Second of two parts

Sexual abuse:
Management strategies and legal issues

By M. Ranee Leder, MD, John R. Knight, MD, and S. Jean Emans, MD

A range of issues must be addressed once sexual abuse is suspected or identified. Here we cover prophylactic treatment for STDs, emergency contraceptive options, documentation and reporting guidelines, tips for communicating with patients and families, and more.

The discovery that a child has been sexually abused or assaulted often precipitates a family crisis. Physicians can be an important source of support for child and family by better understanding the dynamics of sexual abuse and the process by which multiple disciplines work together to protect the child and strengthen the family.

Physicians need to know, for example, how to communicate with not only the child and family but also with child protective services and law enforcement. They must know the appropriate community resources for follow-up of the child's mental health needs. From a legal perspective, they must be aware of the standard for reporting sexual abuse, how to document the findings of the physical exam, and how to testify in court if called to do so. From a medical perspective, they need to be familiar with recommended treatments for sexually transmitted disease (STD) and with options for emergency contraception.

Preventing and treating STDs

After obtaining appropriate cultures for STDs in a patient who has been sexually abused (see the article "Sexual abuse: When to suspect it, how to assess for it"), most clinicians give antibiotic prophylaxis in the following circumstances:

• an STD is suspected based on the physical examination,

• follow-up of the patient is uncertain,

• the parent or patient requests prophylaxis, or

• the patient is an adolescent who has been assaulted within the preceding 72 hours.

Administer the first hepatitis B immunization to the sexual abuse patient who has not been immunized against this infection. The issue of providing postexposure prophylaxis for human immunodeficiency virus (HIV) is evolving, and a number of pertinent clinical trials are ongoing; consultation with a pediatric infectious disease expert in this regard may be useful.

Prophylactic regimens for various STDs are summarized in Table 1. (No prophylactic treatment is recommended for herpes simplex virus or human papillomavirus.) Treatment regimens for patients in whom an STD has been confirmed are listed in Table 2.^1-4

TABLE 1
Prophylaxis for STDs

TABLE 2
Treatment of STDs

Neisseria gonorrhoeae
Child <45 kg: Ceftriaxone 125 mg IM in a single dose
or
Spectinomycin 40 mg/kg (maximum 2 g) IM in a single dose

Child >=45 kg: Ceftriaxone 125 mg IM in a single dose
or
Cefixime 400 mg po in a single dose
or
Spectinomycin 2 g IM in a single dose

Adolescents: Cefixime 400 mg po in a single dose*
or
Ceftriaxone 125 mg IM in a single dose*
or
Ciprofloxacin 500 mg po in a single dose*^†
or
Ofloxacin 400 mg po in a single dose*^†

*Plus either azithromycin 1 g po in a single dose or doxycycline^† 100 mg po bid for 7 days as cotreatment for Chlamydia^†Pregnant women should not be treated with quinolones or tetracyclines

Chlamydia trachomatis
Child <45 kg: Erythromycin 50 mg/kg/d divided into 4 doses for 10-14 days

Child >45 kg but <8 years of age: Azithromycin 1 g po in a single dose

Child >8 years of age and adolescents: Azithromycin 1 g po in a single dose
or
Doxycycline 100 mg po bid for 7 days^††Pregnant women should not be treated with quinolones or tetracyclines

Emergency contraception

The overall risk of conception following rape of an adolescent is 2% to 6%.⁵ Female rape victims should be offered emergency contraception; the sooner such contraception is initiated, the lower the risk of pregnancy. Perform a baseline urine or serum pregnancy test to detect existing pregnancy.

Options for emergency contraception are listed in Table 3.^6-8 With the estrogen-progestin method, the patient takes at least 1 mg norgestrel (or 0.5 mg levonorgestrel) and 100 mg ethinyl estradiol within 72 hours of the assault and again 12 hours later. A variety of oral contraceptives can be used for this purpose. This method reduces the expected number of pregnancies by 74% by inhibiting or delaying ovulation, preventing fertilization, affecting the endometrial lining, or changing tubal transport.^6-8 Side effects include nausea and vomiting. Meclizine (25 mg) can be given one hour before the first dose to ameliorate nausea.

