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 Anal signs of child sexual abuse: a case–control study - NCBI / https://www.ncbi.nlm.nih.gov › pmc › articles › PMC4047438 Anal signs of child sexual abuse: a case–control study - NCBI / https://www.ncbi.nlm.nih.gov › pmc › articles › PMC4047438
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4047438/
May 27, 2014 ... There is uncertainty about the nature and specificity of physical signs following anal child sexual abuse. The study investigates the extent to ...


Abstract Abstract
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4047438/%23idm139782030750160title
Abstract


Methods Methods
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4047438/%23__sec6title
Methods



Results Results
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4047438/%23__sec13title
Results


Discussion Discussion
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4047438/%23__sec14title
Discussion


 'He told me not to tell anybody': Children ages 9 to 15 testify about ... / https://www.pennlive.com › news › 2017/06 › he_told_me_not_to_tell_an...
https://www.pennlive.com/news/2017/06/he_told_me_not_to_tell_anybody.html
Jun 1, 2017 ... Several children of a former Amish couple testified about the abuse they ... All six of the young girls, as well as Savilla Stoltzfus, were considered his wives. ... The child said Kaplan began having anal sex with her when she ...



Can I Get Pregnant If I Have Anal Sex? - Connecticut Children Can I Get Pregnant If I Have Anal Sex? - Connecticut Children's ... / https://www.connecticutchildrens.org › health-library › teens › al-pregnancy
https://www.connecticutchildrens.org/health-library/en/teens/al-pregnancy/
Can I Get Pregnant If I Have Anal Sex? - Connecticut Children's ...https://www.connecticutchildrens.org › health-library › teens › al-pregnancy


Texas School District Mandates Teaching Kids How to Have Anal Sex / https://www1.cbn.com › cbnnews › october › texas-school-district-mandate... Texas School District Mandates Teaching Kids How to Have Anal Sex / https://www1.cbn.com › cbnnews › october › texas-school-district-mandate...
https://www1.cbn.com/cbnnews/2019/october/texas-school-district-mandates-teaching-kids-how-to-have-a
Texas School District Mandates Teaching Kids How to Have Anal Sexhttps://www1.cbn.com › cbnnews › october › texas-school-district-mandate...


Explaining sex to children of all ages - The Globe and Mail / https://www.theglobeandmail.com › life › parenting › article570833 Explaining sex to children of all ages - The Globe and Mail / https://www.theglobeandmail.com › life › parenting › article570833
https://www.theglobeandmail.com/life/parenting/explaining-sex-to-children-of-all-ages/article570833/
Explaining sex to children of all ages - The Globe and Mailhttps://www.theglobeandmail.com › life › parenting › article570833



Anus Injury - an overview | ScienceDirect Topics / https://www.sciencedirect.com › topics › medicine-and-dentistry › anus-inj... Anus Injury - an overview | ScienceDirect Topics / https://www.sciencedirect.com › topics › medicine-and-dentistry › anus-inj...
https://www.sciencedirect.com/topics/medicine-and-dentistry/anus-injury
Anus Injury - an overview | ScienceDirect Topics Skip to Main content ScienceDirectJournals & BooksRegisterSign inScienceDirect GuestsJournals & BooksRegisterSign InHelpAnus InjuryAnal and rectal injuries are reported at about the same rate for males and females who report a history of anal penetration.From: Child Abuse and Neglect, 2011Related terms:AdolescentsRectumHuman Immunodeficiency VirusView all TopicsDownload as PDFSet alertAbout this pageLearn more about Anus InjuryAnorectal DiseaseEmily Miraflor MD, in Abernathy's Surgical Secrets (Seventh Edition), 201817 What are the nonoperative treatment options?The two goals of treatment are to prevent further anal trauma by improving stool consistency and to improve blood flow to the area. The first is accomplished by initiating a high-fiber diet with fiber supplementation (at least 25 g per day) and increasing hydration. Blood flow is encouraged by taking frequent warm sitz baths to relax the pelvic floor muscles and applying topical agents containing antiinflammatory agents, local anesthetics, and vasodilators (nitroglycerin or calcium channel blockers). Injection of Botox (botulin toxin) has also been reported to be effective by relaxation of the sphincter muscles.Read full chapterPurchase bookPhysical Findings in Children and Adolescents Experiencing Sexual Abuse or AssaultDeborah Stewart MD, FAAP, in Child Abuse and Neglect, 2011Anal InjuriesChildren can experience both penetrating and nonpenetrating anal contact. Adolescents are more likely to report penetrating anal contact. Penetration can be by a penis, finger, or foreign object, and in rare cases, can lead to severe injuries.50 Anal and rectal injuries are reported at about the same rate for males and females who report a history of anal penetration. Common anal injuries after penetration include lacerations, abrasions, and bruising (Figures 11-14).FIGURE 11-14. Anal lacerations extending out onto the normal squamous epithelium at 12 (arrow A) and 6 o’clock (arrow B). Anal dilation can be a normal finding. History of sodomy 6 hours before examination. On follow up, the lacerations resolved.In Heppenstall-Heger's longitudinal study of anal findings in assaulted and injured children,24 anal trauma was documented in 30 of the 62 cases referred