**4. Clinical examination**

128 Sexual Abuse – Breaking the Silence

In all cases, the evocation depends on the vigilance of the physician who receives the child 1. Process of protection is possible if the child can be "heard" in those circumstances 7.

The interpretation of a word depends on the development and age of the child. The

However, it is informative and based on cognitive and language development despite the age. "A young child of two years may report sexual abuse directly and clearly" [9]. The words are simple and correlated to the possibilities of the child. They sometimes refer to the act of aggression, and sometimes to the pain and consequent anxiety. They are called in special circumstances of personal hygiene, diaper or clothes changing, and sometimes

It is often a story without words, indirect consequences on the child's behavior may suggest the diagnosis. The subjective perception of one parent or the environment will lead to a discussion on recent changes. Many signs have been described as true indices [6], and often





If the child speaks or if its behavioral consequences reveals an history of abuse, its

The first adult who received the confidence should look for an experienced professional

There is no way for the physician to bring together suspected children and adults, even to

The collection of the child's speech must be done with consideration to avoid leading

questions at any age as the predictive value of words is not related to age [12].



during a clinical examination for instance when the child shows the assaulted area.

3. Discovery of direct or indirect suspect signs during a routine examination

language of a child is structured between the ages of 4 and 6 years 8.

1. Declaration of the victim or witness (sibling, friend) 2. Questions for the family who suspects abuse

4. Review requested by judicial authorities

**3. The words and silent stories** 

reflect the impact of recent trauma [9]:


gestures of the child on the adult or another child - unusual or even aggressive behavior with people nearby

interpretation requests a rigorous approach [2-12-7].

within 2-3 days after the revelation.

observe the reactions of the child.

situation, feeling insecure

dysfunction. [10]

examination

Clinical examination of a child in circumstances of sexual abuse is difficult for a child of any age. Its interpretation requires a skill that will avoid repetition of intolerable procedures [17]. Misinterpretations are common, particularly in young children.

The legal and social services eagerly await objective evidence of sexual assault. **However, this rarely leads to a review of the findings of abnormalities.** 

The work of Heger et al. and their analysis with a rigorous methodology of 2384 records shows that an abused child and clinical abnormalities are found in only 4% of cases [3]. In 96% of cases, the diagnosis is based on the child's words and on the circumstances. Without denying the importance of a clinical examination, it must be considered in the course of the child's assessment as an important and sometimes significant element specific to this age, but rarely as a contributing factor.

How Do We Recognize Recent Sexual Abuse in Children Less than 10 Years of Age?

What Is the Role of Paediatric Wards? Experience in a French Paediatric Hospital 131

General clinical abnormalities are traumatic signs in non genital areas reflecting physical

Genital anomalies are looked at in a **girl** of that age in a supine position in the attitude of the so-called "frog" [6-20-22]. Children less than three years of age can also be considered sitting or lying on the lap of an accompanying individual [6]. There is no need to touch and it should be painless. The examiner should have precise notions about normal anatomical variations [6-20]

Among the specific lesions, we find direct acute injury (laceration, bruises) or injuries related to the penetration (bruises, cuts, lacerations, and even destruction of the hymen).

Good knowledge of the circumstances and clinical aspects of genital trauma of a girl can

**Anal anomalies** are sought by examination in the supine or sometimes prone position [1-6- 20]. They can be distinguished by examining the simple assault suspect fissure cracks associated with frequent constipation, and are always sagittal. The interpretation of anal dilatation is difficult. Instances of anal dilatation isolated to a degree greater than or equal to two centimeters are regarded by Adams as unspecific [20]. Warts also have a low specificity [1]. The practice of rectal examination or anuscopy is not recommended as routine.

**Sexually transmitted infections** must be sought and treated. They sometimes reveal elements of sexual abuse. Vaginal swabs and blood tests are sometimes informative, particularly if the abuse was less than 72 hours ago or if there is a local sign (flow). They are regarded under the same conditions as for other ages. The preparation of the child is

The presence of gonorrhea in the genital, anal, or oral region should be considered suspect after the neonatal period according to Adams [20]. Non-sexual transmission has been

The diagnosis of syphilis should suggest sexual abuse outside of a maternal-fetal

The presence of *Trichomonas vaginalis* (6 months) or *Chlamydia trachomatis* (after three years)

abuse (hematoma shoulders, trace of restraint on the limbs, oral mucosa lesion, etc.).

as the large variations of aspects of the hymen before puberty to avoid errors [22].

