Sexual Abuse Evaluation

Sexual Abuse Eval - First Alerts

• Definition: Any sexual act with a child without informed consent or capacity to consent due to age or developmental stage.
• Initial Red Flags:
  • Sudden, unexplained behavioral changes:
    • Anxiety, depression, fear, aggression, withdrawal.
    • Sleep/appetite disturbances, enuresis/encopresis (new onset).
    • School problems (e.g., ↓ performance, absenteeism).
  • Age-inappropriate sexual knowledge or behavior.
  • Recurrent genital/anal pain, itching, discharge, or bleeding.
  • Urinary tract infections (UTIs), sexually transmitted infections (STIs) in prepubertal children.
  • Child's disclosure (direct, indirect, or through play/drawings).

⭐ Most perpetrators are known to the child, often a family member or a person in a position of trust (e.g., teacher, coach).

Sexual Abuse Eval - Eliciting Truth

• Goal: Obtain child's account accurately, minimize distress.
• Interviewer: Specially trained, empathetic, patient.
• Setting: Private, child-friendly, non-intimidating.
• Key Principles:
  • Build rapport before discussing abuse.
  • Use simple, age-appropriate language.
  • One-time interview if possible to avoid re-traumatization.
  • 📌 N.I.C.E. approach: Non-leading questions, Individualized pace, Child's own words, Empathetic listening.
  • Truth-Lie ceremony (younger children) to assess understanding of truth.
  • Anatomical dolls/drawings: for demonstration by child, not direct questioning by interviewer; expert use only.

⭐ Use open-ended, non-leading questions (e.g., "Tell me more about that") to avoid implanting false memories and ensure the child's account is genuine.

Sexual Abuse Eval - Clinical Clues

• General Physical Findings (Non-specific but concerning):
  • Bruises, welts, burns in various stages of healing, especially in unusual patterns or locations (e.g., torso, ears, neck).
  • Human bite marks.
  • Unexplained fractures, especially multiple or in non-ambulatory child.
  • Failure to thrive, poor hygiene (neglect indicators).
• Anogenital Findings (More specific):
  • Genital/anal trauma: bruising, abrasions, lacerations, scars.
  • Hymenal changes: transections (especially posterior), tears, notches, absent hymen (if prepubertal).
    • Normal prepubertal hymenal opening: <4-5 mm (variable).
  • Anal findings: fissures (especially multiple/chronic, >6 o'clock), skin tags, bruising, gaping.
  • Sexually Transmitted Infections (STIs) in prepubertal child (e.g., gonorrhea, syphilis, chlamydia, HIV).
  • Recurrent UTIs, vaginal discharge, bleeding.
• Behavioral Clues:
  • Sudden changes in behavior: aggression, withdrawal, anxiety, depression.
  • Sexually inappropriate behavior or knowledge for age.
  • Sleep disturbances, nightmares.
  • School problems, running away.

⭐ Most children (~50%) with confirmed sexual abuse have normal genital exams during a single evaluation; findings may heal or be subtle. Repeated exams or specialized colposcopy may be needed if suspicion is high based on disclosure or other signs.

Sexual Abuse Eval - Proof & Protection

• Core Aims: Ensure child's safety, meticulous evidence collection, holistic care.
• Documentation: Precise, objective, verbatim quotes. Standardized forms. Photos with consent.
• Investigations:
  • STIs: GC/Chlamydia (baseline, 2 wks); Syphilis, HIV, Hep B (baseline, 6 wks, 3 mo, 6 mo).
  • Pregnancy test (if pubertal).
  • Forensic evidence: Use designated kits.
• Management Steps:

• Prophylaxis:
  • STIs (e.g., Ceftriaxone, Azithromycin).
  • Emergency Contraception (ECP): Within 72-120 hrs.
  • Hep B vaccine ± HBIG.
  • HIV Post-Exposure Prophylaxis (PEP): Start within 72 hrs.
• Legal Duty:

  ⭐ Mandatory reporting: POCSO Act, 2012 (India). Protects children.

High‑Yield Points - ⚡ Biggest Takeaways

• Forensic examination ideally within 72 hours for optimal evidence collection.
• SANE nurse or specifically trained physician should conduct the examination.
• Colposcopy can be valuable for detailed visualization of genital injuries.
• Normal anogenital findings do NOT exclude sexual abuse; history is key.
• Key findings: posterior fourchette tears, hymenal transections/notches, acute anal fissures.
• Comprehensive STI screening (GC, Chlamydia, HIV, Syphilis, HBV) is crucial post-assault.
• Immediate psychological support and mandatory legal reporting (e.g., POCSO Act) are essential.