for sexual assault. There was one child with accidental trauma. There were 13 abrasions and 18 lacerations or tears; most of the acute trauma occurred at the midline at 12 and 6 o’clock. Four tears were transiently associated with changes in anal tone. Most acute trauma healed quickly and completely and only three cases (9.6%) healed with anatomic changes; one had an anal tag and two had scarring and hyperpigmentation after surgery for extensive tissue damage.Anal findings indicative of trauma are rare in children who are not examined shortly after an assault. Adams et al20 found anal lacerations (“clear evidence”) in 2 of 213 (1%) of legally confirmed cases of childhood sexual abuse: Ninety-four percent had normal or nonspecific examinations.Read full chapterPurchase bookOverview of Pelvic Floor DisordersJames L. Whiteside, Tyler Muffly, in Women and Health (Second Edition), 2013Risk Factors for Anal IncontinenceAnal incontinence is caused by a multitude of physiological and anatomical factors. Structural abnormalities and functional motility disorders are known risk factors. The most common identified cause of AI in the US is external anal sphincter injury during childbirth.64 In addition to the anal sphincter complex circumferentially closing the anal canal, the anorectal angle is important. The internal anal sphincter, external anal sphincter, and puborectalis all keep the anorectal junction at an acute angle narrowing the genital hiatus. A normal continence maintaining anorectal angle is between 90 and 110 degrees. Childbirth can impact the anorectal angle by injuring the puborectalis. Nerve damage to these muscles from trauma, pelvic or anal surgery, or childbirth can contribute to anorectal dysfunction. The nerve innervation to the external anal sphincter is the pudendal nerve (S2-4) that, in passing through Alcock’s canal, can sustain a stretch injury during vaginal delivery. Most pathophysiologies are initiated during vaginal childbirth but become symptomatic only later in life with normal age-related decline in nerve and muscular function.65 Metabolic or physiological mechanisms involved in stool formation can also contribute to functional pathologies causing AI. A twin study from 271 identical sister pairs indicated that the major risk factors were age 40 years or older, menopause, increasing parity greater than or equal to 2, and the presence of stress urinary incontinence (SUI).66 Because most patients have more than one type of damage to the pelvic floor, isolating the causes and mechanisms of AI is challenging. This is one of the reasons why previous devices, such as an artificial anal sphincter, targeting just 1 contributing factor have been unsuccessful.67Read full chapterPurchase bookSexual AbuseCharles Schubert MD, Kathi Makoroff MD, in Pediatric Clinical Advisor (Second Edition), 2007Workup•Screening for sexually transmitted diseases (STDs) should be considered in following situations:○Historical factors: perpetrator with STD, patient with STD or genital discharge, sibling with STD, or other high‐risk situations such as prostitution or multiple perpetrators•Examination factors: vaginal discharge, genital or anal injuries, adolescent age group○The most common STDs are gonorrhea, Chlamydia, genital warts.•Interpretation of positive tests for STDs and their relationship to sexual abuse, excluding congenital infections are as follows (note: confirmatory testing is generally required):○Gonorrhea, syphilis, human immunodeficiency virus (HIV), Chlamydia: diagnostic of abuse (if not acquired from birth; rare cases of nonsexual transmission excluded)○Trichomonas: highly suspicious for abuse○Genital warts, genital herpes: suspicious for abuse○Bacterial vaginosis: inconclusive for abuse•Material collected for forensic analysis includes:○Swabs of mouth, rectum, vagina, and any suspicious staining on skin (identified by an ultraviolet light source)○Swabs of mouth, rectum, and vagina should also be performed to evaluate for STDs○Swabs of all bite marks○Saliva or blood specimen of victim for a DNA standard○Collection of underwear and any clothing and linens with suspicious staining○Collection of combed pubic hair (before the genital examination is performed) as well as plucked (preferred by most crime labs) or cut pubic hair for hair standards•Expected results: forensic evidence is most likely to be recovered when collected close to the time of assault, ideally within 12 to 24 hours. It is not useful to attempt collection of forensic evidence after 72 hours.•Interpretation of abnormal results:○Definitive evidence of sexual contact: sperm, seminal fluid, or pregnancy○Highly suspect for sexual contact: acute injuries of the genitalia or an STDRead full chapterPurchase bookStructural reflex zone therapy for pregnancyDenise Tiran MSc, PGCEA, RM, RGN, ADM, ... Maggie Evans RM, RN, HV Cert, MSc (Complementary Therapies), in Reflexology in Pregnancy and Childbirth, 2010Structural physiology and aetiologyConstipation is common in pregnancy as progesterone relaxes the intestines, slowing peristalsis. It is worsened by poor diet, inadequate fluid intake, lack of exercise and some iron tablets, and may accompany gestational nausea and vomiting, or irritable bowel syndrome, in combination with diarrhoea. The diagnosis is somewhat subjective, being based on a reduction in frequency of defaecation compared to normal, altered consistency of the stool, difficulty in passing the stool, palpable stools in the rectum and, in