Adams classifies the aspect of girls' genital into 4 categories [20-23]:

Scarring may have a high specificity (scarring of the posterior fourchette).

Anuscopy under suitable conditions can allow a rare staging of lesions.

necessary. The use of local analgesia for blood sampling is required.

The transmission of certain germs may be perinatal.

demonstrated beyond this period by other authors [6-25].

The analysis of sexually transmitted infections depends on the age of the child.

damage caused by other medical conditions

The genitals of **boys** are examined by simple inspection.

Fifty lesions or situations are thus classified.

distinguish sexual assaults [24].

variants of normal

 injury uncertain more specific lesions

transmission.

is also very suspicious [1-6-20].

Consultation, even on the basis of a court application, must be part of the caring process. The complete pediatric examination should resemble, as closely as possible, the usual consultations. Apart from the objective forensic aspect, it is also designed to detect a sexually transmitted disease and reassure the child and its family of the normality of the body as this participates in the repair process [1-2]. The review is integrated into the comprehensive pediatric examination and requires no sedation beyond exceptional cases of lesions requiring surgery.

The examination may be experienced by the child as a second attack if not conducted in a supportive manner: explanations are allways required. We must use language appropriate to the age of the child, and must ask the parents for the words they usually use to name the genitals [6].

The examination is performed at this age in the presence of a parent that is not suspected and another person (from the nursing team). In our experience, the physician should never examine the child alone. This fits into the general reception which will be discussed.

Instrumental help with a genital examination is discussed at this age: using a pediatric colposcope to improve the performance of the examination or consideration for some simple situations, including systematic use of a video colposcope for the discussion of lesions. The use of a catheter with balloon inflation for a better visualization of the hymen is unnecessary and traumatic at this age. Instrumental help requires expertise [3-18], and should be reserved for pubescent patients [20].

The urgency of the review is still under discussion. It is indisputable if the abuse was less than 72 hours ago. Between three and 15 days after the abuse, the examination must be made quickly. Beyond 15 days, the examination may be delayed [6-21].

J.A. Adams gives further indications of an emergency medical examination [20]:


The physical examination cannot be separated from the history of the child. The verbal responses or attitudes of the child during the examination must be carefully noted. Children sometimes give additional information during the examination of the genitals [1-2-20].

In practice, it is recommended that this review include apart from genital and anal examinations "a complete physical examination with emphasis on growth parameters and sexual development of children examined mucocutaneous rigorous, searching for traces of violence throughout the body and especially at the inner thighs and chest, as well as areas of support and restraint (neck, wrists, ankles) a review of the oral cavity in search of lesions dental and mucous membranes, as well as the tongue-an observation of child behavior during clinical examination" [1].

The clinical findings can be of three types:


General clinical abnormalities are traumatic signs in non genital areas reflecting physical abuse (hematoma shoulders, trace of restraint on the limbs, oral mucosa lesion, etc.).

Genital anomalies are looked at in a **girl** of that age in a supine position in the attitude of the so-called "frog" [6-20-22]. Children less than three years of age can also be considered sitting or lying on the lap of an accompanying individual [6]. There is no need to touch and it should be painless. The examiner should have precise notions about normal anatomical variations [6-20] as the large variations of aspects of the hymen before puberty to avoid errors [22].

