* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download Conditions mistaken for abuse
Sexual selection wikipedia , lookup
Sexual slavery wikipedia , lookup
Penile plethysmograph wikipedia , lookup
Sexological testing wikipedia , lookup
Ego-dystonic sexual orientation wikipedia , lookup
Human female sexuality wikipedia , lookup
Reproductive health wikipedia , lookup
Sexual reproduction wikipedia , lookup
Sexual stimulation wikipedia , lookup
Female promiscuity wikipedia , lookup
Sexual assault wikipedia , lookup
Kids Can Say No! wikipedia , lookup
Sexual ethics wikipedia , lookup
Human sexual response cycle wikipedia , lookup
Sexual attraction wikipedia , lookup
Father absence wikipedia , lookup
Ages of consent in South America wikipedia , lookup
History of human sexuality wikipedia , lookup
Slut-shaming wikipedia , lookup
Age of consent wikipedia , lookup
Child sexual abuse wikipedia , lookup
North Wales child abuse scandal wikipedia , lookup
Lesbian sexual practices wikipedia , lookup
Rotherham child sexual exploitation scandal wikipedia , lookup
Anogenital and microbiologic findings in sexually abused children. Arne K. Myhre Department of pediatrics / RVTS – M St. Olav’s University Hospital Norwegian University of Science and Technology 1 Prevalence figures CSA world wide 2 Sexually abusive acts - The spectrum • • • • • • • Genital exposure Observation of a child Kissing Fondling Masturbation Fellatio Cunnilingus • • • • 3 Penile penetration of vagina and/or anus Digital penetration of vagina and/or anus Vulvar coitus Pornography Multidisciplinary assessment • Medical examination Part of the puzzle - History - General examination - Colposcopic examination - Different tests (forensics, microbiology) General History examination Colposcopic Other tests examination 4 Genital colposcopic examination • Child well prepared and relaxed Supine position for prepubertal girls Stirrups in adolescent girls Never use of force!! 5 Labial separation Illustrations borrowed from prof. Joyce Adams, University of California, San Diego 6 Labial traction Supplementary techniques: When something looks wrong Floating method Knee – chest position 7 Other methods Cotton swab Foley catheter Aim: Improve visualisation of posterior hymen 8 Anal examination Examine in left lateral position Separation of buttocks for 30 seconds 9 Sexual transmitted infection (STI) An infection that can be acquired and transmitted trough sexual activity. Specific for children: identification of an STI can have, in addition to medical implications, serious legal and child protection implications. 10 As a consequence…. • We have to consider the possibility of other form of transmission Vertical transmission “Innocent” heteroinoculation Autoinoculation Possibility of transmission from objects (fomite transmission) • To be aware of false positive tests, use tests with high specificity, and confirmation tests • Positive predictive value: the proportion of patients with positive tests who are correctly diagnosed – is dependent on prevalence 11 Hammerschlag, M.R. Sexual assault and abuse of children. Clinical Infectious Diseases 2011; 53(S3): 103-9. 12 Anogenital warts and HPV • Anogenital warts detected in abused (1 – 4%) and non-abused (4/305, 1,3%) children • HPV detected in abused (5 - 30%) and non-abused (1 - 2%) children • Of children with AGW, few – 80% sexually transmitted • Different modes of transmission and long latency period: Sexual Non-sexual: - Vertically during pregnancy or birth (pooled transmission risk 6,5% in meta-analysis) - Horizontally: Auto- or heteroinnoculation - Fomite 13 Herpes simplex • Epidemiology: few studies done, but HSV seems to be rare in abused children. • Transmission: few studies Avaliable evidence is to weak to allow an estimate of the likelihood of sexual transmission Sexual transmission has been reported more commonly in children over 5 years of age where genital lesions alone occur and where type 2 herpes simplex virus is isolated 14 Criteria for testing CDC 2010 • Symptoms and signs of an STI (discharge, pain, genital itching, odor, urinary symptoms, genital ulcers or lesions). • A suspected assailant is known to have an STI or to be at high risk for STI. • A sibling or another child or adult in the household or the child’s immediate environment has an STI. • The patient or parents requests testing • Evidence of genital, oral or anal penetration or ejaculation is present BASHH 2010 • Disclosure of penetrative sexual abuse • Physical signs of penetrative sexual abuse • Consensual sexual activity • Genitourinary symptoms, e.g. vaginal discharge 15 Timing of testing • Baseline testing of secretions, urine and blood • Two weeks after last contact if early baseline • Serology at 3 and 6 months after contact 16 Sites to be sampled Orifices involved in the act of abuse, can involve: Genital: vagina, cervix (adolescents), urethra, meatus or introitus Anal: anal canal and/or rectum Oral: pharynx Abuse of a particular orifice may not be disclosed, even when abuse elsewhere has been established. When disclosure of abuse – consider sampling all sites. Should also avoid causing pain in the child When abuse is suspected, case – by – case decision based on symptoms, signs and probability of abuse. 