severe cases, faecal soiling with overflow. Physically these symptoms may be due to poor diet and/or fluid intake, reduced gut motility or an altered sensation of the need to defaecate (often associated with haemorrhoids in pregnancy or perineal and anal trauma immediately postnatally), but may be exacerbated by discomfort, embarrassment or fear of pain.Pelvic congestion from downwards pressure of the uterus in late pregnancy can also add to the general discomfort. Weakness of abdominal and pelvic floor musculature will exacerbate the problem, creating neural irritation and disordered enteric coordination. Since peristaltic movement is affected by vagus nerve activity, any factor affecting vagal function will also predispose a woman to more severe constipation than normal. This may, for example, be related to problems in the upper cervical spine or the occipital ridge. Disordered sacrococcygeal mechanics will affect, or may be caused by, tension on the uterus and uterosacral ligaments and will indirectly affect circulation in the rectum. Some women experience accompanying backache, possibly related to additional deviations within the spine, or more local discomfort as a result of straining at stool, and pain in the coccygeal area is common. Osteopaths believe that there is an embryological link between the coccyx and the ethmoid bone in the anterior skull at the roof of the nose (Stone 2007:306) and that, therefore, any misalignment of one will affect the other.Read full chapterPurchase bookOperative Therapy for Ulcerative ColitisKaterina Wells, ... Matthew Mutch, in Shackelford's Surgery of the Alimentary Tract, 2 Volume Set (Eighth Edition), 2019Ileoanal Anastomosis: Comparison of Handsewn Versus StapledTwo techniques of IPAA have been described: transanal mucosectomy with handsewn anastomosis technique and a stapled anastomosis technique. Mucosectomy in theory removes all diseased mucosa. However, this is a time-consuming and technically challenging procedure that risks anal trauma and incontinence. Stapling is quicker and easier to perform, with minimal anal trauma, but the retained mucosa is at risk for dysplasia or symptomatic cuffitis.The risk of dysplasia in the retained anorectal mucosa after double-stapled anastomosis is low and rarely progresses to carcinoma with regular endoscopic surveillance.38,76 In the case of mucosectomy, residual mucosa can be present 14% of the time within the rectal cuff that is excluded from endoscopic surveillance.64,77,78The anorectal cuff created after mucosectomy can be a source of perianastomotic abscess. Comparison of handsewn versus stapled IPAA demonstrated that handsewn IPAA is associated with higher rates of anastomotic disruptions, peripouch abscess, pouch removal, postoperative anastomotic stricture, and small bowel obstruction. 19,42,47,63Double-stapled anastomosis is associated with better fine control of continence due to preservation of the richly innervated ATZ. Simple passage of the stapling device decreases trauma to the anus.35,79 After a mean follow-up of 7.1 years, Kirat et al. reported that a handsewn IPAA anastomosis was associated with worse incontinence, seepage, pad usage, and dietary/work restrictions. Quality of life metrics were significantly greater in those who underwent a stapled anastomosis.47,63In a recent comparison of 91 patients with ulcerative colitis undergoing handsewn versus stapled IPAA, older patients with handsewn anastomoses had higher rates of fecal soiling and frequency of bowel movements. However, no significant differences in functional and quality-of-life measures were noted at 3 years.49,80 In a meta-analysis of 4183 patients, the functional disadvantage of handsewn anastomosis is clear, with anal rest and squeeze pressures and increased nocturnal incontinence.45,65Read full chapterPurchase bookFissure-in-AnoRahila Essani, Harry T. Papaconstantinou, in Shackelford's Surgery of the Alimentary Tract, 2 Volume Set (Eighth Edition), 2019EtiologyTrauma to the anal canal, because of passing hard stools, is probably the most frequent cause of fissure-in-ano. Patients will often remember the exact time the fissure developed based on the symptoms. Classically, this will almost always be associated with an episode of constipation. Anal fissure can also be a consequence of frequent defecation and diarrhea. Preexisting anal canal irritation has been postulated to lead to fissure. Scarring, stricture, and stenosis, from prior anal injury or surgery, are recognized conditions that predispose to fissure formation.2 Because fissures occur most often in the posterior midline, various structural theories have been proposed as causes,3–5 the most compelling of which is the vascular anatomy of the internal sphincter.In 1989 Klosterhalfen et al.5 reported on anatomic dissections that detailed the blood supply of the inferior hemorrhoidal artery. In the majority of cadaver specimens (85%), the posterior commissure of the anal canal was not directly perfused except by end arterioles. Branching from the sphincteric arterioles occurred at right angles to the parent vessels and coursed perpendicularly through the circular fibers of the internal sphincter. These anatomic findings established the possibility of decreased mucosal perfusion, particularly in the posterior midline. Others have confirmed in cadaveric studies that there is a significant trend to an increasing number of arterioles posterior to anterior in the subanodermal space at all