Adams classifies the aspect of girls' genital into 4 categories [20-23]:

variants of normal

130 Sexual Abuse – Breaking the Silence

Consultation, even on the basis of a court application, must be part of the caring process. The complete pediatric examination should resemble, as closely as possible, the usual consultations. Apart from the objective forensic aspect, it is also designed to detect a sexually transmitted disease and reassure the child and its family of the normality of the body as this participates in the repair process [1-2]. The review is integrated into the comprehensive pediatric examination and requires no sedation beyond exceptional cases of

The examination may be experienced by the child as a second attack if not conducted in a supportive manner: explanations are allways required. We must use language appropriate to the age of the child, and must ask the parents for the words they usually use to name the

The examination is performed at this age in the presence of a parent that is not suspected and another person (from the nursing team). In our experience, the physician should never

Instrumental help with a genital examination is discussed at this age: using a pediatric colposcope to improve the performance of the examination or consideration for some simple situations, including systematic use of a video colposcope for the discussion of lesions. The use of a catheter with balloon inflation for a better visualization of the hymen is unnecessary and traumatic at this age. Instrumental help requires expertise [3-18], and should be

The urgency of the review is still under discussion. It is indisputable if the abuse was less than 72 hours ago. Between three and 15 days after the abuse, the examination must be

The physical examination cannot be separated from the history of the child. The verbal responses or attitudes of the child during the examination must be carefully noted. Children sometimes give additional information during the examination of the genitals [1-2-20].

In practice, it is recommended that this review include apart from genital and anal examinations "a complete physical examination with emphasis on growth parameters and sexual development of children examined mucocutaneous rigorous, searching for traces of violence throughout the body and especially at the inner thighs and chest, as well as areas of support and restraint (neck, wrists, ankles) a review of the oral cavity in search of lesions dental and mucous membranes, as well as the tongue-an observation of child behavior


made quickly. Beyond 15 days, the examination may be delayed [6-21].

J.A. Adams gives further indications of an emergency medical examination [20]:

examine the child alone. This fits into the general reception which will be discussed.

lesions requiring surgery.

reserved for pubescent patients [20].


during clinical examination" [1].


The clinical findings can be of three types:

from sexually transmitted infections)



genitals [6].


Fifty lesions or situations are thus classified.

Among the specific lesions, we find direct acute injury (laceration, bruises) or injuries related to the penetration (bruises, cuts, lacerations, and even destruction of the hymen). Scarring may have a high specificity (scarring of the posterior fourchette).

Good knowledge of the circumstances and clinical aspects of genital trauma of a girl can distinguish sexual assaults [24].

The genitals of **boys** are examined by simple inspection.

**Anal anomalies** are sought by examination in the supine or sometimes prone position [1-6- 20]. They can be distinguished by examining the simple assault suspect fissure cracks associated with frequent constipation, and are always sagittal. The interpretation of anal dilatation is difficult. Instances of anal dilatation isolated to a degree greater than or equal to two centimeters are regarded by Adams as unspecific [20]. Warts also have a low specificity [1]. The practice of rectal examination or anuscopy is not recommended as routine. Anuscopy under suitable conditions can allow a rare staging of lesions.

**Sexually transmitted infections** must be sought and treated. They sometimes reveal elements of sexual abuse. Vaginal swabs and blood tests are sometimes informative, particularly if the abuse was less than 72 hours ago or if there is a local sign (flow). They are regarded under the same conditions as for other ages. The preparation of the child is necessary. The use of local analgesia for blood sampling is required.

The analysis of sexually transmitted infections depends on the age of the child.

The transmission of certain germs may be perinatal.

The presence of gonorrhea in the genital, anal, or oral region should be considered suspect after the neonatal period according to Adams [20]. Non-sexual transmission has been demonstrated beyond this period by other authors [6-25].

The diagnosis of syphilis should suggest sexual abuse outside of a maternal-fetal transmission.

The presence of *Trichomonas vaginalis* (6 months) or *Chlamydia trachomatis* (after three years) is also very suspicious [1-6-20].

How Do We Recognize Recent Sexual Abuse in Children Less than 10 Years of Age?

**The conditions of reception** of the child victim of sexual assault are important.

certificates to ensure the appropriate care of the children [1-20].

victims (The Voice of the Child).

roles.

the emergency level and safety of the child.

21.

