Child Sexual Abuse-A Hidden Epidemic

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Derek Roberts
6 years ago
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1 Child Sexual Abuse-A Hidden Epidemic C H A N L O W E, M D, S F H M, F A A P D I V I S I O N C H I E F, P E D I A T R I C H O S P I T A L M E D I C I N E D E P A R T M E N T O F P E D I A T R I C S T H E U N I V E R S I T Y O F A R I Z O N A B A N N E R - D I A M O N D C H I L D R E N S M E D I C A L C E N T E R

2 Disclosures I serve as a patient examiner at the Southern Arizona Children s Advocacy Center. I have served as a paid expert witness for child abuse cases. No unapproved or off-label treatments will be discussed.

3 Cautions This is a sensitive subject. As abuse is common, there may be those that have been abused here today. The topic may be difficult for some to hear. Some pictures are graphic. If you are bothered in any way by the talk, please feel free to step out at any time.

4 Statistics 1 in 7 girls is sexually abused by age in 25 boys is sexually abused by age 18. Estimated 39 million child abuse survivors in US today.

5 Internet Stats 1 in 5-7 children are sexually solicited on the internet 1 in 25 children are aggressively solicited 1 in 25 children were solicited for sexual pictures of themselves Most common first encounter (76%) with a predator took place in a chat room. 11% of teens say they have shared naked photos of themselves online or by text. Only 25% of those believe the images were not shared

Rescued 4 days later By Rattlenoun - Own work, CC BY-SA

6 The Alicia Project Alicia Kozakiewicz, age 13 New Years 2002 abducted Left willing to meet her chatroom friend Rescued 4 days later By Rattlenoun - Own work, CC BY-SA 4.0,

7 Age 14, founded the Alicia Project 2007 testified before Congress 2008, Protect our Children Act Alicia s Law State funding for victims of internet crimes against children taskforces Passed in AZ in 2015

9 No age is too young Median age of reported abuse is 9 years old >20% are abused before age 8 Almost ½ of victims of sodomy, sexual assault with an object or forcible fondling are under 12.

10 Who s abusing? 30-40% are abused by a family member 50% are abused by a known and trusted person outside the family ~40% are abused by an older or larger child they know <10% are abused by a stranger Our kids are safer with a stranger than with us

11 The unfortunate truth MANY CHILDREN NEVER DISCLOSE ABUSE Young victims may not recognize abuse is occurring >30% of abuse victims never tell anyone ~80% initially deny abuse or are hesitant to disclose 75% disclose accidentally > 20% subsequently recant their disclosure

12 Why Don t They Just Say So Our children think we know already. Parents know everything right. The abuser may be manipulating them. If you tell, we ll both be in trouble. Your parents will be so mad at you You don t want uncle John to get in trouble, do you? They may not realize until much later what was actually going on. WE MUST BE ON THE LOOK OUT FOR THESE PATIENTS.

13 Children rarely lie about it Only 1-4% of reports are fabricated 75% of these reports are made by adults Custody disputes, etc. often come up Children only fabricate 0.5% of the time TAKE THE REPORT SERIOUSLY

14 Some Good News We re Winning! 56% decline in physical abuse and 62% decline in sexual abuse from 1992 to 2010 Data from National Child Abuse and Neglect Data System Confirmed by multiple other data sources

15 Remember Abuse is rarely suspected unless a report is made. Most don t report. Most get missed.

16 Abusers are Methodical 1. Identify a child target. 2. Engage the child in a friendly way Get to know the child and vice-versa 3. Desensitization of the child to touching by offender. Start off with innocent touching and proceed from there as child becomes comfortable. 4. Isolate the child for the abuse to occur. 5. Make the child feel responsible. You practically asked me to do that. It s our secret, special time no one can know. You wouldn t want us both to get in trouble.

17 Presenting Symptoms Often are somewhat vague Behavioral changes are often attributed to a stage Genital complaints are often attributed to hygiene or clothing issues We can t diagnose what we don t think of.

18 Symptoms to Note Nervous, hostile, disruptive behavior towards adults Arriving early/leaving late from school Withdrawing into fantasy world Drug/alcohol use Isolation/inability to make friends Sexual promiscuity

19 Physical signs Redness/irritation of genital area Pain in genital area Difficulty urinating Bruises Bed wetting Tears Discharge from vagina or penis STI s Pregnancy Somatic symptoms are common in preteen years

20 Normal Female Anatomy Significant variation in normal Many have a false idea of what normal is E.g., hymen doesn t seal off the vaginal opening Knowing normal vs. abnormal is 1 st step to identifying injury

21 Normal anatomy Positioning is described using a clock face. 12:00 is always anterior (even if pt. is prone) Hymen best viewed with labial separation and traction ALL GIRLS HAVE A HYMEN Congenital absence has never been described

