Suspicion Of Sexual Abuse Research Articles

Anogenital Lesions in Children: A Critical Alert for Pediatricians.

A 7-y-old girl presented to the pediatric department with a two-week history of a skin lesion in the anogenital region. She appeared well-nourished, quiet, afebrile; vitals and her systemic examination was normal. Examination revealed a greyish white wart-like perianal lesion, unusual for her age. Further history revealed the child had become withdrawn, avoiding play recently, and had oral and vaginal ulcers a month earlier without treatment. These findings raised suspicion of sexual abuse. Investigations confirmed positive VDRL (1:64 titres), positive TPHA, and negative results for her parents' TPHA and HIV. A medicolegal case was registered, involving child welfare services and police. A psychiatrist diagnosed post-traumatic stress disorder and recommended counselling. Treatment with a single dose of intramuscular Benzathine penicillin led to improvement, with VDRL titres decreasing to 1:8 and complete resolution of the lesion after 3 months. Pediatricians are pivotal in identifying and managing child sexual abuse cases promptly.

How to prepare for conversations with children about suspicions of sexual abuse? Evaluation of an interactive virtual reality training for student teachers

BackgroundTraining for child interviewing in case of suspected (sexual) abuse must include ongoing practice, expert feedback and performance evaluation. Computer-based interview simulations including these components have shown efficacy in promoting open-ended questioning skills. ObjectiveWe evaluated ViContact, a training program for childcare professionals on conversations with children in case of suspected abuse. Participants and setting110 student teachers were divided into four groups and took part either in a two-hour virtual reality training through verbal interaction with virtual children, followed by automated, personalized feedback (VR), two days of online seminar training on conversation skills, related knowledge and action strategies (ST), a combination of both (ST + VR), or no training (control group, CG). MethodsWe conducted a pre-registered, randomized-controlled evaluation study. Pre-post changes on three behavioral outcomes in the VR conversations and two questionnaire scores (self-efficacy and – undesirable – naïve confidence in one's own judgment of an abuse suspicion) were analyzed via mixed ANOVA interaction effects. ResultsCombined training vs. CG led to improvements in the proportion of recommended questions (ηp2 = 0.75), supportive utterances (ηp2 = 0.36), and self-efficacy (ηp2 = 0.77; all ps < .001). Both interventions alone improved the proportion of recommended questions (VR: ηp2 = 0.67, ST: ηp2 = 0.68, ps < .001) and self-efficacy (VR: ηp2 = 0.24, ST: ηp2 = 0.65, ps < .001), but not supportive utterances (VR: ηp2 = 0.10, ST: ηp2 = 0.13, both n. s.). ConclusionsThe combination of VR and ST proved most beneficial. Thus, VR exercises should not replace, but rather complement classical training approaches.

Diagnostic challenge in a case of foul-smelling vaginal discharge in a newly attained menarche girl

Foul-smelling vaginal discharge in adolescents often stems from infectious origin, foreign body insertion, neoplasm, congenital anomaly, and sexual abuse. Diagnosing the causes of the discharge remains challenging, especially in cases where sexual and reproductive health awareness is relatively low in the population from marginalized ethnographies and socio-cultural backgrounds. Suspicion of sexual abuse must be explored carefully and sensitively. A history of sexual exposure might not be forthcoming in adolescents where premarital sex is frowned upon. The process of eliciting the causation may be a challenge to healthcare professionals, delaying the diagnosis and subsequent management. In rare circumstances, imaging studies may help confirm the origin of the infection, giving insight into the presentation’s aetiology. We describe a case of Obstructed Hemivagina and Ipsilateral Renal Anomaly (OHVIRA) Syndrome presented with foul-smelling vaginal discharge in a newly attained menarche girl in the North-East region of Peninsular Malaysia. We also discussed the theories and reasons behind the occurrence of such a presentation, along with the diagnostic dilemma in this current case.

Reliability of the Sexual Knowledge Picture Instrument: a potential diagnostic instrument for sexual abuse in young children

ObjectiveTo determine the intra-rater and inter-rater reliability of the Sexual Knowledge Picture Instrument (SKPI), a potential diagnostic instrument for young suspected victims of sexual abuse containing three scoring forms, that...

