Sexual Abuse

Overview

Definitions

• Intimate partner violence is a pattern of assaultive and coercive behavior that may include physical injury, psychological abuse, reproductive coercion, and/or sexual assault.
• Sexual assault is a crime of violence and aggression Aggression Behavior which may be manifested by destructive and attacking action which is verbal or physical, by covert attitudes of hostility or by obstructionism. Oppositional Defiant Disorder defined as attempted sexual touching of another person without their consent.
• Sexual abuse of children is defined as sexual activity for which a child cannot give consent, is unprepared for developmentally, or cannot comprehend, including noncontact abuse.

Epidemiology

• Affects all communities:
  • All genders
  • All ages
  • All sexual orientations
  • Children from all social, cultural, and economic backgrounds
• Incidence Incidence The number of new cases of a given disease during a given period in a specified population. It also is used for the rate at which new events occur in a defined population. It is differentiated from prevalence, which refers to all cases in the population at a given time. Measures of Disease Frequency is much higher in girls and women than in boys and men.
• Prevalence Prevalence The total number of cases of a given disease in a specified population at a designated time. It is differentiated from incidence, which refers to the number of new cases in the population at a given time. Measures of Disease Frequency is difficult to document accurately.
  • Worldwide estimate: 5%–25% of girls and 5%–9% of boys have been exposed to some type of sexual abuse.
  • Often unreported because of:
    • Fear of medical evaluation
    • Shame and embarrassment
    • Privacy concerns
• Approximately 1 in 3 women have experienced sexual assault during their lifetime.
  • Approximately 1 in 5 women have experienced completed or attempted rape.
    • 33% state the assault occurred between 11 and 17 years of age
    • 12% before age 10 years
  • 5% of girls who have been sexually assaulted have a STI STI Sexually transmitted infections (STIs) are infections that spread either by vaginal intercourse, anal sex, or oral sex. Symptoms and signs may include vaginal discharge, penile discharge, dysuria, skin lesions (e.g., warts, ulcers) on or around the genitals, and pelvic pain. Some infections can lead to infertility and chronic debilitating disease. Sexually Transmitted Infections (STIs).
  • Prevalence Prevalence The total number of cases of a given disease in a specified population at a designated time. It is differentiated from incidence, which refers to the number of new cases in the population at a given time. Measures of Disease Frequency during pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care is approximately 8%. 
• Approximately 1 in 4 men have experienced sexual violence involving physical contact.
  • Approximately 1 in 38 men have experienced completed or attempted rape.
    • 25% state the assault occurred between 11 and 17 years of age
    • 25% before age 10
  • Approximately 1 in 14 men were forced to penetrate an individual (completed or attempted) in his lifetime
• Perpetrators (according to the Rape, Abuse & Incest National Network):
  • Intimate partner: 33%
  • Acquaintance: 39%
  • Family member: 2.5%
  • Stranger: 19.5% 
• Special populations at increased risk:
  • Developmentally delayed children
  • Elderly patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship with cognitive decline
  • Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship institutionalized with mental health disorders
  • Sexual and gender Gender Gender Dysphoria minority adolescents (gay, lesbian, bisexual, and transgender Transgender Persons having a sense of persistent identification with, and expression of, gender-coded behaviors not typically associated with one’s anatomical sex at birth, with or without a desire to undergo sex reassignment procedures. Gender Dysphoria)
  • Female members of the military and veterans

Classification

• Sexual abuse includes:
  • Rape: penetration Penetration X-rays of the vagina Vagina The vagina is the female genital canal, extending from the vulva externally to the cervix uteri internally. The structures have sexual, reproductive, and urinary functions and a rich blood supply, mainly arising from the internal iliac artery. Vagina, Vulva, and Pelvic Floor: Anatomy or anus with any body part or object, or oral penetration Penetration X-rays by a sex Sex The totality of characteristics of reproductive structure, functions, phenotype, and genotype, differentiating the male from the female organism. Gender Dysphoria organ of another person, without the consent of the victim
  • Contact abuse: unwanted kissing, touching, or fondling
  • Sexual coercion
• Acquaintance rape/date rape: sexual assault committed by someone known to the victim
• Statutory rape: consensual sexual intercourse with an individual younger than a specific legal age (varies from state to state, usually 16‒18 years of age)
• Incest: the perpetrator and victim are family members.
• Child sex Sex The totality of characteristics of reproductive structure, functions, phenotype, and genotype, differentiating the male from the female organism. Gender Dysphoria abuse:
  • Any sexually explicit conduct (or simulation of such conduct) with a child for the purpose of producing a visual depiction of the conduct
  • Rape, statutory rape, incest, or prostitution of a child

Clinical Presentation and Diagnosis

The patient should be approached in a nonjudgmental and respectful manner. In addition to psychological consequences, sexual assault can be associated with unintended pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care, STIs STIs Sexually transmitted infections (STIs) or sexually transmitted diseases (STDs) are infections that spread either by vaginal intercourse, anal sex, or oral sex. Symptoms and signs may include vaginal discharge, penile discharge, dysuria, skin lesions (e.g., warts, ulcers) on or around the genitals, and pelvic pain. Some infections can lead to infertility and chronic debilitating disease. Sexually Transmitted Infections (STIs), and physical injury.