levels.6 Furthermore, sphincter spasm and hypertonicity, which is common in this disease, may further decrease blood flow posteriorly. Schouten et al.7,8 have shown increased anal canal pressures correlated with decreased mucosal blood flow, as measured by laser Doppler flowmetry. Reports of normal anal maximal resting pressure are highly variable, ranging from 60 to 100 cm H2O in females and slightly higher in males; however, the measurement is defined as the maximal pressure recorded at rest.9 The higher pressures seen in patients with anal fissures will produce a sawtooth pattern on manometry tracings. This vascular-anal hypertonic resting pressure hypothesis has prompted trials aimed at improving blood flow and lowering anal canal resting pressures. Whether sphincter hypertonia is a cause or effect is unknown.The most common systemic conditions that are associated with atypical anal fissure/anal ulcer are Crohn disease and acquired immunodeficiency syndrome. Both of these conditions lead to an immunocompromised patient. Atypical features include fissures off the true midline, shaggy large defects with undermined edges, and granulation tissue in the base. Actual cavitation of the internal sphincter is another ominous clue to the presence of systemic disease. In the immunocompromised patient, a fissure or an ulcer and a concomitant mass should raise the question of malignancy. Lymphoma, leukemic ulcer, and anal canal epithelial tumors are often associated with surface defects. There are subtle changes, which distinguish these conditions from uncomplicated acute or chronic anal fissure.Infections also cause fissure-in-ano. Syphilis and tuberculosis were seen frequently in the United States over the last century but are currently uncommon causes of anal fissure. Today, sexually transmitted diseases and infections associated with immunocompromised conditions may be the cause of anal fissure and include chancroid, herpes simplex virus, and cytomegalovirus. Herpes simplex infection manifests as multiple superficial ulcers and vesicles, while syphilitic ulcers are purulent and have a granular base. The treatments for these disease processes are different, and therefore it is important to recognize the differences between anal canal fissures and atypical anal canal ulcers (see Fig. 159.2).Read full chapterPurchase bookElimination ConditionsALISON SCHONWALD, LEONARD A. RAPPAPORT, in Developmental-Behavioral Pediatrics, 2008CauseMore than 90% of cases of encopresis result from constipation.24 Anything that causes constipation can therefore cause encopresis. In rare cases, the cause is a neurological disorder, such as a tethered spinal cord. Children with tethered cords may have been continent and then regressed; as the child grows, the spinal cord stretches as a result of the abnormal tethering, causing neurological impairment. In addition to deterioration of continence, these children also may have gait changes, lower back pain, abnormal lower extremity reflexes, or lower back skin manifestations including lumbosacral dimples or hair tufts.Another cause of encopresis without constipation is emotional trauma. Affected children may have been abused and, at times of stress, become disorganized and overwhelmed, which is manifested as stool accidents. Some children may purposely have accidents to keep an abuser away. Direct anal trauma may cause loss of sphincter control as well.CONSTIPATION OF VARYING DEGREESMost children with encopresis are constipated.26 However, mild constipation can lead to overflow incontinence, whereas some severely constipated children have no encopresis. The critical variable seems to be the amount of rectal dilatation, not the absolute amount of stool in the bowel. Historical details elucidate the degree of impaction and dictate the intensity of intervention.CAUSES OF CONSTIPATIONConstipation is common in U.S. children, affecting 5% of children aged 4 to 11 years.27 In most children, there is no specific abnormality or disease that necessitates treatment. Again, history and physical examination identifies children in need of investigation for a pathological cause of constipation. The symptoms of slow growth, depression, and weight gain and a positive family history are indications for thyroid function testing to assess for hypothyroidism. A thorough physical examination should include an assessment for any signs of neuropathy or myopathy, which could manifest in the gastrointestinal tract with constipation. Conditions such as cerebral palsy or myelomeningocele are frequently associated with chronic constipation. It is also possible on physical examination to detect anatomical abnormalities, such as a very anterior ectopic anus or anal ring stenosis. Although inflammatory bowel disease more commonly manifests with loose stools, constipation is possible, and systemic symptoms, anal tags, weight loss, and a family history of autoimmune disorders may indicate the need for a workup for these conditions. Severe constipation is also possible in celiac disease.Children with lifelong constipation symptoms may have Hirschsprung disease. They have had difficulty in evacuation from birth with recurrent abdominal distension. They may have frequent emesis and may suffer from failure to thrive and enterocolitis in infancy. Encopresis is rare in children with Hirschsprung disease and is found only in affected children with the rare short-segment form of Hirschsprung disease. In addition to historical