TABLE 3
Emergency contraception

Estrogen/progestin
(first dose within 72 hours after unprotected intercourse)
2 tablets of Ovral or Preven followed by 2 tablets 12 hours later
or
4 tablets of Lo/Ovral, Levlen, Levora,
or
Nordette, or 4 yellow tablets of Triphasil or Tri-Levlen, or 4 pink tablets of Trivora, followed by 4 tablets 12 hours later*
or
5 tablets of Alesse or Levlite followed by 5 tablets 12 hours later

*Colors of pills are specified only when there is more than one pill color for different doses of hormone

1 tablet of Plan B (1 dose 0.75 mg levonorgestrel ) followed by 1 tablet 12 hours later. If not available, 20 tablets of Ovrette (1.5 mg norgestrel) followed by 20 tablets 12 hours later.

Sources: Emans SJ,⁶ Trussell J et al,⁷ Taskforce on postovulatory methods of fertility regulation⁸

The World Health Organization (WHO) and Planned Parenthood list pregnancy as the only contraindication to the estrogen-progestin method. Product labeling from the US Food and Drug Administration lists a number of contraindications in addition to pregnancy: clotting problems, ischemic heart disease, stroke, migraine, liver tumors, and breast cancer.

The progestin-only method of emergency contraception consists of a dose of 0.75 mg levonorgestrel within 72 hours of assault and a second dose 12 hours later. An 88% reduction in the number of pregnancies has been reported with this method, as well as less nausea and vomiting than when estrogen-progestin is used.⁸ Pregnancy and undiagnosed abnormal genital bleeding are the only contraindications.

The estrogen-progestin and progestin-only methods are more effective if given early. A recent WHO trial showed substantial waning of effect with every 24 hours of delay.

To detect treatment failures, perform a follow-up urine pregnancy test two or three weeks after emergency contraception is used, especially if the adolescent has not had a normal period.

Documentation and reporting

Clear and complete documentation of each component of your evaluation is of utmost importance. Depending on your state's laws, a report of suspected sexual abuse filed with child protective services may be forwarded to a representative of law enforcement, who may want to review the medical record. In addition, sexual abuse or assault cases usually do not go to court for months, making accurate documentation in the medical record essential. The more detailed the documentation, the more you will remember about the case if your testimony is requested. (See "If you are called to testify" below.) In some cases, complete, legible documentation may even eliminate the need for court testimony. So be sure to document in a legible handwriting, preferably in black ink.

Describe the findings of both the complete physical examination (including any injury) and the anogenital examination. If the examinations are normal, state so; if not, document abnormalities. Diagrams can be useful in describing the type or location of abnormal or unusual anogenital findings. If findings are consistent with a child's or adolescent's disclosure of penetrating injury to the anus or hymen, clearly document this.

Parents, child protective services workers, and members of law enforcement may mistakenly think that the absence of physical findings negates a child's or adolescent's clear and consistent disclosure of sexual abuse or assault. It is important to make clear that a normal or nonspecific physical examination is common in sexual abuse and assault. Here are some examples of how to state this in your documentation:

In a normal prepubertal girl. "______ has a normal [or nonspecific] anal and genital exam. More than two thirds of girls with substantiated sexual abuse have normal or nonspecific findings on examination. Therefore, today's findings do not exclude sexual abuse."

In a normal boy. "______ has a normal [or nonspecific] anal and genital exam. Only a small minority of boys who are sexually abused have abnormal physical exam findings, so today's normal [or nonspecific] findings do not exclude sexual abuse."

In a normal pubertal girl. "______ has a normal [or nonspecific] anal and genital exam. The hymen in pubertal girls becomes thickened and elastic under the influence of hormones. For this reason, it is less prone to injury during intercourse. Therefore, today's findings do not exclude sexual abuse [or assault]."

Physicians are mandated by law to report suspected child abuse, usually to child protective services. Determine whether your state also requires that you report an alleged rape to the police. Medical providers cannot be held liable for reporting suspected sexual abuse that subsequently cannot be substantiated, provided the report is made in good faith. If you are unsure about the significance of a medical finding and the child has not disclosed a history of sexual abuse, defer reporting and refer the case to a child abuse expert for assessment.

The American Academy of Pediatrics (AAP) has developed guidelines to help physicians determine when a report to child protective services of suspected sexual abuse is indicated (Table 4).⁹ The AAP has also clarified the implications of making the diagnosis of an STD in an infant or prepubertal child (Table 5).⁹ Refer to this information when a culture is positive for an STD in a patient in this age group.