22 Anatomy review Labium Minus Urethra Hymen Clitoral Hood Periurethral Band Hymen Fossa Navicularis Ant. Vaginal Wall/ Hymenal opening Posterior Fourchette

23 Visualization techniques Positioning is crucial to getting accurate views Any concerning finding should be verified in another position An abnormality in only one position is unlikely to be a true abnormality Remember the child s developmental staging Some positions are better at various ages, both for visualization and pt. comfort. E.g. toddlers are not placed in stirrups

24 Frog-leg position

25 Supine Knee-Chest

26 Prone Knee-Chest 12 O clock

27 Labial separation

28 Labial traction

29 Why use two positions? Supine frog leg Prone knee-chest

30 The Hymen Annular Crescentic

31 Abnormalities

32 Findings with assault MOST (96%) EXAMINATIONS ARE NORMAL Even with significant abuse and penetration Acute injuries heal quickly so delayed exams may miss previous injuries Most injuries heal completely without any evidence of damage It is extremely uncommon for the hymen to scar Be suspicious of scars, especially in the midline. These may be normal variants, such as linea vestibularis

33 Mechanism of assault in children More often rubbing, not pounding. Often not the violent rape typified in adult cases. Changes the type of injury that may be found. Hymenal injury may or may not be present. Child may be brought in to medical services due to injury (bleeding, etc.) by the abuser because they don t want the child hurt.

34 A quick word about the law 15 is the age of consent in Arizona 14 and under cannot consent in any circumstance are bound by a 2 year age differential 15 y/o can consent to a 17 y/o but not an 18 y/o In Arizona, penetration is defined as entrance beyond the labia majora, not entrance into the vaginal canal. Exclusion for appropriate care (diaper changes, etc.)

35 Labia Majora bruising 4 y/o girl with vague report of oral-genital contact 3-7 days before exam Note bruise possibly due to suction but mechanism cannot be definitively established.

36 Hymenal abrasions 9 y/o girl. Mom caught her BF fondling her daughter. Pt. in prone knee-chest position

37 Hymenal bruising 12 y/o girl 8 hrs post rape 15 y/o girl, note use of foley for visualization

38 12 y/o girl with penile-vaginal penetration several hours before exam Hemorrhage Not visualized in this pictures is a posterior hymenal laceration

39 Same girl 10 days later Supine Prone

40 5 y/o girl assaulted by father Condylomata Deep hymenal cleft

41 A few mimics

42 Bumps and Mounds

43 Linea Vestibularis

44 Failure of midline fusion

45 Injuries to boys S O T H E G U Y S D O N T F E E L L E F T O U T

46 Bruising Thought to be toilet seat infliction

47 Reported zipper injury Child too young to zip his own zipper

48 STI s W H A T D O T H E M E A N?

49 Summary of illnesses STI confirmed Gonorrhea Syphilis HIV Chlamydia Trichomonas Condylomata Acuminata Herpes Simplex Bacterial Vaginosis Sexual abuse Diagnostic Diagnostic Diagnostic Diagnostic Highly suspicious Suspicious Suspicious Inconclusive Caveats exist for most of these

50 Caveats NAAT s are now common place for testing. A positive NAAT should be confirmed by another site or a different test. Consider other modes of infection (vertical, blood transfusions, etc.) Rare nonsexual contact has been described with some of these infections (these are suspicious) Chlamydia, gonorrhea Remember, coinfections are common

51 Timing of Exams Acute exam done ASAP Last contact > 72 hours, can be scheduled when convenient Rape Kit reported to detect DNA up to 5 days out In prepubertal children, rare to have + findings beyond 1 st 24 hours. Almost never beyond 48. Beyond 72 hours, generally an exam is done but no forensic collections.

52 Where do I turn for help/more info? 911 if suspicion of sexual abuse exists we are mandated reporters. Report to LE LE will guide from there LE authorizes rape kit to be collected. If concerned about injury, send to ER Local children s advocacy center Feel free to call me or a child abuse pediatrician AAP Section on Child Abuse and Neglect Councils-Sections/Section-on-Child-Abuse- Neglect/Pages/Child-Abuse-Neglect.aspx

53 National Center for Missing and Exploited Children

54 Thank you!

Disclosures. Case 1: Objectives: Case 1 11/4/13. Doctor, was there penetration? Why we usually can t tell by looking.

Disclosures. Case 1: Objectives: Case 1 11/4/13. Doctor, was there penetration? Why we usually can t tell by looking. Doctor, was there penetration? Why we usually can t tell by looking. Joyce A. Adams, MD Professor of Clinical Pediatrics University of California, San Diego Rady Children s Hospital San Diego 1 Disclosures