information, a tight aganglionic rectum around the examining finger found during rectal examination should raise suspicion. Typically, children with encopresis have either normal rectal examination findings or decreased rectal tone and a palpable stool mass.Many medications can cause constipation. Several psychoactive treatments can be constipating, such as selective serotonergic reuptake inhibitors, α-adrenergic agents (clonidine, guanfacine), and atypical neuroleptic agents. Anticholinergic medications, such as oxybutynin chloride (used for urinary incontinence), can be constipating as well.IMPAIRED BOWEL SENSATION AND MUSCULAR STATUSWhen encopresis is caused by constipation, impairment of bowel integrity is thought to be the cause. Stool is retained, dilating the rectum and sometimes the sigmoid colon. The bowel wall is stretched by the stool mass, and often the rectum becomes impacted with hard feces. Water is absorbed by the gut wall, and the feces becomes harder the longer they remain in the bowel. The stretched muscle layers lose ability to contract effectively against the large mass, and stool leakage around the stool mass develops.BODY SIGNALS BECOME INCONSISTENTWhen impacted stool blocks the rectum, stretch receptors are thought to lose the ability to sense when the rectal vault becomes filled, as the receptors remain stretched by the abnormally large fecal mass. Theoretically, no signal that the rectum is filling and the external sphincter should be contracted is sent to the brain. Softer stool formed proximally then leaks around or between hardened rocks of stool in the rectum, leaking into underwear without warning. This leakage is the main hallmark of encopresis. Leakage may be liquid or formed, daily or less frequent. Some children have more leakage just before evacuating, which indicates that the rectum has filled, has stretched, and cannot detect and respond to stool reaching the anus. For those children, they may have intact sensation when their rectum is not filled and thus frequently sense the need to defecate, voluntarily contract the external sphincter, and prevent accidents. However, as the impacted stool enlarges, sensation deteriorates, and accidents occur.Read full chapterPurchase bookInterviewing Children and Adolescents About Suspected AbuseNancy D. Kellogg MD, in Child Abuse and Neglect, 2011Information About Abusive EventsAlthough the type of information (abuser identification, type of abusive contact, timing of contact) medical professionals rely on for diagnosis is similar for physical and sexual abuse, details gathered when sexual abuse is suspected differ from details gathered when other types of abuse are suspected. The type of sexual contact and timing of the most recent sexual contact will assist in the interpretation of examination findings and will determine whether emergent forensic evidence collection is indicated. Children and adolescents presenting within 48 to 72 hours of sexual abuse involving genital, anal, or oral contact, an evaluation for forensic evidence collection is often indicated. The medical history can provide important information about the need to collect other forensic materials such as assailant debris and hairs (pubic and head) that may be found on the child's body or clothing and linens from the scene of the event.Information about the type of sexual contact will determine which examination procedures and tests are most appropriate. If there is a history of the perpetrator's genitals contacting the child's body, then testing for sexually transmitted infections (STIs) should be considered. With repeated genital contact, risk of STIs, including AIDS, increases. Condom use by the assailant reduces, but does not eliminate, the risks of pregnancy and diseases. The use of lubrication can reduce the likelihood of anal or genital trauma. The child, police, or caretakers might describe characteristics of the perpetrator that increase the risk of AIDS, such as known positive serology for HIV, stranger, gang member, intravenous drug user, and multiple sexual partners. When any of these characteristics are identified during the medical history, the clinician should discuss HIV testing with the child and family, enabling them to make an informed decision about whether to undergo testing, and possible prophylactic treatment in some circumstances (see Chapter 24).Children and adolescents that present for medical evaluations after an acute sexual assault should be questioned and examined carefully for other nongenital injuries. Injuries can result from the assailant's blows, grabbing, restraining, or gagging, or from the defensive efforts of the victim. Assault injuries most frequently involve the face and neck and are inflicted to silence the victim. Slap marks, grab marks, and contusions from blows by a fist or object may be seen on the face, neck, head, and extremities. Areas where patients indicate they have been bitten or licked can yield important forensic information and should be swabbed and photographed in accordance with protocols.Victims sometimes report tenderness over body surfaces after an acute sexual or physical assault. Victims of chronic sexual abuse often have genital concerns or complaints that have no identifiable pathological etiology. Children should be asked if they have had any pain, bleeding, or discharge. After examination, if appropriate, it is important to reassure children that they are normal. Genital symptoms that can indicate trauma or