What Is the Role of Paediatric Wards? Experience in a French Paediatric Hospital 133

**Preventive treatment (Post Exposure Prophylaxis, PEP)** is discussed at this age (prepubertal). There is no systematic chlamydia, trichomonas or syphilis, and assessment is based on laboratory diagnosis. HIV preventive treatment is evaluated according to the circumstances of the assault, and must be weighed against the disadvantages of treatment at this age. Serological surveillance in post-exposure is also tailored to the assessed risks 1-20-

They must be appropriate for the child's age during the entire process. The interview and examination should not repeat the trauma, and the permanent presence of a third adult caregiver is essential. Repeated examinations are unacceptable [1]. The review cannot be limited to the technical expertise of forensic aspects. The pediatric home team must be competent to collect details of history, examine the child, make a differential diagnosis with other causes of behavioral or clinical features, request additional tests, and send the

In France, the passing of a law on 17 June, 1998 recognized the status of the victimized minor with enhanced rights, including assistance at hearings, filmed bond hearings, and the interests of health care professionals being represented at hearings. The association "Voice of Children" offered care to children affected by sexual abuse, and led to the assistance for "permanence and home units Multidisciplinary forensic child sexual assault victims" 26. This "permanence" must improve the reception of minors. For the entire process of an initial investigation, the child is supported in one place suitable for children and is located in a pediatric hospital structure. In this structure, the child can be heard, admitted in cases of emergency if necessary, can receive treatment for pain if samples are needed under suitable conditions, and receive assessment on a psychological level. Psychological and social support of the child may be arranged with the relevant partner agencies. Management of these hotlines is conducted jointly by Social Services, the judicial services of Inquiry, Hospital Trust and the Regional Agency of Hospitalization, and advocacy groups for child

In Nantes, following the Prosecutor of the Republic's request, minors meet at first a pediatric nurse who explains the steps and accompanies the children and their families. Judicial investigators are invited to the hospital for a hearing filmed session under suitable and specific conditions. The medical team (pediatricians, gynecologists, psychiatrists and psychologists, including a social worker), conducts the initial medical and psychological assessments as requested. These reviews and assessments can be deferred after evaluation of

The nurse and social worker with the medical team organize an assessment of the

This new organization, dating back more than a decade, now covers more than 40 French hospitals. It has been, and remains, controversial. The main criticism is the concept of proximity Clinical (Pediatric ward ) and Forensic (Justice) which could lead to a mixture of

Our experience is very close to that of the CAC (Child Advocacy Center). The studies of Edinburgh [27] and Smith [28] focused on young adolescents, but included children of these

psychological and social development of the child even if no judicial action results.

HIV transmission is theoretically possible, but exceptional with the waning of sexual abuse at that age. Maternal serology will eliminate maternal-fetal transmission [20].

Other transmissions are available: Papillomavirus, Herpes Hepatitis B, Hepatitis C, etc., but few are specific and are therefore of uncertain significance.

**The sampling for forensic investigation involving the search for sperm, DNA identification**, and a toxic syndrome (abuse under drug) is the subject of specific protocols for identification, storage, and transmission. Each country has determined these conditions, and hence they have a legal value.

**Samples used to research sexually transmitted infections** do not represent a consensus before puberty, and must be adapted to the circumstances:



Fig. 1. Signs and those suggestive of uncertain significance [1-20-22]

HIV transmission is theoretically possible, but exceptional with the waning of sexual abuse

Other transmissions are available: Papillomavirus, Herpes Hepatitis B, Hepatitis C, etc., but

**The sampling for forensic investigation involving the search for sperm, DNA identification**, and a toxic syndrome (abuse under drug) is the subject of specific protocols for identification, storage, and transmission. Each country has determined these conditions,

**Samples used to research sexually transmitted infections** do not represent a consensus

research of gonorrhea, *Chlamydia trachomatis*, *Trichomonas vaginalis* by culture and

indirect research techniques for chlamydia and gonorrhea by PCR have no forensic

serology HIV, Syphilis, Hepatitis B, Hepatitis C, according to circumstances [20-

Injury acute or scarring of the vulva

Notch or partial thinning of the

posterior hymen

Herpes simplex I and II

does not reach the hymen

at that age. Maternal serology will eliminate maternal-fetal transmission [20].

few are specific and are therefore of uncertain significance.

before puberty, and must be adapted to the circumstances:

value and must be confirmed by bacteriological cultures [21]

