, as appropriate. RESULTS: Seventy-seven eligible girls participated; 51 returned for follow-up. The mean age of the subjects was 13.5 years (SD 1.4 years). Fifty-one percent of the sample was Caucasian, 29% African-American, 18% Hispanic, and 2% other. Seventy-nine percent of the girls chose to watch the examination on the video monitor. The girls' post-examination perceptions were significantly more positive than their pre-examination anticipations (p <.001), even though some aspects continued to be embarrassing, painful, or "scary". Anxiety, as measured by the STAI, significantly decreased from pre- to post-examination (p <.001). Pre-examination and post-examination anxiety were negatively associated with pre-examination anticipation and post-examination perceptions, respectively. Information-avoiding coping styles on the MBSS were associated with positive anticipations of the examination, but exhibited a trend toward negative associations with perceptions of video colposcopy. Scores assessing knowledge of the reproductive functions of their bodies at 3 months revealed no significant differences during the period from pre-examination assessment to three month follow-up. CONCLUSIONS; Teens generally reported that the medical examination, which included the use of video colposcopy, was beneficial. There was a significant reduction in anxiety from pre-examination to post-examination and the girls' feelings about the medical examination were significantly more positive afterwards.