Aim: To ascertain the frequency of significant anogenital signs, at medical examination, following an allegation of sexual abuse, in relation to the timing of the examination.
Method: A case series of 331 children, who were referred by the police or social services for examination, following an allegation of child sexual abuse or suspicion of this, over a 3½-year period in a defined geographical area.
Results: Two hundred and fifty-seven children alleged penetrative abuse, of whom 114 were seen within 7 days of the abuse. Twenty-three children alleged penetrative anal abuse within the previous 7 days; 13 of these had abnormal findings (56.5%) compared with 9 (18%) of the 50 children seen more than 7 days after anal abuse. Ninety-two girls alleged penetrative vaginal abuse within the previous 7 days and of these 46 (50%) had abnormal findings, compared with 31 (30.7%) of the 101 girls seen more than 7 days after the alleged abuse. In addition 33 girls seen within 7 days had other signs associated with probable assault. Abnormal findings were more common in post-pubertal girls.
Conclusion: Pubertal and post-pubertal girls are more likely to have significant genital signs if they are examined within 7 days of the last episode of sexual abuse. Our findings suggest that abnormal anal signs are more likely to be present in the acute phase. This study indicates that children should be examined as soon as possible following a referral. This will have implications for clinical practice. Regardless of the lack of accurate history it will always be important to examine the child as soon as possible after disclosure.
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Over the past 30 years there has been increasing awareness of child sexual abuse, and a growing body of research concerning children who have been abused in this way. This has included studies on the medical assessment of sexually abused children1–6 and a small number of studies of anogenital appearances in abused children compared to those selected for non-abuse.7 There have also been limited studies on healing of anogenital findings.8–10
It is very difficult to conduct scientifically robust research in this sensitive clinical area. There are difficulties in interpreting data, and lack of consensus regarding the frequency of abuse. There are also ethical issues with setting up comparative studies which may involve unnecessary assessment of children who are presumed not to have been abused. It is often difficult to persuade children and young people to return for follow-up.
Furthermore, interpretation of the existing medical literature is fraught with difficulty. The paucity of case control studies, a lack of consistency in describing the physical signs and differing methodology employed and interpretation of results, has led to confusion. A few papers refer to the physical findings that may or may not be present at “early” examination. Some studies have highlighted the overall low rate of significant findings at paediatric assessment (others have described a greater proportion of children with signs). Heger1 and Berenson7 in their papers dealt only with pre-pubertal girls and found more signs in children who alleged penetration and those seen in the acute phase (less than 7 days from the last alleged assault). The prevalence of significant findings varied between 3.5% and 8%. Early examination is thought to be beneficial emotionally for the child and family. A qualitative study of carers11 whose children had suffered sexual abuse showed that in all the cases the timeliness of the response fell far short of the expectations and needs of families and children. Once sexual abuse is disclosed, families expect an immediate and appropriate response. This is partly conditioned by families’ understandable perception of abuse as a catastrophic event. Furthermore, it would seem that there is an increased likelihood of findings that could assist in the investigative process, which would help support the child’s disclosure.2 12 There has been an increasing awareness among referring agencies (Police and Social Services) that significant physical signs or forensic evidence may be useful in criminal and civil proceedings.
This study was undertaken as part of a departmental audit to ascertain the frequency with which physical signs occurred in a series of all children referred to a community paediatric department by police or social services, where there had been allegations of sexual abuse. The Community Paediatric Department serves three unitary authorities in South Wales, where there are 107 010 children aged less than 17 years. The area covered is predominantly urban with pockets of high deprivation (Jarman score of 3.3; the overall Wales score is –0.08). The audit considered the proportion of children with abnormal anogenital findings considered diagnostic of abuse.3 Comparisons were made between those children presenting within 7 days of the alleged abusive episode with those who presented after 7 days. The incidence of abnormal anogenital findings was also compared between pre- and post-pubertal girls. The notes of all children (aged under 17) who presented between July 2002 and December 2005, following an allegation of sexual abuse, were scrutinised. The children were examined as part of the multiagency investigation by police or social services. All children who were investigated for any form of alleged abuse were referred to our child health department by local police and social services. Children referred with alleged physical abuse and neglect were only examined for possible sexual abuse if they made a disclosure, had symptoms, or suspicious bruising was noted. The paediatricians were trained forensic examiners as well as being trained in the holistic assessment of children. Forensic samples were taken when requested by the police. Each examination was conducted by one of four paediatricians who worked in the same department, to the same guidelines, and using a standardised clinical proforma. This recorded the source of referral, history, type of abuse, timing of abuse and details relating to the disclosure and the alleged perpetrator. Information regarding previous sexual activity was noted (if relevant). Second opinion was available in-house, usually at the time of examination, or the following day. In addition to case histories, a colposcope was used for photo documentation of medical findings, although photographs were not taken routinely when findings were unequivocally normal. Cases including photographs were reviewed in the departmental peer-review meetings.