History

• Reluctance to talk is common.
• Children may present with behavioral changes (e.g., imitating sexual acts).
• Document the location, timing, duration, and type of force.
• Document other injuries or forms of abuse (e.g., physical abuse Physical Abuse Violence inflicted on an individual through physical contact. Child Abuse).
• Assess current safety and the presence of an emergency plan.
• Assess for suicidal ideation Suicidal ideation A risk factor for suicide attempts and completions, it is the most common of all suicidal behavior, but only a minority of ideators engage in overt self-harm. Suicide.

Physical examination

• May need photos for legal proceedings
• Anoscopy Anoscopy Anal Fissure and colposcopy Colposcopy The examination, therapy or surgery of the cervix and vagina by means of a specially designed endoscope introduced vaginally. Cervical Cancer Screening may be useful for visualizing injuries.
• Document findings:
  • Hymen Hymen A thin fold of mucous membrane situated at the orifice of the vagina. Vagina, Vulva, and Pelvic Floor: Anatomy trauma or scarring Scarring Inflammation
  • Healed genital injuries (e.g., skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions tags or granulation Granulation Wound Healing tissue)
  • Ecchymoses
  • Abrasions Abrasions Corneal Abrasions, Erosion, and Ulcers
  • Vaginal or anal tears
  • Hymen Hymen A thin fold of mucous membrane situated at the orifice of the vagina. Vagina, Vulva, and Pelvic Floor: Anatomy trauma or scarring Scarring Inflammation in children
  • Signs of STIs STIs Sexually transmitted infections (STIs) or sexually transmitted diseases (STDs) are infections that spread either by vaginal intercourse, anal sex, or oral sex. Symptoms and signs may include vaginal discharge, penile discharge, dysuria, skin lesions (e.g., warts, ulcers) on or around the genitals, and pelvic pain. Some infections can lead to infertility and chronic debilitating disease. Sexually Transmitted Infections (STIs), such as vesicles Vesicles Female Genitourinary Examination or condylomatous lesions
• Children may or may not have signs of abuse on physical exam.
• Vulvovaginitis Vulvovaginitis The term vulvovaginitis is used to describe an acute inflammation of the vulva and vagina. Vulvovaginitis can be caused by several infectious and non-infectious etiologies, and results from disruption of the normal vaginal environment. Common signs and symptoms include pain, pruritus, erythema, edema, vaginal discharge and dyspareunia. Vulvovaginitis in girls should elicit consideration for an evaluation of sexual abuse. 

Management

Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship who present with a report of sexual assault or abuse need proper examination, testing, and psychological support.

