Management of the Young Female as a Possible Victim of Sexual Abuse

CHAPTER 158 Management of the Young Female as a Possible Victim of Sexual Abuse

David B. Bosscher

Sexual abuse is so common that primary care clinicians should consider it as a possibility even during routine office visits. The prevalence is estimated to be 22.3% for girls and 8.5% for boys. Although child advocacy centers are increasingly available in many regions and communities, the generalist clinician is often the critical first line of evaluation.

In young females, common initial complaints include itching, redness, burning, irritation, discharge, or bleeding at the vagina. The abuse may be disclosed initially or discovered later. Occasionally, the abuse will be discovered when a parent wants a child examined after their use of sexually explicit language, demonstration of a sexual act on their doll, or other overtly sexual behavior. Because children may be exposed to sexually explicit media, the examiner must carefully sift through such allegations and concerns. Often the complaints are nonspecific and parents hope that a medical test can prove or disprove abuse. Unfortunately, in the majority of cases, children are seen long after the incident may have occurred. If, however, the alleged incident took place within 72 hours of complaint, immediate examination using a carefully structured protocol (e.g., a rape kit; see Chapter 157, Treatment of the Adult Victim of Sexual Assault) is mandatory.

A careful physical examination for children with allegations of sexual abuse is imperative, either in the clinician’s office or through a regional child advocacy center. Nonetheless, only about 4% of physical examinations result in positive findings. A negative finding does not negate the claim of abuse, but does make interviews with social workers and other trained interviewers critically important to sort out allegations.

Although this chapter focuses on females, it is not meant to deny the possibility of abuse in males. If abuse is suspected in a young male, many of the same principles apply. It is important to know local laws regarding collection of evidence because they vary by location. The examiner should be certain to follow local standards for collection of forensic specimens.

Indications

• Suspicion of sexual abuse after initial questioning or preliminary physical examination

• Referral from teacher, parent, or other responsible person alleging sexual abuse

Equipment

• Either a hand-held lens with an adequate examination light or a colposcope to examine details. One major benefit of a colposcope is that it allows the clinician to use both hands for the examination. If a hand-held lens is used, an assistant will be needed.

• Camera (helpful but not mandatory).

• A rape kit should be available in case it is necessary to document rape. If alleged sexual contact was within the past 72 hours, consider using the rape kit to collect evidence in an organized manner (see Chapter 157, Treatment of the Adult Victim of Sexual Assault).

Preprocedure Patient Preparation

Explain the entire procedure to the caregiver and the child at a language level that both will understand. The child needs to know that she will be asked a lot of questions and that some may seem “silly.” Explain that after the questions, the child will be examined.

It is often helpful to allow a young girl to maintain her sense of control over the process. After establishing rapport with the child, assure her that she will be allowed to be as active a participant as possible. If possible, she should know that she will be asked for permission before proceeding with any part of the examination.

Issues of privacy and confidentiality are important when examining older children. Although most young girls will prefer to have a parent, usually the mother, in the room at all times, in some cases it will be helpful to later spend time alone with the child. When alone with an examiner, a child may disclose abuse or other concerns. Letting her and the parent(s) know ahead of time (before the examination) that the clinician will be spending time alone with her may increase her comfort. Allowing that time alone may give her a greater sense of control and a feeling of responsibility for her own health. Consideration should be given to having a second person in the room with the patient and examiner at all times to serve as an assistant, chaperone, and witness. If the examiner is male, having a female assistant in the room may make the patient more comfortable.

Parents should be reassured that the child’s hymen will not be altered in any way by the examination. Anatomic diagrams may be helpful for demonstration.

Technique

Taking the History

1 Assuming that a social worker or trained interviewer is responsible for taking a detailed history, the primary care clinician should take sufficient history to perform all pertinent portions of the examination. If no trained interviewer is available, a complete history should be taken in an unhurried and comfortable setting. Consider setting aside separate visits for the history and the physical examination.

2 Take some time to establish rapport. Ask about the current family structure, recent life changes, and which activities she enjoys, as well as about school and friends. Take notes while obtaining the history. It is often complicated. Obtain the names of persons potentially involved.

3 Document the descriptions of any potential sexual abuse in the child’s own words. When the meaning of a word is unclear, ask clarifying questions. Document the meaning of the word in her terms. For example, if the child mentions sex, ask her what that means (e.g., because of depictions on television, children often think that sex means just being naked and in bed with another person).

4 Do not be any more leading in questioning than is absolutely necessary. Begin with very general questions and go to more specific ones if the child does not offer sufficient information. For example, ask “Has anyone touched you in a way that made you feel funny or bad?” before asking “Has anyone touched your bottom?” Leading questions can not only misdirect the child and, subsequently, the examiner, they can also be neutralized by a defense attorney.

5 Do not allow the caregiver(s) to adopt a coaching role. Such a role may negate the clinician’s testimony as well as the child’s.

6 Young children have an incomplete concept of numbers and time. They often cannot tell how many times something occurred, but can often specify in general terms: “a lot,” “once in a while,” or “one time.” Likewise, regarding time, small children do not understand the difference between “3 months ago” and “8 months ago.”

Tags: Pfenninger and Fowlers Procedures for Primary Care Expert Consult

May 14, 2017 | Posted by admin in GENERAL & FAMILY MEDICINE | Comments Off

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