pathology, including bleeding, pain, dysuria, urinary tract infections, vaginal discharge, and abdominal pain. Recent drug/alcohol use or mental status changes suggest the need for drug testing or alcohol blood levels. In some states, criminal charges are affected by the victim's level of intoxication (and hence, inability to consent). Some victims require emergent or long-term treatment for substance abuse. The presence of illicit substances in child or adolescent victims of physical or sexual abuse should prompt careful questioning about prostitution and exploitation for pornography.The initial approach to the interview of a child who is a suspected victim of physical abuse is similar to the approach for a suspected victim of sexual abuse. (“Can you tell me what you know or understand about why you are here to see me today?”) In physical abuse cases, it is important to establish where the injuries are, when they occurred, and how they occurred. Descriptions of pain and disability will assist in assessing the need for further testing (such as radiographs) or follow-up examinations. Understanding the context and chronicity of the abuse, and the triggers that led to the child's injury can assist the physician in assessing whether the child is in ongoing danger. For example, injuries inflicted for minor, expected incidents (such as breaking a toy) and humiliation of a child in public might indicate greater risk of harm to the child in other, more provocative or less public situations. Physical abuse victims often provide limited information about the extent and severity of their injuries. It is not unusual for the physician to uncover additional acute and healed injuries during a child's examination that were not discussed or disclosed during the medical history. As injuries are revealed, the clinician should ask, “I see a long scar on your lower back here. What can you tell me about how this happened? Do you know when?” As with interviews of children who are suspected victims of sexual abuse, the clinician should be careful to clarify terms used by the victims. For example, many children say they are “spanked,” but when asked to clarify, many will indicated that a spanking is when they are hit with a belt or another object.Victims can have acute emotional shock, depression, and suicidal ideation. The clinician should ask victims of abuse directly about suicidal thoughts regardless of whether they have overt symptoms of depression. (“Have you ever felt so bad that you thought about killing or hurting yourself?” If the answer is yes, the clinician should establish the most recent suicidal thoughts/action and consider an immediate referral to a mental health professional. The clinician should be cautious in prescribing anxiolytic or antidepressant drugs, and should refer to a child psychiatrist whenever possible.Other behavioral responses to abuse include aggressive behaviors, sleep disturbances, school dysfunction, weight changes, and delinquent behaviors (see chapters 49 and 50).Gynecological HistoryInformation regarding prior gynecological evaluations will assist the clinician and support staff in preparing the adolescent for an examination. Prior infections, pregnancies, and gynecological conditions should be noted. A menstrual history, including menarcheal age, last menstrual period, use of pads and/or tampons, and regularity of menstrual periods assist in determining the need for pregnancy testing. In addition, adolescents that have had prior gynecological examinations or who use tampons may tolerate certain examination procedures more readily. It is not unusual for physically abused adolescents to have also been sexually abused or sexually active and in need of a gynecological assessment.A sexual history should include the gender and number of partners, type(s) of sexual contact (including anal and oral contact), and frequency of barrier contraceptive use so the type and optimal timing of testing can be determined. For example, venereal warts have a latency phase of 2 weeks to 2 years, averaging 2 months, so an examination might be indicated 2 months after the most recent sexual assault or contact. Information about the last menstrual period will determine risk and best timing for pregnancy testing.Family History and Responses to Abuse DisclosureSometimes the child might reveal that the nonabusive caretaker does not believe them or is ambivalent about whether abuse has occurred. When there is compelling evidence of abuse, either in the child's history or in medical findings, the clinician should report any perceived lack of support or belief in the child to child protective services. Prior abuse history of the child or family should be noted. History of intimate adult partner abuse in the home of the child is particularly important as the risk of further violent outbursts and the risk of homicide increases when a battered adult leaves the batterer. In one study,29 more than half of sexually abused children and adolescents reported adult intimate partner violence in their homes. When the abuse of the child by a batterer is revealed, this can be the first time the battered partner attempts to leave the batterer. This presents considerable risk to the adults and children in the home.The child's coping depends on how the nonabusive adult reacts to the disclosure of abuse. Children perceive adults’ distress as threatening, often affecting their willingness to talk about the abuse. Such concerns should be