Highly suggestive signs Uncertain signs

Lesion of the fourchette acute or healed Anal dilatation

Fig. 1. Signs and those suggestive of uncertain significance [1-20-22]

Important anal acute lesion or scar Warts

Syphilis (outside maternofoetal contamination)

and hence they have a legal value.

bacteriological examination

**Sexual contact** shown by the presence of

Scarring: Total posterior tear (between 4 and 8

Partial or total absence of hymen posterior notch or partial thinning of the posterior

21].(Figure 1)

semen

hours)

hymen

**STI** 

**Hymen injury** 

Acute: tear, bruise, abrasion

Trichomonas after 6 month Chlamydiae after 3 years

HIV ( if seronegative mother)

**Preventive treatment (Post Exposure Prophylaxis, PEP)** is discussed at this age (prepubertal). There is no systematic chlamydia, trichomonas or syphilis, and assessment is based on laboratory diagnosis. HIV preventive treatment is evaluated according to the circumstances of the assault, and must be weighed against the disadvantages of treatment at this age. Serological surveillance in post-exposure is also tailored to the assessed risks 1-20- 21.

#### **The conditions of reception** of the child victim of sexual assault are important.

They must be appropriate for the child's age during the entire process. The interview and examination should not repeat the trauma, and the permanent presence of a third adult caregiver is essential. Repeated examinations are unacceptable [1]. The review cannot be limited to the technical expertise of forensic aspects. The pediatric home team must be competent to collect details of history, examine the child, make a differential diagnosis with other causes of behavioral or clinical features, request additional tests, and send the certificates to ensure the appropriate care of the children [1-20].

In France, the passing of a law on 17 June, 1998 recognized the status of the victimized minor with enhanced rights, including assistance at hearings, filmed bond hearings, and the interests of health care professionals being represented at hearings. The association "Voice of Children" offered care to children affected by sexual abuse, and led to the assistance for "permanence and home units Multidisciplinary forensic child sexual assault victims" 26. This "permanence" must improve the reception of minors. For the entire process of an initial investigation, the child is supported in one place suitable for children and is located in a pediatric hospital structure. In this structure, the child can be heard, admitted in cases of emergency if necessary, can receive treatment for pain if samples are needed under suitable conditions, and receive assessment on a psychological level. Psychological and social support of the child may be arranged with the relevant partner agencies. Management of these hotlines is conducted jointly by Social Services, the judicial services of Inquiry, Hospital Trust and the Regional Agency of Hospitalization, and advocacy groups for child victims (The Voice of the Child).

In Nantes, following the Prosecutor of the Republic's request, minors meet at first a pediatric nurse who explains the steps and accompanies the children and their families. Judicial investigators are invited to the hospital for a hearing filmed session under suitable and specific conditions. The medical team (pediatricians, gynecologists, psychiatrists and psychologists, including a social worker), conducts the initial medical and psychological assessments as requested. These reviews and assessments can be deferred after evaluation of the emergency level and safety of the child.

The nurse and social worker with the medical team organize an assessment of the psychological and social development of the child even if no judicial action results.

This new organization, dating back more than a decade, now covers more than 40 French hospitals. It has been, and remains, controversial. The main criticism is the concept of proximity Clinical (Pediatric ward ) and Forensic (Justice) which could lead to a mixture of roles.

Our experience is very close to that of the CAC (Child Advocacy Center). The studies of Edinburgh [27] and Smith [28] focused on young adolescents, but included children of these

How Do We Recognize Recent Sexual Abuse in Children Less than 10 Years of Age?

sequelae.