Conservative management of urethral prolapse in African girls: a report of 15 cases

BackgroundUrethral prolapse is a rare disease, mainly occurring in African prepubertal girls. Its etiology remains unclear; however, some risk factors have been reported. The diagnosis is made clinically. The treatment can be conservative or surgical.MethodsWe report our experience in the service of pediatric surgery at Albert Royer National Children’s Hospital Centre. We conducted a retrospective descriptive cross-sectional study, on which considered patients were managed for urethral prolapse in our service from 2014 to 2019.ResultsOur study has included 15 girls whose mean age was 4.08 years (1.17–10). Two risk factors (chronic cough and constipation) were found in 20%. Genital hemorrhage was the main symptom (73.3%), and suspicion of sexual abuse was documented in 13.3%. The clinical finding was classical (donut-shaped vulvar mass) in all patients. All patients underwent conservative management, which was successful in 73.3%. Patients with failed conservative management were treated surgically by resection of the prolapsed mucosa on a Foley catheter. No complication was reported after surgical treatment, and after a 13-month mean follow-up, no recurrence was reported in all patients.ConclusionsConservative management is an efficient option for urethral prolapse. It has the advantage of avoiding general anesthesia with its potential complications and restricted availability in sub-Saharan Africa. Surgical management should be reserved for failed conservative management.

Awareness levels of teachers of child negligence and abuse: Rural area example

It was aimed to determine the frequency of teachers' encounters with child neglect and abuse and their views on this subject in this study. It is a cross-sectional and descriptive study. Three hundred eighty-eight teachers working in 40 primary schools and 18 high schools were selected with the cluster sampling method. Data was collected through a survey. The Chi-Square tests were applied. 21.6% of the research group reported that they encountered cases of neglect and 46.1% reported cases of abuse. 41.8% of the research group stated that they did not receive child neglect and abuse training. While 26.2% of them find themselves sufficient in diagnosing cases of neglect and abuse, 73.8% find themselves partially sufficient or insufficient. A significant relationship was found between self-efficacy in diagnosing cases according to gender, the number of years of work, receiving education about neglect and abuse, type of abuse, and reporting. While the rate of women who consider reporting suspected child neglect or abuse mandatory is significantly higher than men, the rate of those who find themselves sufficient in diagnosing child neglect or abuse is significantly higher in males. Among the abuse types, the rate of teachers who are faced with the suspicion of sexual abuse in diagnosing the case is significantly higher than the other types of abuse. The rate of teachers receiving training on cases of neglect and abuse and finding themselves competent in this regard is low. Men, those who have worked for 16-20 years, and teachers who have been trained in this subject find themselves more competent in diagnosing child neglect or abuse. Diagnosis the sexual abuse is higher than the other types. Regardless of the incident, the most important factor for teachers to find themselves competent is acquiring knowledge through pre-service or in-service training.

Sexual abuse of people with intellectual disabilities in residential settings: a 3-year analysis of incidents reported to the Dutch Health and Youth Care Inspectorate

ObjectivesTo explore characteristics of sexual abuse within residential settings for people with an intellectual disability and to map out measures undertaken and improvement plans made by healthcare organisations after sexual...

24.1 DIAGNOSIS AND MISDIAGNOSIS OF SEXUAL BEHAVIOR IN CHILDREN

Problematic sexual behavior (PSB) in children has often been interpreted as a sign of sexual abuse. However, research indicates that some sexual behaviors are an expected and developmentally appropriate part of childhood. Sexual behaviors such as exposing one’s genitals to others, self-stimulation, standing too close to others, and attempting to look at people who are naked are not uncommon. These behaviors are most often noted in children younger than 6 years old, tend to occur more often at home than in school, and decline with age. Problematic or nonnormative behaviors include imitation of adult intercourse, masturbation with an object, insertion of objects into the vagina or rectum, and oral-genital contact. Likewise, the use of coercion in sexual behaviors and behaviors directed toward much younger children are cause for concern. PSB can be associated with a number of mental health diagnoses in childhood, including OCD, bipolar disorders, and developmental disorders associated with intellectual disability and other impulse control disorders. A case example will illustrate the misdiagnosis of sexual behaviors in a young girl with OCD. Normative and inappropriate sexual behavior in children will be reviewed as will the assessment and differential diagnosis of PSB in children. Interactive techniques will be used with the audience to poll opinions about normative vs PSB in children and in which mental health disorders PSB is most prominent. Participants will understand the differential diagnosis of PSB in children and be able to identify behaviors that are often a part of normal development. The audience will have a chance to express their own views of what is normative vs inappropriate sexual behavior in children. Specific red flags for suspicion of sexual abuse will be discussed, providing a foundation for the review of specific evidence-based screening tools to be presented in the next section. Sexual behavior in children is not often discussed and can be easily misunderstood. It is important for clinicians to be able to distinguish developmentally appropriate sexual behavior from PSB. Likewise, specific patterns of PSB can be observed in a variety of mental health disorders. The topic of evidence-based screening tools for sexual abuse will be introduced.