identified and addressed. The clinician should also ask children what concerns they have about the medical consequences of the abuse, including disfigurement, diseases, pregnancy, virginity, and alterations in body appearance or function. By providing answers and reassurance, clinicians can directly enhance the healing process.Read full chapterPurchase bookChild abuse: sexual abuseAndrew Sirotnak MD, Antonia Chiesa MD, in Berman's Pediatric Decision Making (Fifth Edition), 2011Children are sexually mistreated most commonly by family members, less frequently by friends and acquaintances, and least commonly by strangers. A child may present to medical care after specific disclosure by the child, with either specific or nonspecific behavioral changes or medical complaints. A detailed account of sexual experiences, unexplained vaginal bleeding, other genital symptoms, compulsive masturbation, precocious sexual behaviors, specific examination findings, sexually transmitted disease (STD), rectal or vaginal foreign body, or vaginitis should prompt consideration of the diagnosis of sexual abuse.A.Take a careful history; few sexual abuse victims have physical or laboratory findings. Interview parents and children separately. Children older than 3 years can provide an accurate description to a skillful interviewer. Coordination with Child Protection Services or law enforcement for the medical examination of a child who has previously disclosed sexual abuse is important, as details of an interview and type of sexual contact may be known. Repeated questioning of such a child is not indicated.When a nondisclosing child suspected of being sexually abused presents for care, an experienced clinician should do a nonleading, unbiased interview. Establish rapport; be supportive, not authoritarian; be nonjudgmental and honest with the child about the visit. Allow the child the opportunity to stop the interview (or examination). Observe and document the child’s affect.Ask open-ended and nonleading questions, such as “Tell me more about that,” or “What happened next?” Progress to more specific questions if the child discloses sexual abuse. Document all details concerning type and frequency of sexual contact. Note the child’s special names for body parts. Document date, time, place, person, and sites of sexual abuse. In older children, record menstrual history, whether force was involved, the patient’s concept of intercourse, and whether penetration or ejaculation occurred. Refer the patient to a child psychiatrist or psychologist for additional evaluation if there is a possibility of unintentional or intentional suggestion (induced memory or coached disclosure).B.Examine the body surface for signs of nongenital trauma. Examine the mouth and rectum for signs of acute trauma. Visually examine the external genitals for signs of trauma or vaginal discharge. Use labial traction (grasp the labia and protract them directly away and posteriorly from the child) and labial separation to examine the hymen and posterior fourchette areas. Although hymen width measurement and measurement of the posterior hymenal rim in abused and nonabused populations have been studied, the overall appearance of the tissue is more important than these measurements. When attempted, hymen width measurement is best done by colposcope with standardized optical measuring devices, noting, however, that measurements have not been shown to be a reliable diagnostic tool. In prepubertal children, vaginal speculum examination or surgical exploration under anesthesia is not indicated unless acute bleeding is unexplained or a foreign body is expected. Consider magnification and photographic documentation of the genitalia with use of a colposcope if injuries are found. Most penetrating hymenal injuries occur posteriorly, between the 3- and 9-o’clock positions. Acute trauma of the genitals, rectum, or mouth usually has epithelial closure within about a week and complete restoration of the tissues within a few weeks. Acute injuries appear as lacerations, contusions, fissures, and abrasions. Anal laxity leading to dilation greater than 20 mm without stool present is not necessarily specific for sexual abuse, but some authors have suggested there may be an association with a history of rectal penetration. Female genital injuries frequently heal without any residua of prior trauma. When apparent, healed injuries can appear as transections completely through the posterior hymen and hymenal attenuation. Healed anal injuries usually leave no discernible findings; however, scars or anal skin tags outside the midline suggest previous injury.C.Consider consultation with a local child protection team or physician or nurse experienced in child sexual abuse evaluations. The female genitalia and anal examination have normal variability, and reliable evaluation requires some practiced skill. Some conditions can be misdiagnosed as resulting from trauma (e.g., lichen sclerosus, urethral prolapse, group A streptococcal infection). If forensic evidence collection is indicated, care should be taken to ensure the appropriate handling of specimens and maintenance of chain of evidence. Attention to proper completion of forms that accompany the collection of evidence kits is also required. Report to Child Protection Services if you are uncertain whether the concerns warrant a finding of abuse. Child abuse will produce psychological distress that can span the spectrum of child psychopathology, so consider