**5. References** 

www.has-sante.fr

Pédiatr 1998;5:84–9

vérité. Montréal Ed. 1999

l'université. Montréal 1990

Press Med 2001;30:1912–23

Human Dev 1989;20:39–47

Enfant. 1992;35:197–271

Montréal 1996

sexuels. Rev Int Ped 1999;9–14

l'enfant et de l'adolescence. 2003;51:105–10

implications. J Exp Psychol Gen 1987;117:38–49

What Is the Role of Paediatric Wards? Experience in a French Paediatric Hospital 135

In conclusion, recognition of sexual abuse in children less than 10 years of age is based on the word of the child associated with indirect signs of a nonspecific nature. Clinical examination is essential, but it is difficult and rarely contributory. The forensic approach must be combined with an approach incorporating pediatric care and protection. The development of integrated units in forensic pediatric service for the reception of the whole child seems to us an essential change that will improve the entire process and prevent

[1] Repérage et signalement de l'inceste par les médecins :reconnaître les maltraitances

[2] American Academy of Pediatrics Guidelines for the evaluation of sexual abuse of

[3] Heger A, Ticson L, Velasquez O, Bernier R. Children referred for possible sexual abuse: medical finding in 2384 children. Child Abuse & Neglect 2002;26:645–59 [4] Nathanson M., Muller MH., Belasco C., Dieu-Osika S., Camard O. Gaudelus J. Les

[5] Van Gisenghem H – L'enfant mis à nu: L'allégation d'abus sexuel: la recherche de la

[6] Frappier JY., Haley N., Allard-Dansereau Cl. Abus sexuels Ed. Les presses de

[7] Kellog N. American Academy of Pediatrics Committee on Child Abuse and Neglect. The

[10] Garignon C., Mure PY, Parapel P, Chiche D, Mouriquand P. Dysfonctionnement

[11] Roussey M, Balençon M. La valeur de la parole de l'enfant dans les situations d'abus

[12] Ceci SJ, Ross DF, Toglia MP. Age differences in suggestibility; psychological

[13] Yuille JC. L'entrevue de l'enfant dans un contexte d'investigation et l'évaluation

[14] Jodoin Cl. L'expert et ses outils in Us et abus de la mise en mots en matière d'abus

[15] August RL, Forman BD. A comparison of sexually abused and non sexually abused

[16] Hayez JY. Sexual abuse of underage children: incest and extra-familial abuse. Psychiat

sexuel Van Gijsegehm H Ed. Méridien Psychologie Montréal 1999

Evaluation of Sexual Abuse in Children Pediatrics. 2005;116:506–12 [8] Messerschmitt P. La vérité sort elle de la bouche des enfants? Arch Pediatr 2011;18:55–6 [9] De Becker E, Hayez JY. L'enfant en dessous de 3 ans maltraité sexuellement: comment

children: subject review. Pediatrics 1999;103:186–191

sexuelles intrafamiliales chez le mineur Haute Autorité de Santé France (HAS) 2011

enfants et adolescents victimes d'abus sexuels. Diagnostic et prise en charge. Arch

les tout petits parlent d'un abus et comment y faire face? Neuropsychiatrie de

vésicaux graves chez l'enfant victime de maltraitance: Le syndrome d'Hinman

systématique de sa déclaration in L'enfant mis à nu Ed. Méridien Psychologie

children's behavioural responses to anatomically correct dolls. Child Psychiatry

structures as incorporated into pediatric hospitals. Their experience showed better results not only for the assessment of speech in a clinical approach, but also in relation to the advice given to children and their families. The organization of monitoring is also facilitated by this approach [27]. In accordance with the recommendation of Edinburgh, we incorporated a role for pediatric nurses with a long experience in childcare.

Tishelman confirms the value of an integrative model and justice for the pediatric care of affected children by setting 6 goals in these structures 29:


All this confirms the value of an integrated pediatric and forensic approach. This attitude is reinforced by the importance of physical and psychological consequences observed in adults who have suffered sexual assault in their childhood. Early care of the child within a pediatric approach should help to avoid such troubling developments 30. Tishelman also speaks of a particular population of children whose judicial evaluation has not confirmed the sexual assault. Those children who leave without a judicial conclusion after a grueling investigation should also receive monitoring and care 29.

In conclusion, recognition of sexual abuse in children less than 10 years of age is based on the word of the child associated with indirect signs of a nonspecific nature. Clinical examination is essential, but it is difficult and rarely contributory. The forensic approach must be combined with an approach incorporating pediatric care and protection. The development of integrated units in forensic pediatric service for the reception of the whole child seems to us an essential change that will improve the entire process and prevent sequelae.