The examination was considered to have medical findings diagnostic or indeterminate of trauma and/or sexual contact as per Adam’s classification.3 Adam’s classification was used because it gave specific guidance in the interpretation of findings and was based on current research at the time of its publication. Diagnostic features included acute lacerations or extensive bruising of the labia, penis, scrotum, perianal tissues or perineum; fresh lacerations of the posterior fourchette, peri-anal scars or scars of the posterior fourchette; acute lacerations and/or bruising of the hymen; perianal lacerations extending deep to the external anal sphincter; healed hymenal transections between the 3 and 9 o’clock positions; and missing segments of hymenal tissue. Indeterminate signs included deep notches or smooth non-interrupted rim of hymen of less than 1 mm; and wart like lesions on the anus, ulcers on the anus, marked immediate dilatation of the anus to a diameter of ⩾2 cm in the absence of other predisposing factors such as constipation, sedation, anaesthesia, and neuromuscular disorders.
When clinically indicated, the paediatricians undertook forensic sampling. This service was available on a 24-h basis. All children, where the abuse may have occurred within the previous week, were seen on the day of referral. This study was undertaken as part of annual departmental audit and the data collected were fully anonymised.
Between July 2002 and December 2005, 331 children were referred in total. Fifty-nine boys (18%) and 272 girls (82%) were seen. Ninety-nine per cent were white British (1 from the Indian sub-continent, 2 African and 1 Afro Caribbean) and were aged between 3 months and 17 years (mean age of referral = 8.79 (SD 4.65)). Of these, 257 children had made an allegation that they had been sexually abused by either penile or digital penetration. The numbers of children examined are shown in fig 1.
The other 74 children were examined for a number of reasons, summarised in table 1. The findings related to these are not included in the subsequent analysis.
We looked in more detail at the 257 children who had disclosed penetrative abuse. The time range since last alleged abusive incident to examination, was less than 7 days for 114 children. Of the other 143 children presenting after 7 days, 73 were seen 7 days to 1 month after last alleged abuse; 35 between 1 and 6 months and 35 after 6 months and up to 6 years. Sixty-two children alleged only penetrative anal abuse and 11 girls alleged both penetrative anal and vaginal abuse.
1. Examination findings in children seen within 7 days of the alleged penetrative abuse
The date of last contact was taken as the last time the child/young person had contact with the alleged perpetrator. In the majority of cases this was the time given to us during history taking of the alleged abuse. Of the 73 children who alleged anal penetration (either penile or digital), and including the girls who also alleged vaginal abuse, 23 (31.5%) were examined in less than 7 days following the last contact with the alleged perpetrator. Thirteen (56.5%) of these had abnormal findings of the anal area; in all of these cases anal penetration had been alleged, two by fingers and the remainder with penile penetration. Seven of the children had bruising around the anus; six had acute anal lacerations and one had a scar from a previous laceration. Reflex anal dilatation was noted in one of the children with bruising. Findings are summarised in table 2.
Ninety-two girls who alleged penile and/or digital vaginal penetration in the previous 7 days were examined. We defined penetration when during disclosure the child or young person described “something” going inside. We acknowledge that the accuracy of this allegation is likely to increase with age. Forty-six (50%) had abnormal findings, summarised in fig 2.
We noted the presence of other “acute” physical findings in both the girls who had abnormal genital signs and those who had normal genitalia. These signs are summarised in table 3.
We also looked at the physical signs according to the child’s pubertal status.
Of the 33 pre-pubertal children we examined who had alleged penetrative abuse, five (15.2%) had abnormal findings. These included three with bruising of the hymen/posterior vaginal wall and two with tears in the hymen; one had marked oedema of the hymen (which had disappeared at follow-up 1 week later) and one had adhesions around the hymen (these were not peri-hymenal bands). Two girls had bruises on the nipple; one had a bite mark on the breast.
Of the 59 post-pubertal girls alleging penetrative abuse seen within 7 days of the alleged assault, 18 (30.5%) had normal findings on genital examination. Forty-one girls (69.5%) had physical signs diagnostic of trauma to the genital area, including acute hymenal tears (with or without bruising) and bruising and tearing of the posterior fourchette. Seventeen of the girls had hymenal openings that permitted vaginal examination with no discomfort. Ten had a history of alcohol ingestion or were clinically “drunk”/smelling of alcohol. (This had implications in obtaining informed consent not only for the examination but also for the alleged abusive sexual activity.) Four girls had bacterial vaginosis; two girls had genital warts; and there were two pregnancies, both of which were terminated.