17 Prepubertal girls: Hymenal surface is painful, use introital swab or trans-hymenal swab. Apply one drop of water on swab Borrowed from dr. Joyce Adams 18 Anal swabs Even if proctoscope is recommended, normally taken from the anal canal after separation of buttocks 19 Test methods • N. Gonorrhoeae: Culture is method of choice (used from all sites) NAAT: from urine and vagina can be used, positive test confirmed with culture • Chlamydia trachomatis: Culture is rarely avaliable. NAAT’s are mainly used (genital sites and urine) Different NAAT for confirmation. Not approved for extragenital sites. 20 Test methods • Tricomonas vaginalis: Culture and / or wet mount. • Herpes simplex virus: NAAT Culture Type specific serology for HSV1 and HSV2 (repeat after 3 weeks) HSV2 serology not reliable for children < 14 Motile trichomonads seen in a wet mount 21 Test methods • Anogenital warts and human papillomavirus: AGW is mainly a clinical diagnosis HPV typing of biopsies or from swabs is controversial 22 23 UK National guidelines -2010. www.bashh.org 24 UK National guidelines - 2010. www.bashh.org 25 UK National guidelines - 2010. www.bashh.org 26 Classification according to abuse 27 Approach to interpretation of colposcopic findings (JA 2011) 1. Findings documented in newborns or commonly seen in nonabused children Normal variants Findings commonly caused by other medical conditions Conditions mistaken for abuse 2. Indeterminate findings: Insufficient or conflicting data from research studies, or no expert consensus 3. Findings diagnostic of trauma and/or sexual contact Acute trauma Residual (healing) injuries Injuries indicative of blunt force penetrating trauma (or from abdominal/pelvic compression injury if such history is given) Presence of infection confirms mucosal contact with infected and infective bodily secretions; contact most likely to have been sexual in nature 28 Findings diagnostic of trauma and/or sexual contact 29 Acute trauma to external genital/anal tissues Acute lacerations or extensive bruising of labia, penis, scrotum, perianal tissues or perineum. Fresh laceration of posterior fourchette May be from unwitnessed accidental trauma or from physical or sexual abuse Girl, trampoline accident Borrowed from JA Boy, sexual abuse 30 Boy, sexual abuse From anal study Residual (healing) injuries Perianal scar (may be due to other medical conditions as Crohn’s disease, accidental injuries or previous medical procedures. Scare of posterior fourchette or fossa (pale area in the midline may also be due to linea vestibularis or labial adhesions) Illustrations borrowed from J. Adams 31 Injuries indicative of blunt force penetrating trauma (or from abdominal/pelvic compression injury if such history is given) Bruising of the hymen Laceration (tear, partial or complete) of the hymen 32 Perianal laceration extending deep to the external anal sphincter (not to be confused with partial failure of midline fusion) Borrowed from J. Adams 33 Hymenal transection (healed): An area between 4 o’clock and 8 o’clock on the rim of the hymen, where it appears to have been torn through, to or nearly to the base, so there appears to be virtually no hymenal tissue remaining at that location. This finding has also been referred to as a “complete cleft” in sexually active adolescents or young adult women. 34 Missing segment of hymenal tissue. Area in the posterior (inferior) half of the hymen, wider than a transection, with an absence of hymenal tissue extending to the base of the hymen, which is confirmed using additional positions or methods 35 STI Presence of infection confirms mucosal contact with infected and infective bodily secretions; contact most likely to have been sexual in nature. 36 • Positive confirmed culture for gonorrhea, from genital area, anus or throat, in a child outside the neonatal period • Confirmed diagnosis of syphilis, if perinatal transmission is ruled out • Trichomonas vaginalis in a child older that one year of age, with organisms identified by culture or, in vaginal secretions, by wet mount examination • Positive culture from genital or anal tissues for chlamydia, if child is older than 3 years at time of diagnosis and if specimen was tested using cell culture or comparable method approved by CDC • Positive serology for HIV if perinatal transmission, transmission from blood products, and needle contaminations have been ruled out. 37 Indeterminate findings: Insufficient or conflicting data from research studies, or no expert consensus These findings may support a child’s clear disclosure of sexual abuse, if one is given, but should be interpreted with caution if the child gives no disclosure. Report to CPS may be indicated in some cases. 38 Deep notches or clefts in the posterior/inferior rim of hymen, that extend through more than 50% of the width of the hymen. Deep notches or complete clefts in the hymen at the 3 o’clock or nine o’clock location in adolescent girls 39 Marked, immediate anal dilatation to an AP diameter of 2 cm or more, in the absence of other predisposing factors such as chronic constipation, sedation, anesthesia, and neuromuscular conditions Total anal dilatation in LLP and KCP. 40 Genital or anal condyloma accuminata in a child, in the absence of other indicators of abuse. Lesions appearing for the first time in a child older than 5 – 8 years may be more suspicious for sexual transmission 41 Herpes type 1 or 2 in the genital or anal area in a child with on other indicators of sexual abuse. Isolated genital lesions caused by HSV – 2 in a child older than 4 – 5 years may be more suspicious for sexual transmission 42 Findings documented in newborns or commonly seen in nonabused