Rare (uro-)genital pathologies in young girls mimicking sexual abuse

Examinations of young children for suspicions of sexual abuse are challenging for the involved medical specialists because the consequences of the interpretation of the findings can be severe and dramatic. A broad knowledge of differential diagnoses including rare pathologies like urethral prolapse and failure of the midline fusion of the perineum, known as perineal groove, is essential in order to avoid unnecessary diagnostics and treatment, prejudgment, and to reduce patient family’s anxiety. We report two independent cases of girls aged 7 months and 5 years suffering from these rare pathologies, one presenting with painless lower genital tract bleeding, the other showing a lesion of the perineum as random finding during a neuropediatrician’s consultation. In both cases, the pathologies were initially misdiagnosed as injuries due to sexual assault, and judicial investigation procedures were initiated. In this paper, the characteristic symptoms and morphology of urethral prolapse and perineal groove are presented to enhance the awareness of these pathologies among forensic experts and help to establish the correct diagnosis.

Anogenital warts in children: Analysis of a cohort of 34 prepubertal children.

Anogenital warts are caused by infection with the human papillomavirus. We reviewed the clinical data of 34 children younger than 13 with anogenital warts referred to the department of dermatovenereology of a tertiary care hospital. Suspicion of sexual abuse was raised in 11 (32.4%). Human papilloma virus testing and genotyping was performed in 19 (55.9%) children, and human papilloma virus type 16 was found in 4, which raises the question regarding what type of follow-up is required for children infected with high-risk oncogenic HPV types. Although the diagnosis of anogenital warts in children raises concerns regarding sexual abuse, our study supports that pediatric anogenital warts can be associated with nonsexual transmission.

Child sexual abuse — Initial suspicion and legal outcome

ObjectivesTo evaluate the association of primary reason to suspect child sexual abuse with the legal end-point in medically examined, police reported cases. Study designObservational post hoc analysis of retrospective review of records of 155 medically examined, police reported alleged child sexual abuse (CSA) cases during 2001–2009. Primary referral indications for medical examinations or criminal investigations were analyzed with an end-point in the legal process. The data consists of official investigation documents from University Hospital records, police, crime laboratories, state prosecutor, and courts of Law. ResultsThe median age of the children was 7.1 years (range 11 months–17.5 years) at the time when suspicion of sexual abuse was reported to police. Conviction of the alleged perpetrator was significantly more likely in cases where the child’s disclosure was the reason for the initial suspicion of CSA, compared to cases with referrals for “suspicious circumstances” (39/92, 42.4% vs. 7/37, 19%, p<0.001). In 92 (59.5%) cases the initial suspicion of CSA arose from child’s disclosure. The forensic interviewer’s report supported more likely CSA allegations where the suspicion of CSA arose by child’s clear, detailed and credible disclosure of what had happened, compared to the other initial reasons of suspicion (35/61, 57.4% vs. 13/42, 31.0%, p=0.001). In child’s age category of 4–9 years conviction was significantly more likely where the initial suspicion of CSA arose with child’s disclosure, compared to other reasons of suspicion (21.45, 46.7% vs. 5/27, 16.7%, p=0.001). No association was found regarding to whom the initial suspicion of CSA arose and legal outcome. Forensic interviewer’s report supported the allegation of CSA more often if the suspicion was arose first to a neutral person (p=0.019). Legal outcome of conviction was associated with child’s disclosure of perpetrator’s physical contact regardless of how the suspicion arose (45/99, 45.5% vs. 10/46, 21.7%, p<0.001). ConclusionThe reason which initially arise a suspicion of child sexual abuse plays an important role in the criminal investigation. Initial suspicion of CSA by child’s disclosure, an eyewitness or objective material may lead to higher conviction rates. If a concerning physical symptom or finding arise the suspicion of CSA, referral to expert consultation is recommended to prevent unnecessary allegations and investigations. Other possible differential diagnostic medical conditions need to be evaluated. Furthermore, when child’s disclosure arise a suspicion of CSA, it needs to be thoroughly investigated, regardless to whom the child discloses to.