2. Examination findings in children seen after 7 days of the alleged penetrative abuse
Fifty children were examined following an allegation of penetrative anal abuse, the last episode of which was said to have been more than 7 days before examination. Nine (18%) of these had abnormal findings, with visible healed fissures or scars.
One hundred and one girls who had made an allegation of penetrative vaginal abuse, were examined more than 7 days after the last alleged abusive act of whom 70 (69.3%) had normal genital findings and 31(30.7%) had physical signs.
Of these 101 girls, 57 were pre-pubertal and 44 were post-pubertal. Forty-three (75.4%) of the pre-pubertal girls had normal findings on examination and 27 (61.4%) of the post-pubertal girls also had normal findings on examination (fig 3).
The abnormal signs seen were healed tears in the hymen, or scarring of the posterior fourchette or fossa navicularis, and one young child had scarring of the labia minora. The post-pubertal girls who had a tear, or tears, in the hymen gave a history of previous consensual sex. We noted no difference in the presence of bruising or occurrence of acute tears in the girls seen within 7 days of the alleged abuse regardless of their past sexual activity.
Three hundred and thirty-one children were referred to our service over a 3-and-a-half-year period. They represent a series of children in a defined population who presented to police or social services following an allegation of sexual abuse or suspicions that sexual abuse may have occurred. The local police and social services relied absolutely on the community paediatric department for the provision of paediatric and forensic assessments for all cases of alleged sexual abuse referred to them; the local referral pathway also meant that children, where sexual abuse was alleged, presenting for example to their general practitioner, would be referred in the first instance for a joint investigation with police and social services rather than attending as a paediatric emergency.
Our case series included all cases where there was any possibility that sexual abuse may have occurred such as children being left unsupervised in the care of a known sex offender. We looked in greater detail at the records of 257 children who actually disclosed penetrative (or what they thought was penetrative) abuse, either penile or digital. The interpretation of physical signs in alleged sexual abuse has over the years, often been a contentious issue and we were mindful of this at the time of our audit. We found the most contemporaneous and helpful guide to the interpretation of physical signs was that provided by Adams.3
The Royal College of Paediatrics and Child Health (RCPCH) will shortly be publishing a clinical handbook describing the physical signs in child sexual abuse. This is based on a comprehensive trawl of the known literature on this topic and presents for the first time an evidence base for interpreting the signs associated with child sexual abuse.13 They note that there is a lack of research on children with a history of anal penetration.
In our study, although more than half the children seen within 7 days had signs of anal trauma, the actual number (seven) was small. Although this may be a relevant finding, we cannot place too much reliance on it. Further multi-centre audits are urgently needed to look at anal signs and their resolution following penetrative anal abuse. We only saw one child with reflex anal dilatation (RAD). The draft RCPCH guidelines state “the evidence suggests that RAD is more commonly seen in sexually abused than non abused children”. It would be helpful for further studies to look at the occurrence of this sign and how soon after acute buggery this sign disappears.
Signs were more likely if the children were seen early but the numbers overall are small, and it is difficult to be sure of the extent to which lack of signs was related to length of delay between the alleged incident and physical examination. It is known that anal abrasions, lacerations and some fissures heal quickly and completely.4
However, an important difference in the incidence of genital physical signs between pre- and post-pubertal girls, was noted, especially for adolescent girls seen within 7 days post assault; 69.5% had abnormal findings as opposed to 15.2% of younger girls. Pre-pubertal girls often made allegations that digital or penile penetration had been attempted. In girls who had alleged vaginal abuse, the majority of the post-pubertal girls gave a clear history of penile penetration (often in vulnerable situations such as being drunk or under the influence of drugs). We were concerned to note the high number of girls with a significant history of alcohol ingestion. In these cases the history obtainable from the victim was often vague and there were issues around obtaining informed consent that delayed the medical assessment.
Several authors have looked at findings in post-pubertal girls and adult victims of sexual assault.14–16 They have tried to address the issue of findings after consensual versus non-consensual sex and noted genital injuries in both groups of similar frequency; however, when sex was not consensual they noticed more bruising and abrasions. In our study we were unable to note any difference in the presence of bruising nor occurrence of acute tears regardless of their previous sexual activity and whether the activity had been “consensual” or not.
We found more normal examinations were seen in the post-pubertal girls examined after 7 days (70%); this is similar to the findings of other authors. Kellog17 for example, looked at pregnant girls who had alleged abuse, and noted only two of her 36 subjects had positive findings; it was likely that they were seen some time after the “incident”, which is thought to explain the lack of injury. Adams18 found a high correlation of signs if the adolescent was seen within 72 hours, while Biggs15 found that a substantial proportion of women regardless of prior sexual experience would not have visible genital injuries. This is because the post-pubertal genital area is vascular and healing of lacerations and abrasions is rapid.