TABLE 4
Guidelines for deciding to report child sexual abuse

None

Possible report**
Follow closely (possible mental health referral)

Possible report**
Follow closely

Intermediate

Possible report**
Follow closely

*Some behavioral changes are nonspecific; others are more worrisome. (Krugman RD: Pediatr Rev 1986;8:25)
**A report may or may not be indicated. The decision to report should be based on discussion with local or regional experts or child protective services agencies.
^†Other reasons for findings are ruled out.

Authors' recommendation
Source: Pediatrics 1999;103:186-191. Used with permission of the American Academy of Pediatrics

TABLE 5
What the diagnosis of an STD in an infant or prepubertal child says about the possibility of sexual abuse

Communicating with the child and family

Provide feedback on the physical examination to the patient and family, including the significance of anogenital findings. Use diagrams to augment your explanation if possible because many parents, unfamiliar with prepubertal female anatomy, mistakenly believe that the hymen covers the vaginal opening completely. When the anogenital examination is normal, explain that this is often the case and that normal findings do not discount a child's or adolescent's clear and consistent statement that sexual contact has occurred.

Many children and adolescents who have been sexually abused feel they are "damaged goods" or believe they are responsible for the abuse. It is a tremendous relief for them to know that their body is normal and that nobody can tell they have been abused just by looking at them. Reassure the child that the abuse is not her (or his) fault and that she is not in trouble. Tell her that she is brave for telling the truth about what happened.

Some victims of sexual abuse have unprotected consensual intercourse later in life because they believe that abuse has made them infertile. Explain to older children and adolescents that there is no reason, based on their history of abuse, that they will not be able to have children in the future. Victims who are abused by a perpetrator of the same gender may worry about their sexual orientation; they may require supportive psychological counseling to address this concern.

When physical findings are present, explain to patients and families that a remarkable healing process allows such injuries to resolve with few, if any, signs. A follow-up appointment at the sexual abuse clinic of a pediatric center to document the progress of such healing may be reassuring to patients and families.

Arranging follow-up

Management of a child or adolescent who has been sexually abused or assaulted doesn't end when you identify the problem or offer initial treatment. Follow-up is needed in several areas.

Medical issues. Patients whose anogenital cultures are positive need treatment for their infection and repeat cultures in approximately three weeks. In addition, patients who develop anogenital symptoms should be seen for follow-up cultures even if initial cultures were negative. Patients who receive baseline serologic testing should have follow-up blood work (rapid plasma reagin and HIV testing) in six months. Adolescents who receive pregnancy prophylaxis need a repeat pregnancy test in two to three weeks, especially if their menstrual period is late.

Mental health support. A variety of mental and physical consequences may result from sexual abuse. A victim of rape may blame herself. The assault may diminish her self-esteem or interfere with her trust in future relationships.¹⁰ Referral to a rape crisis team, if available, may be helpful in the early stages of the victim's psychological treatment. As many as 80% of adolescent rape victims experience a form of posttraumatic stress disorder characterized by re-experiencing the traumatic event by intrusive thoughts, dreams, or flashbacks; avoidance of previously pleasurable activities; avoidance of the place where, or circumstances in which, the rape occurred; and an increased state of psychomotor arousal leading to difficulties with sleep and memory.¹¹

Provide information about psychological counseling to patients and families when sexual abuse or assault is suspected or confirmed. Although the family and patient may at first believe that counseling is unnecessary, they may reconsider if they are given information about available resources.

Protective issues. After a report to child protective services has been made, a member of that agency may determine that the child can remain in the home, especially when the alleged perpetrator is a stranger or noncustodial adult. If the alleged perpetrator is a custodial adult or the child's safety cannot be ensured, the child may need to be placed in foster care. You will need to closely collaborate with child protective services in such a case to ensure that the child's safety remains a priority.

Prevention

Sexual abuse is common enough to warrant prevention efforts in the primary care setting.¹² Given the large number of preschool-aged victims of sexual abuse, prevention efforts should begin early in life. Keep in mind that most sexual offenses against children and adolescents are committed by someone they know. It is, therefore, inadequate to warn them about the dangers posed by strangers.