Reasons for reported suspicion of child maltreatment and responses from the child welfare - a cross-sectional study of Norwegian public dental health personnel

BackgroundTo prevent child maltreatment, the identification of vulnerable children is essential. In Norway, public dental health personnel (PDHP) report suspicion of child maltreatment to child welfare services (CWS) at a relatively high rate. However, their reasons for reporting and the response from CWS have not been investigated. The objectives of this study were to (1) explore the reasons that PDHP send reports of concern, (2) examine how CWS responds to PDHP reports, and (3) assess whether different reasons for concern are associated with a given response from CWS.MethodsA national cross-sectional study was conducted by an electronic survey distributed to public dental hygienists and dentists in Norway. Descriptive statistics were calculated in terms of mean (SD) distributions and frequency, expressed as % (n). To account for clustering of responses among respondents, binomial generalized estimating equation analysis was used to estimate odds ratios (ORs) and confidence intervals (CIs) of CWS responses across number of reports with different reasons for concern.ResultsOf a total of 1542 questionnaire recipients, 1200 (77.8%) responded to the survey. From 2012 to 2014, 42.5% of the respondents sent 1214 reports to CWS, with a mean number of 2.7 (SD = 2.0) reports per respondent. The PDHP sent the reports due to suspicion of neglect or physical, sexual and/or psychological abuse. Non-attendance at dental appointments and grave caries were reported most frequently. Among the reports, 24.5% resulted in measures being taken by CWS, 20.7% were dropped, and 29.4% lacked information from CWS on the outcome. Reports due to suspicion of sexual abuse, (OR 1.979, 95% CI (1.047–3.742), P = 0.036), grave caries (OR 1.628, 95% CI (1.148–2.309), P = 0.006), and suspicion of neglect (OR 1.649, 95% CI (1.190–2.285), P = 0.003) had the highest association with the implementation of measures.ConclusionsPDHP report on several forms of child maltreatment and contributes in detection of victimized children. However, the relatively low number of measures being taken by CWS and the number of reports that lack a response to reporters reveal a need for a closer cooperation between the services, as this would benefit both the children at risk and the services.

Evaluation of genital condyloma accuminata seen during pediatric age as for sexual abuse: Case report

Anogenital wart is the most frequently seen during sexually transmitted disease in sexually active adults caused by Human Papillomavirus. The transmission with sexual contact has been defined for anogenital warts which emerge during childhood, however other routes of infection are also considered. We presented a case of a female child who had two genital warts. There is no history or suspicion of sexual abuse and the girl was infected by her mother. In the cases of condyloma accuminata seen in childhood, taking history and physical examination for sexual abuse of the child should be done by the clinician in a detailed way. Opinions should be achieved from forensic experts about the case and the legal authorities should be notified of the suspicion.

Characteristics of children under 12 years subjected to forensic examination on suspicion of child sexual abuse in Salvador Brazil

ObjectiveTo describe the demographic and clinical characteristics of a population of children under 12 years submitted to forensic sexual examination and the proportion of confirmed cases of sex abuse by material evidence. Material and methodsA retrospective descriptive study was conducted by reviewing all examination reports of forensic sexology for suspicion of child sexual abuse carried out at the forensic institute of Salvador, Brazil, between 2005 and 2010. ResultsDuring the study period, 2802 children under 12 years with suspicion of sexual abuse were submitted for forensic examination. The mean age was 6.6 years (SD 3.09), and 78.4% were female. In 84.9% of the cases, examination was required based on previous allegations of sexual abuse. The physical examination showed no alteration in 67.0% of the children investigated. The proportion of confirmed cases of sexual abuse by material evidence was 8.9% (248 cases). ConclusionIn view of the consensus of the low proportion of false allegation of sexual abuse made by children found in the specialized literature, the data obtained in this study emphasize the low sensitivity of the forensic examination for the confirmation of sexual abuse by material evidence, as well as the need for the comprehension of this fact by all those to whom these examinations are intended.