Medical issues

• Obtain consent to perform an exam and/or collect evidence.
• Forensic evidence collection (rape kit) should be done within 72 hours.
  • May be falsely negative if delayed
  • Should always be done if there is bleeding or acute injury
  • Specimens obtained for DNA analysis DNA analysis Biochemical identification of mutational changes in a nucleotide sequence. Hyper-IgM Syndrome
• Offer emergency contraception Emergency contraception Means of postcoital intervention to avoid pregnancy, such as the administration of postcoital contraceptives to prevent fertilization of an egg or implantation of a fertilized egg. Hormonal Contraceptives, if indicated.
• Consider prophylactic STI STI Sexually transmitted infections (STIs) are infections that spread either by vaginal intercourse, anal sex, or oral sex. Symptoms and signs may include vaginal discharge, penile discharge, dysuria, skin lesions (e.g., warts, ulcers) on or around the genitals, and pelvic pain. Some infections can lead to infertility and chronic debilitating disease. Sexually Transmitted Infections (STIs) treatment.
• Recommended lab tests:
  • Chlamydia Chlamydia Chlamydiae are obligate intracellular gram-negative bacteria. They lack a peptidoglycan layer and are best visualized using Giemsa stain. The family of Chlamydiaceae comprises 3 pathogens that can infect humans: Chlamydia trachomatis, Chlamydia psittaci, and Chlamydia pneumoniae. Chlamydia testing of the vagina Vagina The vagina is the female genital canal, extending from the vulva externally to the cervix uteri internally. The structures have sexual, reproductive, and urinary functions and a rich blood supply, mainly arising from the internal iliac artery. Vagina, Vulva, and Pelvic Floor: Anatomy and anus
  • Gonorrhea Gonorrhea Gonorrhea is a sexually transmitted infection (STI) caused by the gram-negative bacteria Neisseria gonorrhoeae (N. gonorrhoeae). Gonorrhea may be asymptomatic but commonly manifests as cervicitis or urethritis with less common presentations such as proctitis, conjunctivitis, or pharyngitis. Gonorrhea testing of the pharynx Pharynx The pharynx is a component of the digestive system that lies posterior to the nasal cavity, oral cavity, and larynx. The pharynx can be divided into the oropharynx, nasopharynx, and laryngopharynx. Pharyngeal muscles play an integral role in vital processes such as breathing, swallowing, and speaking. Pharynx: Anatomy, vagina Vagina The vagina is the female genital canal, extending from the vulva externally to the cervix uteri internally. The structures have sexual, reproductive, and urinary functions and a rich blood supply, mainly arising from the internal iliac artery. Vagina, Vulva, and Pelvic Floor: Anatomy, and anus
  • Viral testing of lesions suspicious for herpes simplex Herpes Simplex A group of acute infections caused by herpes simplex virus type 1 or type 2 that is characterized by the development of one or more small fluid-filled vesicles with a raised erythematous base on the skin or mucous membrane. It occurs as a primary infection or recurs due to a reactivation of a latent infection. Congenital TORCH Infections
  • Trichomonas Trichomonas A genus of parasitic flagellate eukaryotes distinguished by the presence of four anterior flagella, an undulating membrane, and a trailing flagellum. Nitroimidazoles and bacterial vaginosis Bacterial vaginosis Polymicrobial, nonspecific vaginitis associated with positive cultures of gardnerella vaginalis and other anaerobic organisms and a decrease in lactobacilli. It remains unclear whether the initial pathogenic event is caused by the growth of anaerobes or a primary decrease in lactobacilli. Vulvovaginitis testing
  • HIV HIV Anti-HIV Drugs serology Serology The study of serum, especially of antigen-antibody reactions in vitro. Yellow Fever Virus
  • Hepatitis B Hepatitis B Hepatitis B virus (HBV) is a partially double-stranded DNA virus, which belongs to the Orthohepadnavirus genus and the Hepadnaviridae family. Most individuals with acute HBV infection are asymptomatic or have mild, self-limiting symptoms. Chronic infection can be asymptomatic or create hepatic inflammation, leading to liver cirrhosis and hepatocellular carcinoma (HCC). Hepatitis B Virus and C
  • Syphilis Syphilis Syphilis is a bacterial infection caused by the spirochete Treponema pallidum pallidum (T. p. pallidum), which is usually spread through sexual contact. Syphilis has 4 clinical stages: primary, secondary, latent, and tertiary. Syphilis testing ( rapid plasma reagin test Rapid plasma reagin test Treponema)
• Evaluate psychosocial support system and refer as needed.
• Survivors of sexual abuse may need lifelong mental health care for:
  • Substance use disorder
  • PTSD PTSD Posttraumatic stress disorder is a psychiatric illness characterized by overwhelming stress and anxiety experienced after exposure to a life-threatening event. Symptoms last more than 1 month and involve re-experiencing the event as flashbacks or nightmares, avoiding reminders of the event, irritability, hyperarousal, and poor memory and concentration. Posttraumatic Stress Disorder (PTSD)
  • Major depressive disorder Major depressive disorder Major depressive disorder (MDD), commonly called depression, is a unipolar mood disorder characterized by persistent low mood and loss of interest in association with somatic symptoms for a duration of ≥ 2 weeks. Major depressive disorder has the highest lifetime prevalence among all psychiatric disorders. Major Depressive Disorder 
  • Suicidality
  • Distorted self-perception
  • Panic disorder Panic disorder Panic disorder is a condition marked by recurrent and episodic panic attacks that occur abruptly and without a trigger. These episodes are time-limited and present with cardiorespiratory (palpitations, shortness of breath, choking), GI (nausea, abdominal distress), and neurologic (paresthesias, lightheadedness) symptoms. Panic Disorder

Legal issues Legal issues Healthcare System

• Accurately record events.
• Document all injuries.
• Ensure samples are collected according to local protocols and regulations.
• Identify the presence or absence of sperm in vaginal fluids.
• Report to authorities as required and/or as desired by the victim.
• Ensure security of the chain of evidence.

Screening Screening Preoperative Care for sexual abuse

• The American College of Obstetricians and Gynecologists recommends screening Screening Preoperative Care women for sexual assault at every patient encounter 
• Use nonjudgmental language.
• Clearly explain that screening Screening Preoperative Care is universal (e.g., include screening Screening Preoperative Care questions on your intake forms).
• Always screen patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship alone.
• Use a professional language interpreter (instead of a family member) for patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship with a language barrier.
• Always ensure appropriate confidentiality Confidentiality Confidentiality is a set of rules that dictates the protection of health information shared by a patient with a physician. In general, this information should only be used to dictate medical decision-making steps and can only be disclosed to a 3rd party with the patient’s express consent. Patient-Doctor Confidentiality.