Introduction

Assessment of child sexual assault (CSA) requires a dedicated, well-trained and experienced doctor who is able to spend a significant amount of time making an unhurried and thorough assessment and detailed documentation of history and examination findings. The doctor must have an accurate knowledge of genital anatomy, and experience in performing gynaecological examinations. Skills and experience in this field are developed through postgraduate studies, significant case numbers, a knowledge of current literature and involvement in peer-review practices.³

Inexpert assessment of such cases may have a profound negative influence on the child and family. It may potentially lead to inappropriate removal of the child from the family or wrongful imprisonment.⁴

The roles of the emergency physician in this process are:

In the majority of cases, determination of whether or not sexual assault has occurred is not possible within the emergency department (ED). In the majority of cases, physical examination will neither confirm nor refute an allegation of sexual assault. The most important indicator of possible CSA is disclosure by the child.

Definitions

CSA is the use of a child for sexual gratification by an adult or significantly older child/adolescent.⁵ It may involve a range of activities that vary from exposing the child to sexually explicit materials to anal or vaginal penetration of the child. Central to the definition is the limitation of the child to provide truly informed consent for sexual activity with adults.

Sexual play between children of similar age does not fit into this description.

The term ‘assault’ is preferred over ‘abuse’ as it highlights the criminal nature of the activity and avoids minimisation of such abusive acts.

Attitudes/myths surrounding CSA

The subject of CSA is an emotive one. Emergency physicians will often have strongly held opinions and attitudes on this subject. These attitudes may be shaped by past experience and/or social taboos. In order to approach CSA in a calm, non-judgemental and objective manner it is important that emergency physicians are cognisant of their own opinions and emotional responses. In dealing with victims of CSA, expressions of anger, sadness or surprise are not helpful and potentially stigmatising and harmful to the child. With emergency physicians infrequently encountering CSA, it is useful to reflect on the following, sometimes poorly understood, statements.

Epidemiology of CSA

There has been a significant increase in the recognition of CSA,^3,11,12 which has been reflected by a substantial increase in the number of reports made to child protection services across Australia and overseas, particularly in the last 5 years.

Sexual assault has been documented as occurring on children of all ages and both sexes, and is committed predominantly by men, who are commonly members of the child’s family, family friends or other trusted adults in positions of authority.¹¹

Sexual abuse by family members or acquaintances usually involves multiple episodes over periods ranging from a week to years.

Victims of unknown assailants tend to be older than children who are sexually abused by someone they know and are usually only subjected to a single episode of abuse.

The estimated proportion of children exposed to some form of sexual assault varies depending on the definition of sexual abuse and methodology used. In the United States, literature surveys provide estimates of 9–52% for females and 3–10% for males.⁶ There is no comprehensive comparative Australian literature.

CSA and emergency medicine

Children who are victims of sexual assault may present to EDs in a variety of circumstances:

They may be seen for an unrelated matter when routine history and physical examination produce information where sexual assault forms part of the differential diagnosis.

They are brought by a parent or carer to the ED for evaluation of suspected abuse.

They are brought to the ED by social services or the police for a medical evaluation for possible sexual abuse as part of an investigation.

They are brought to an ED after a suspected acute sexual assault for evaluation, evidence collection, and crisis management.

Recognition of CSA

Recognition of the possibility of CSA is dependent on history and examination findings, both of which are normally non-specific.

History from the child remains the single most important diagnostic feature in coming to the conclusion that a child has been sexually abused.¹³

Signs and symptoms

Genitoanal injury

Only 4% of all children referred for medical evaluation of sexual abuse have abnormal examinations at the time of evaluation. Even with a history of severe abuse, such as vaginal or anal penetration, the rate of abnormal medical findings is only 5.5%.¹³

The physical examination of sexually abused children should not result in additional emotional trauma.

When the alleged sexual abuse has occurred within 72 hours, or there is bleeding or acute injury, the examination should be performed immediately. In this situation, protocols for CSA victims should be followed to secure biological trace evidence such as epithelial cells, semen, and blood, as well as to maintain a ‘chain of evidence’. When more than 72 hours has passed and no acute injuries are present, an emergency examination usually is not necessary. An evaluation, therefore, should be scheduled at the earliest convenient time for the child, physician, and investigative team.¹⁷

In the child presenting with genitoanal injury or abnormality, CSA is only one of a number of diagnoses that should be considered. The differential diagnosis of genitoanal injury includes:

Genital findings in children are difficult to interpret. Such interpretation is generally beyond the expertise of most emergency physicians.¹⁴ Whilst acute trauma may be easily recognised, interpretation of such findings may be problematic for the occasional examiner.¹⁴

Genitoanal anatomy

Knowledge of what constitutes normal and abnormal anatomy has evolved over recent years. This has been driven partly by several highly publicised cases where misinterpretation of normal findings led to inappropriate separation of children from parents and wrongful conviction.

Sexually transmitted diseases

The diagnosis of a sexually transmitted disease in a child may be highly suggestive but is not diagnostic of sexual contact. Rectal and genital Chlamydia infections in young children may be due to a persistent perinatally-acquired infection, which may last for up to 3 years.^15,16

Diagnostic considerations

The diagnosis of CSA can often be made based on a child’s history. Physical examination is infrequently diagnostic in the absence of a history and/or specific laboratory findings. Physical findings are often absent even when the perpetrator admits to penetration of the child’s genitalia. Many types of abuse leave no physical evidence, and mucosal injuries often heal rapidly.

On examination, findings which are suggestive, but not diagnostic, of CSA include:

Findings that are of greater concern include:

Many cases of alleged sexual abuse involve parents who are in the process of separation or divorce and who allege that their child is being sexually abused by the other parent during custodial visits. Although these cases are generally more time consuming, they should not be dismissed because a custody dispute exists. Allegations of abuse that occur in the context of divorce proceedings should either be reported to the child protective services agency or followed-up closely.

Role of the emergency physician

The emergency physician (EP) has many roles in CSA. The EP should ensure that any physical injuries are detected, accurately documented and correctly treated.

Medical issues, such as sexually transmitted diseases and emergency contraception, should be discussed and managed.

The EP should collect, or provide opportunity for collection of, forensic specimens, ensure appropriate psychological support is provided to the child and family, and report the case to protective agencies within the legislation of the local jurisdiction.

Mandatory reporting legislation

Some form of mandatory reporting legislation exists in all Australian jurisdictions. Although this legislation varies from state to state, the basic principles are similar. Doctors are mandated to report cases where there is reasonable suspicion that CSA will occur, or is occurring, and the guardian is unlikely to prevent such acts (Table 18.1.1). The reporting practitioner has statutory protection from prosecution if a report is made in good faith.

Table 18.1.1 Guidelines for decision making