Cinsel İstismar ve Cinayet Şüphesi Olan Bir Çocuk Otopsi Olgusu

Son yıllarda artan cinai çocuk ölümleri ve çocuğa yönelik cinsel istismar vakaları toplumda ciddi infial yaratmaktadır. Olası bir hatalı değerlendirme; kişi, kişinin ailesi ve toplum açısından geri dönüşümü olmayan, telafisi güç durumlar oluşturabilir. Bu çalışmada; tecavüz edilip, boğazı kesilerek öldürülme iddiası olan dört yaşındaki erkek otopsi olgusu sunulmuştur. Olgu, dedesi tarafından kullanılmayan izbe bir evde pantolonu sıyrılmış, boğazından ve kolundan yaralanmış olarak bulunmuştu. Yaralar ile olay yerinde yaralanmasına neden olabilecek tahta üzerindeki çivilerin uyumlu olup olmadığı değerlendirilmiştir. Anal muayenesi çıplak gözle ve toluidin mavisi kullanılarak makroskobik olarak yapılmış, anal dokudan patolojik inceleme yapılması için örnek alınmıştır. Yapılan otopsi ve olay yeri incelemesi sonucunda, çocuğun boğazındaki yaraların olay yerinde bulunan kalastaki çivilerle uyumlu olduğu, anal muayenede makroskobik, toluidin mavisi testi ve histopatolojik olarak herhangi bir bulgu olmadığı belirlenmiştir. Bu çalışmada, postmortem anogenital muayene teknikleri ile muayene bulgularının değerlendirilmesi ve olay yeri incelemesinin önemi vurgulanmıştır.

IQ, Speciation and Sexuality: How Suspicions of Sexual Abuse are Produced within a Contemporary Intellectual Disability Service

It is commonplace, in our historical moment, to assume the inherent characteristics of people we label intellectually disabled makes them vulnerable to sexual abuse or exploitation. Drawing on the findings of a qualitative research project regarding the treatment of sexuality within a service for adults with intellectual disabilities in the Republic of Ireland, I take a very different approach. I argue that, suspicions, fears, and allegations of sexual abuse and exploitation are best understood as produced in, and by, the material-semiotic assemblage that both service providers and service users inhabit. In the most reductive terms possible, I am going to suggest that suspicions and allegations of sexual exploitation are continually produced within the disability service because the two social species (‘normal people’ and ‘people with intellectual disabilities’) that inhabit this material territory, and share its spaces, understand intimate relationships with and amongst people with intellectual disabilities through very different discursive lenses.

Características de los menores de 12 años con examen médico forense por sospecha de abuso sexual en Salvador, Brasil

ObjectiveTo describe the demographic and clinical characteristics of a population of children under 12 years submitted to forensic sexual examination and the proportion of confirmed cases of sex abuse by material evidence. Material and MethodsA retrospective descriptive study was conducted by reviewing all examination reports of forensic sexology for suspicion of child sexual abuse carried out at the forensic institute of Salvador, Brazil, between 2005 and 2010. ResultsDuring the study period, 2802 children under 12 years with suspicion of sexual abuse were submitted for forensic examination. The mean age was 6.6 years (SD 3.09), and 78.4% were female. In 84.9% of the cases, examination was required based on previous allegations of sexual abuse. The physical examination showed no alteration in 67.0% of the children investigated. The proportion of confirmed cases of sexual abuse by material evidence was 8.9% (248 cases). ConclusionIn view of the consensus of the low proportion of false allegation of sexual abuse made by children found in the specialised literature, the data obtained in this study emphasize the low sensitivity of the forensic examination for the confirmation of sexual abuse by material evidence, as well as the need for the comprehension of this fact by all those to whom these examinations are intended.

Disclosure Suspicion Bias and Abuse Disclosure: Comparisons Between Sexual and Physical Abuse.