the need for immediate psychological resources.D.Two categories of sexual abuse can be distinguished: (1) nonpenetrating contact (viewing or fondling the child’s genitals, asking the child to fondle or masturbate the adult’s genitals, exposure to pornography); and (2) penetrating sexual contact, including attempted and actual vaginal, oral, or rectal penetration. Evaluate each case individually for the following: (1) the degree of force, threat, or coercion; (2) the psychological response of the parents and child; and (3) the need for laboratory investigation.E.For nonpenetrating contact, collect specimens as appropriate to test for semen or saliva on skin or clothing. Data suggest that in prepubertal children, swabs from the body are unlikely to reveal forensic evidence outside of 24 hours, and that there is a much higher yield of DNA evidence from clothing and linens. Follow chain-of-evidence possession procedures.F.If penetration has occurred, collect specimens from the clothing and body (semen, pubic hair, scalp hair, fingernail and debris scrapings, saliva, blood samples) that help to identify the perpetrator. Forensic evidence collection kits are helpful only if collected within 72 hours of alleged sexual contact or assault (up to 120 hours for adolescents with a disclosure of rape). Use protocols to guide specimen collection. Adhere to chain-of-evidence possession procedures. When there has been trauma or significant exposure to body fluid, collect a serum sample for immediate baseline testing for hepatitis B and C, human immunodeficiency virus, and syphilis, as well as for comparison with follow-up sera.G.For the postpubertal patient, assess the possibility of pregnancy. Medication to prevent pregnancy can be given to girls who are postmenarchal and have had vaginal intercourse within 72 hours. Recent studies have suggested that this window of treatment may be extended to 120 hours. If the pregnancy test result is negative, U.S. Food and Drug Administration–approved products can be prescribed to prevent pregnancy. Although not specifically labeled for emergency contraception, there are also well-described, safe, and effective regimens that use combination oral hormonal contraceptives. There are multiple mechanisms by which emergency contraception prevents pregnancy. Unlike mifepristone (RU-486), an antiprogestin, hormonal emergency contraception is not an abortifacient. Regardless, carefully document decision-making process with family about these drugs.H.After obtaining initial culture and wet mount specimens, treat adolescent victims of penetrating assault prophylactically with ceftriaxone (gonorrhea), azithromycin or doxycycline (chlamydia infection), and metronidazole (trichomonas infection). Nucleic acid amplification tests for the diagnosis of gonorrhea and chlamydia are increasingly used in sexually active adolescents and adults; however, their use in forensic cases of child sexual abuse has not yet been determined, and culture remains the preferred test. If culture is not available, two different nucleic acid amplification tests may be an alternative for testing. Consider postexposure prophylaxis for hepatitis B and human immunodeficiency virus (HIV) infection if trauma is present and an exchange of blood or body fluid occurred. HIV prophylaxis is costly and carries significant risk for adverse effects from the medication; compliance to prescribed regimens can be poor in pediatric and adolescent populations, so prescribing decisions should be based on risk for infection and the ability to monitor follow-up. Before initiating HIV prophylaxis, baseline serum chemistry should be drawn for safety and adverse effect monitoring. Make the decision to evaluate prepubertal children for STDs on an individual basis (type of assault, symptoms, risk of STD in the alleged perpetrator). Routine testing for STDs in every prepubertal child with a suspicion of sexual abuse is not indicated. When necessary, collect suspicious discharge, or specimens from the vagina or urethral meatus. Cervical or urethral swabs are not indicated in the prepubertal patient.I.Follow-up examination for STDs should be done at 2 weeks after assault. Inquire about the effects of postcoital pregnancy prophylaxis. Repeat culture and wet mount tests. Repeat serologic testing for HIV, hepatitis B (unless vaccinated), hepatitis C, and rapid plasma reagin should be arranged at this time. Obtain recent menstrual history. Examine for genital warts and consider routine health screen for adolescents (Pap smear, sexual activity counseling). Evaluate all victims for signs of psychological and emotional sequela. Refer to counseling as needed. Avoidance or denial of a need for psychological resources does not indicate the absence of distress. Long-term follow-up, especially of development, school function, and sustained relationships, is important. Research in the field indicates that childhood sexual abuse is strongly associated with multiple types of future adult health and psychosocial problems.Read full chapterPurchase bookElsevierAbout ScienceDirectRemote accessShopping cartAdvertiseContact and supportTerms and conditionsPrivacy policyWe use cookies to help provide and enhance our service and tailor content and ads. By continuing you agree to the use of cookies.Copyright © 2019 Elsevier B.V. or its licensors or contributors. ScienceDirect ® is a registered trademark of Elsevier B.V.


 

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