children Normal variants Findings commonly caused by other medical conditions Conditions mistaken for abuse 43 Conclusion • Prevalence of medical findings Non acute examinations 5 – 10 % Acute examinations 20 – 50 % (depending on age) • Follow up studies document rapid and complete healing after anogenital trauma. Absence of signs of injuries does not exclude sexual abuse, even abuse with vaginal or anal penetration 44 Controversies regarding transmission Transmission through “bath water, wash clothes and toilet seats“ • • • Dayan, L. Transmission of Neisseria gonorrhoea from a toilet seat. Sex Transm Infect 2004; 80: 327 Goodyear-Smith, F. What is the evidence for non-sexual transmission of gonorrhoea in children after the neonatal period? A systematic review. J Forens Legal Med 2007; 14: 489-502. Bergeron C, Ferenczy A, Richart R. Underwear: contamination by human papillomaviruses. Am J Obstet Gynecol 1990; 162: 25-9 There are reports of fomite transmission, but very rare. Must be decided on a case to case basis, and in most cases it will be found very unlikely 45 Diagnostic interpretation of a “normal examination” • It does not mean ”nothing happened” – Most perpetrators do not intend to physically harm the child while engaging in sexual acts and thus most examinations do not have acute or chronic residual. • Rather than describing an examination without findings as “normal” a more accurate and informative conclusion is.. “the physical examination does not demonstrate any acute or chronic residual to the contact nor would be anticipated to in light of the history provided.” Martin Finkel, DO, FAAP Professor of Pediatrics CARES Institute University of Medicine & Dentistry of New Jersey 46 Findings commonly caused by other medical conditions • Erythema (redness) of the vestibule, penis, scrotum or perianal tissues (may be due to irritants, infection or trauma) • Increased vascularity (dilatation of existing blood vessels) of vestibule and hymen (may be due to local irritants, or normal pattern in the non estrogenizeid state) 47 Labial adhesions: Fusion of the surfaces of the vestibular wall, normally due to some form of irritation. Common in girls wearing diapters, and also associated with skin diseases and rubbing. Girl with extensive labial adhesions Same girl after treatment with oestrogen cream 48 Vaginal discharge: This is a rare finding in prepubertal girls. It has infectious and noninfectious causes, cultures must be taken to confirm if it is caused by sexually transmitted organisms or other infections. 49 Friabillity of the porterior fourchette or commisure: A superficial break in the skin seen when traction of the labia is applied. (may be due to irritation, infection, or skin diseases) 50 Anal fissures: usually due to constipation, perianal irritation Child with Crohn’s disease Small fissure in a child with a history of SA Chronic fissure in a constipated child 51 Multiple fissures in a child with Crohn’s disease Venous congenstion or venous pooling in the perianal area (usually due to positioning of the child, also seen with constipation) Elevated head and crying Laying flat and quiet Two year old girl examined in supine KC position (Pictures borrowed from dr. Kari Ormstad) 52 Conditions mistaken for abuse Urethral prolaps Vulvar ulcers (may be caused by many types of viral infections and other conditions) 53 Lichen sclerosus et atroficus 54 Failure of midline fusion Rectal prolaps (often caused by infection) 55 External anal dilatation Total anal dilatation to less than 2 cm (anterior - posterior dimension), with or without stool visible External anal dilatation Total anal dilatation with stool Prone knee – chest position Supine position 56 Marked erythema, inflamation and fissuring of the perianal or vulvar tissues due to infection with group A beta hemolytic strepptococci 57 References • Adams J.A. Medical evaluation of suspected child sexual abuse: 2011 update. J Child Sex Abuse 2011; 20: 588 – 605 • Royal College of Paediatrics and Child Health. The physical signs of child sexual abuse. An evidence-based review and guidance for best practice. London: Royal College of Paediatrics and Child Health; 2008 • Stoltenborgh M, et al. A global perspective on child sexual abuse: meta-analysis of prevalence around the word. Child Maltreat 2011;16: 79 – 101 • McCann J, et al. Healing of nonhymenal genital injuries in prepubertal and adolescent girls: a descriptive study. Pediatrics 2007; 120: 100011 • McCann J, et al. Healing of hymenal injuries in prepubertal and adolescent girls: a descriptive study. Pediatrics 2007; 119:e1094–106 58 References • United Kingdom National Guideline on the management of sexually transmitted infections and related conditions in children and young people – 2010 • CDC MMWR. Sexually transmitted diseases treatment guidelines, 2010 • Hammerschlag, M.R. Sexual assault and abuse of children. CID 2011; 53 (S3): 103-9 • Reading R, Rannan-Eliya Y. Evidence for sexual transmission of genital herpes in children. Arch Dis Child 2007; 92: 608-13 59 References • Jayasinghe Y, Garland SM. Genital warts in children: what do they mean? Arch Dis Child 2006; 91: 696-700. • Unger, E.R. et al. Anogenital human papillomavirus in sexually abused and non-abused children: a multicenter study. Pediatrics 2011; 128: e658 • Hammerschlag MR, Guillen CD. Medical and legal implications of testing for sexually transmitted infections in children. Clin Microbiol Rev 2010; 23: 493-506 60