Counsel parents of newborns about the importance of choosing reliable caretakers for their infant. As children begin to develop language skills, they should be taught that they have a right to say "No!" if they find certain types of touch uncomfortable or frightening. They should also learn the commonly accepted names for body parts so that sexuality can be dealt with in an open manner and so that they are more likely to be understood if they were to tell someone outside the family about an episode of abuse.

Abuse prevention and sex education are closely linked once children attend elementary school. One study reported that prevention programs for 7- to 12-year-olds have the potential for the greatest effect.¹³ Programs considered the most promising had the following characteristics: role-playing of prevention strategies; a curriculum tailored to the age group and learning abilities; material presented in a varied and stimulating manner; generic concepts such as assertive behavior, decision-making skills, and communication skills that can be used in other daily activities; emphasis on telling when touch is uncomfortable; and longer programs that are integrated into the school curriculum.

By the time children reach adolescence, they need to know about pregnancy, birth control, STDs, and rape prevention. They also need to be aware of high-risk behaviors and settings that may make them vulnerable to sexual assault. These include voluntarily agreeing to go to the home or enter the car of a young man they have known for less than 24 hours; impairment with drugs or alcohol; and hitchhiking.¹⁴

A multifaceted approach

Sexual abuse and assault are indeed challenging cases to manage. (The box below lists resources that medical providers and others can turn to for information about the problem.) Health-care providers must be prepared to address the patient's clinical and mental health needs while attending to such legal concerns as reporting and documentation. Providing anticipatory guidance throughout childhood and adolescence may prevent abuse from occurring again or, more desirably, from occurring in the first place.

Resources on child sexual abuse

For clinicians

Evaluation of the Sexually Abused Child, edited by A. M. Heger, S. J. Emans, and D. Muram (New York, Oxford University Press, 2000)

The Anatomy of Child and Adolescent Sexual Abuse—A CD ROM Atlas/ Reference, by J. J. McCann and D. L. Kerns (order by calling 877-205-7267)

www.pedicases.org . Cases of child sexual abuse available for downloading.

For parents and teachers

Spiders & Flies, by D. F. Hillman and J. Solek-Tefft (New York, The Free Press, 1988)

For adult and adolescent survivors

The Courage to Heal, by E. Bass and L. Davis (New York, HarperCollins, 1994)

The Survivor's Guide, by S. Lee (Thousand Oaks, Calif., Sage Publications, 1995)

Victims No Longer, by M. Lew (New York, HarperCollins, 1990)

Why Me? Help for Victims of Child Sexual Abuse Even if They are Adults Now, by L. B. Daugherty (Racine, Wis., Mother Courage Press, 1985)

For children

A Very Touching Book ... for Little People and for Big People, by J. Hindman (Baker City, Ore., AlexAndria Associates, 1984)

Something Happened and I'm Scared to Tell, by P. Kehoe (Seattle, Wash., Parenting Press, 1986)

Something Happened to Me, by P. E. Sweet (Racine, Wis., Mother Courage Press, 1985)

Something Must Be Wrong with Me, by D. E. Sanford (Phoenix, Ariz., Multnomah Publishers, 1993)

National organizations

REFERENCES

1. Centers for Disease Control and Prevention: 1998 Guidelines for Treatment of Sexually Transmitted Diseases. MMWR 1998;47(No. RR-1)

2. American Academy of Pediatrics, Section on Child Abuse and Neglect: Sexually transmitted diseases in child victims of sexual abuse. Newsletter of Section on Child Abuse and Neglect 1999;11(3):3

3. American Academy of Pediatrics: Sexually transmitted disease, in Pickering LK (ed): 2000 Red Book: Report of the Committee on Infectious Diseases, ed 25. Elk Grove Village, Ill., American Academy of Pediatrics, 2000, p 664

4. American Academy of Pediatrics: Antiretroviral Therapy, in Pickering LK (ed): 2000 Red Book: Report of the Committee on Infectious Diseases, ed 25. Elk Grove Village, Ill., American Academy of Pediatrics, 2000, pp 679-682

5. American Academy of Pediatrics, Committee on Adolescence: Sexual assault and the adolescent. Pediatrics 1994;94:761

6. Emans SJ: Contraception, in Emans SJ, Laufer MR, Goldstein DP (eds): Pediatric and Adolescent Gynecology, ed 4. Philadelphia, Lippincott-Raven, 1998, pp 611-674