There is a need for medical assessment as soon as possible after disclosure. This may need to be before the video interview. The doctor needs to be aware of the sensitivities of history taking in these circumstances. The need for urgent medical assessment is not solely to collect forensic samples but to maximise the potential for observing relevant and short-lived physical signs such as bruising or other trauma in the genital area. We were not routinely made aware of the results of forensic sampling nor whether they were sent for analysis, making the observation and documentation of short-lived physical signs all the more important. After 7 days the reasons for examination are more medical rather than forensic, but even so the victims of abuse find it helpful to complete this part of the investigative process sooner rather than later. Parents and children often find that having a medical examination is reassuring and an event that marks the start of the healing process. Although it may be considered clinically acceptable to “delay” medical assessment following disclosure, the child/young person is usually anxious to be seen as soon as possible if only so he/she can bathe. We were able to offer a 24-h availability of forensically trained paediatricians in all cases regardless of the timing of alleged abuse. Lauritsen19 stated that medical examination seldom provides a legal proof of sexual abuse in her study of 34 children, 90% of whom were seen after 7 days. If important physical evidence is more likely to be found in the early days following a sexually abusive act this has significant implications for practice. Forensically trained paediatricians (as opposed to non-paediatric forensic medical examiners (FMEs)) are best placed to provide a holistic assessment of the child or young person. Children who present following sexual abuse have often suffered other abuse and neglect. The opportunity should not be missed to identify and meet their other health, educational and social needs. Importantly this includes the need for sexually transmitted infections (STI) screening and referral at the appropriate time, which we address in our practice. Although it may seem inappropriate for a paediatrician to examine “street wise, sexually active teenagers”, in our experience these young people often seem to regress emotionally following an alleged assault or sexually abusive incident. The majority attend with their mother in a caring and supportive role and find it comforting rather than insulting to be seen by a paediatrician.
The role of the paediatrician in examining “acute” cases has not always been clear and there are considerable variations in practice in the UK. For example, these examinations are either undertaken by FMEs, forensically trained paediatricians, or may be conducted as joint examinations, depending on the region in which they take place. Guidelines from the Association of Chief Police Officers,20 the RCPCH and the Association of Forensic Physicians21 state that the examination of a child less than 16 years should be conducted by a paediatrician trained in forensic skills, or failing this a paediatrician accompanied by an FME. As a result of this, increasing numbers of adolescents alleging non-familial assault or rape are now investigated alongside younger children. This is placing increasing demand on already-stretched paediatric services.
Pubertal and post-pubertal girls are more likely to have significant genital signs if they are examined within 7 days of the last episode of sexual abuse. This is especially so for post-pubertal girls. Our findings suggest that abnormal anal signs are more likely to be present in the acute phase and so children should be examined as soon as possible following a referral. It is also essential to record other physical signs of trauma which will not persist for more than a few days. The timing of the medical examination should also take into account the child’s wishes, welfare and their emotional state. It might be appropriate to wait until the following morning in some cases, especially with very young children. However balanced against that is the need for the child or young person to “get it all over with” as soon as possible so at the very least they can go home and have a bath. It is the authors’ view that no child should have to wait more than 12 h for an examination following a disclosure of alleged abuse within the previous 7 days. The practice of not seeing children for 2 or 3 days is unacceptable.
We postulate that the assessment of children following a disclosure of sexual abuse is therefore a paediatric emergency if the last reported abusive contact was within 7 days. This is especially so for adolescents. Consequently, all acute paediatric departments should have easy access to forensically trained paediatricians, or FMEs with a paediatric background, who are able to holistically assess children who present with a history of sexual abuse. In order to respond to referrals in a timely manner and act in the best interest of the child and his/her family, there will be significant implications for clinical practice, staffing, resources and training.
What is already known on this topic
The medical assessment (including forensic examination if indicated) of a victim of alleged sexual abuse is an integral part of both the investigative and therapeutic processes.
The interpretation and the relevance of physical findings in the anogenital area, continue to be the subjects of debate and controversy.
Robust evidence is lacking in this area due to the difficulties associated with undertaking such research, including paucity of case control studies and the problems associated with conducting follow-up studies.
What this study adds
This study presents the findings in a case series of all the children in a defined population who were referred for assessment when sexual abuse may have been perpetrated.
It explores the difference in findings depending on the time elapsed since the alleged abusive incident.
It provides information on this difficult area of paediatrics that could help in joint planning of services with investigative agencies.
Competing interests: None.
Patient consent: Written informed consent was obtained for all the examinations (including photography and use of data for teaching and from 2005 for the use of data in publications and research).
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