Prior research has found that children disclosing physical abuse appear more reticent and less consistent than children disclosing sexual abuse. Although this has been attributed to differences in reluctance, it may also be due to differences in the process by which abuse is suspected and investigated. Disclosure may play a larger role in arousing suspicions of sexual abuse, while other evidence may play a larger role in arousing suspicions of physical abuse. As a result, children who disclose physical abuse in formal investigations may be doing so for the first time, and they may be more reluctant to provide details of the abuse. We examined abuse disclosure and evidence in comparable samples of court-substantiated physical (n = 33) and sexual (n = 28) abuse. Consistent with predictions, the likelihood that the child had disclosed abuse before an investigation began was lower in physical (27%) than that in sexual (67%) abuse cases, and there was more nondisclosure evidence of abuse in physical abuse cases. These findings have implications for understanding the dynamics and meaning of disclosure in cases involving different types of abuse.

Prepubertal Girl with Vaginal Bleeding

BackgroundPrepubertal children with vaginal bleeding are frequently brought in to the Emergency Department (ED) for evaluation with the primary concern of sexual abuse. Appropriate history and physical examination can help recognize the specific cause and allay anxiety of parents and reduce unnecessary work-up. ObjectiveThe purpose of this report is to describe a frequently unrecognized cause of vaginal bleeding that is unrelated to sexual abuse. Case ReportWe report the case of a 6-year-old African-American girl referred to our ED as a case of vaginal bleeding with suspicion of sexual abuse. She was clinically diagnosed to have urethral prolapse. ConclusionIn prepubertal girls with vaginal bleeding, urethral prolapse should be strongly considered as a diagnostic possibility. Increased physician awareness and early recognition of urethral prolapse avoids unnecessary examinations and patient anxiety and prevents misdiagnosis as sexual abuse.

Infantile perianal (perineal) pyramidal protrusion.

Infantile perianal (perineal) pyramidal protrusion (IPPP) is a newly described entity with fewer than 100 reported cases. Awareness of this entity is important to avoid an improper inference of sexual abuse or other anogenital disease. A 9-month-old healthy girl was brought by her mother for dermatologic examination of her perineum complaining of a new lesion that developed three weeks ago. Dermatological examination revealed a 1 cm, solitary, flesh-colored, pyramidal protrusion located in the midline anterior to the anus [Figure 1]. The lesion was not tender on palpation. There was no history of constipation or suspicion of sexual abuse. A pediatric surgery consultation excluded rectal prolapse, hemorrhoids and anal fissure by clinical examination. A clinical diagnosis of IPPP was made. After 6 months, the lesion disappeared without treatment. Figure 1 Solitary, flesh-colored, pyramidal protrusion located in the midline anterior to the anus IPPP was firstly described by Kayashima et al. in 1996.[1] It appears as a pyramidal soft tissue protrusion with a smooth surface, covered with rose-colored skin.[2] They are classically located in the midline just anterior to the anus, generally occurring in girls and mostly seen in infants.[2,3] A constitutional anatomic weakness in the perineum of female patients has been hypothesized as a potential cause.[3] Three types of IPPP were defined, including (i) constitutional (inherited) IPPP, (ii) functional IPPP and (iii) IPPP associated with lichen sclerosus and atrophicus. Constitutional IPPP remains unchanged over the years, while functional IPPP can be associated with constipation or diarrhea and regress with time.[2,4,5,6] Some IPPP lesions may represent an early manifestation of lichen sclerosus; this could be due to rearrangement of the fibrous tissue caused by the inflammation related to the disease.[2,5] Histopathology is relatively non-specific and includes acanthosis, upper dermal edema and mild inflammatory infiltrate; vacuolar and lichen sclerosus-like changes may occur in a subgroup of patients.[2,3] In the differential diagnosis, other perianal lesions including sexual abuse signs, hemorrhoids, genital warts, sentinel tag of anal fissure, granulomatous lesions of inflammatory bowel disease, perineal midline malformation, rectal prolapse and infantile hemangioma must be considered.[2,4] The evolution of the lesion is variable, with complete resolution in some cases or residual lesions in others. Preventing constipation or diarrhea may be helpful. Erythema and irritation may be reduced by the application of a topical corticosteriod.[7] Conservative follow-up is sufficient for most patients, as in the present case. In conclusion, it is important to recognize IPPP to avoid an erroneous investigation for sexual abuse or other perianal disease as the evaluation and examination process can be traumatic both for the patient and for the family.