7. Trussell J, Ellertson C, Stewart F: The effectiveness of the Yuzpe regimen of emergency contraception. Fam Plann Perspect 1996;28:58

8. Taskforce on postovulatory methods of fertility regulation: Randomised controlled trial of levonorgestrel vs.the Yuzpe regimen of combined oral contraceptives for emergency contraception. Lancet 1998;352:428

9. American Academy of Pediatrics, Committee on Child Abuse and Neglect: Guidelines for the Evaluation of Sexual Abuse of Children: Subject Review. Pediatrics 1999; 103:186

10. Katz BL: The psychological impact of stranger vs. nonstranger rape on the victims' recovery, in Parrot A, Bechhofer L (eds): Acquaintance Rape: The Hidden Crime. New York, John Wiley and Sons,1991, p 251

11. Pynoos RS, Nader K: Post-traumatic stress disorder, in McAnarney ER, Kreipe RE, Orr DP, et al (eds): Textbook of Adolescent Medicine. Philadelphia, WB Saunders, 1992, pp 1003-1009

12. Jenny C, Sutherland S, Sandahl B: Developmental approach to preventing the sexual abuse of children. Pediatrics 1986;78:1034

13. Daro DA: Prevention of child sexual abuse. The Future of Children 1994;4:198

14. Jenny C: Adolescent risk-taking behavior and the occurrence of sexual assault. Am J Dis Child 1988; 142:770

DR. LEDER is Assistant Professor of Clinical Pediatrics in the Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio, and in the Division of Behavioral-Developmental Pediatrics, Children's Hospital, Columbus, Ohio.

DR. KNIGHT is Assistant Professor of Pediatrics, Department of Pediatrics, Harvard Medical School, and Director, Young Adult Team Program, Division of General Pediatrics, Children's Hospital, Boston.

DR. EMANS is Associate Professor of Pediatrics, Department of Pediatrics, Harvard Medical School, and Chief, Adolescent Division, Children's Hospital, Boston.

If you are called to testify

Physicians who evaluate and treat abused children may be asked to testify in any of several types of court proceedings, including criminal prosecutions, hearings to protect abused children or terminate parental rights, and child custody and visitation litigation.¹ In all cases, your role is to educate the judge or jury.

To prepare for court, contact the attorney who has requested your testimony and review all medical records and laboratory studies pertaining to the case. Have the attorney review the questions that he or she will ask you. (Reading any of a number of articles on preparing to testify may help you.^2-4) If possible, arrange to be "on-call" for the proceeding so that you don't have to spend long periods waiting around to testify.

Dress conservatively for your court appearance. Hospital garb is inappropriate in the courtroom. During direct examination and cross-examination, do not hesitate to ask the attorney to explain a question that is unclear. Avoid medical jargon. If you need to use a medical term that is likely unfamiliar to lay ears, define it for the judge or jury.

It is common during cross-examination to be asked questions based on hypotheses that are extremely unlikely; you may need to point out that unlikelihood. When a question is posed in a manner that calls for a strict "yes" or "no" answer but the appropriate answer is "maybe," reply: "I cannot accurately answer that question with a 'yes' or 'no'." Then attempt to express the true answer.

After a court proceeding, it is helpful to obtain feedback on your performance as a witness from the attorney who requested your testimony.

REFERENCES

1. American Academy of Pediatrics, Committee on Child Abuse and Neglect: Guidelines for the evaluation of sexual abuse of children: Subject review. Pediatrics 1999;103:186

2. Baum E, Grodin M, Alpert J, et al: Child Sexual Abuse, Criminal Justice, and the Pediatrician. Pediatrics 1987;79:437

3. Starling S: Courts and court testimony, in Jones J (ed): A Guide to References and Resources in Child Abuse and Neglect. Elk Grove Village, Ill., American Academy of Pediatrics,1998, pp 21-23

4. Chadwick D: Preparation for court testimony in child abuse cases. Pediatr Clin North Am. 1990;37:955

John Knight, M. Ranee Leder, S. Jean Emans. Sexual abuse: Management strategies and legal issues.

Contemporary Pediatrics

2001;5:77.