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Traumatized samples have relative difficulty in generating specific autobiographical memories on a cue word task, compared to nonexposed controls. Simultaneously, trauma is associated with highly specific intrusive trauma memories in day-to-day life. Possibly, day-to-day intrusions and memories generated to cue words rely on different retrieval processes, with the former dependent on close associations between retrieval cues and specific memory representations (direct retrieval), and the latter on iterative retrieval cycles through a hierarchical memory system (generative retrieval). This study investigated this distinction using two versions of the cue word task. designed to promote generative and direct retrieval. respectively, in participants with or without a history of child sexual abuse (CSA). The data demonstrated that CSA participants were less specific than nonabused controls to generative retrieval cues, but this difference disappeared with direct retrieval cues. This interaction was stronger in CSA participants with relatively greater posttraumatic stress and remained significant when participants with past or current major depressive disorder were excluded and also when only those participants with corroborated CSA were included. Keywords: autobiographical memory specificity, childhood abuse, depression, intrusions, trauma

Objective. To study healing patterns of anogenital trauma in prepubescent children. Methods. A prospective 10-year study was conducted of 94 children who had anogenital trauma and were followed to healing and documented using a colposcope with 35-mm camera attachment. Results. The 13 boys and 81 girls were referred with injuries as a result of sexual assault or anogenital trauma. Hymenal injuries occurred in 37 cases; 2 transections healed after surgery, and 15 persisted unchanged. Partial tears, hymenal abrasions, or hematomas healed completely or with minor nonspecific changes. Of the 47 injuries to the posterior fourchette, 22 abrasions, hematomas, or tears healed completely; 12 tears healed with vascular changes; 2 developed labial fusions; 10 lacerations required surgery; and 6 scarred and 4 healed with vascular changes. Only 2 of 39 cases of perlhymenal trauma healed with vascular changes. All 17 cases of labial trauma healed completely. Anal trauma healed completely in 29 of 31 with scarring occurring in only 2 cases that required surgery. Conclusions. Anogenital trauma heals quickly, often without residua. Of the 94 cases, there were diagnostic anatomic changes in the 15 cases of hymenal transections (2 other cases healed completely with surgical reconstruction), 6 cases after surgical repair of posterior fourchette, and 2 cases of anal scarring after surgery. Pediatrics 2003; 112:829-837; sexual abuse, child abuse, sexual assault, genital injuries, anogenital injuries, accidental genital injuries, healing of anogenital injuries., ABBREVIATIONS. CVC, Center for the Vulnerable Child; PF, posterior fourchette; FN, fossa navicularis. Sexual abuse is traumatic for the victim. Whether the abuse causes physical injuries or not, it triggers [...]

Objective: This study compares abnormal genital examination findings made by pediatric emergency medicine (PEM) physicians to examinations by physicians with training in child sexual abuse in the evaluation of prepubertal girls for suspected sexual abuse. Method: A prospective study was performed following the genital examination by a PEM physician of prepubertal girls suspected of being sexually abused. A physician with training in child sexual abuse re-examined those girls whose examinations were interpreted as abnormal by the PEM physicians. The findings and interpretations of the PEM physician were then compared to those by the physicians with training in child abuse. Results: Between October 1994 and October 1998, 46 patients diagnosed by PEM physicians with nonacute genital findings indicative of sexual abuse were re-examined by a physician with training in child abuse. The follow-up examinations were done 2 days--16 weeks (mean 2.1 weeks) after the emergency department visit. The physicians with training in child abuse concluded that only eight of these children (17%) showed clear evidence of abuse. Normal findings were noted in 32 children (70%), nonspecific changes were noted in 4 children (9%), and 2 children (4%) had findings that are more commonly seen in abused children than nonabused children but are not diagnostic for abuse (concerning for abuse). Conclusions: There was poor agreement between the pediatric emergency medicine physicians and the physicians with training in child sexual abuse. This study suggests that emergency medicine physicians should consider additional training in this area. In addition, all children with abnormal ED examinations should have follow-up examinations by a child abuse trained physician. Keywords: Sexual abuse; Genital findings; Emergency department

Objective. To determine the usefulness of measurements of the vaginal opening and amount of hymenal tissue present inferiorly and laterally in the diagnosis of vaginal penetration. Methods. The transhymenal diameters and the amount of tissue present between the hymenal edge and vestibule inferiorly at 6 o'clock and laterally at 3 o'clock and 9 o'clock were measured from photographs of 189 prepubertal children with a validated history of digital or penile penetration and 197 children who denied previous sexual abuse. Statistical analyses were conducted to compare the mean values and hymenal symmetry between groups as well as to determine the sensitivity and specificity of various cutoff points. Results. Comparison of the mean diameters demonstrated that children with a penetration history had a significantly larger transverse opening than nonabused children when examined in the knee-chest position (5.6 vs 4.6 mm). However, there was extensive overlap in measurements between the 2 groups. No significant differences were noted between groups in the size of the vertical diameter, the amount of tissue present inferiorly or laterally, or the symmetry of the hymen in either position. Children with previous penetration were more likely than nonabused children to have a horizontal opening measuring >6.5 mm in the knee-chest position, but the sensitivity and specificity of this test were low (29% and 86%, respectively). Higher values had better specificity but very low sensitivity. Less than 1.0 mm of hymenal tissue was detected at 6 o'clock only in those with a history of penetration (100% specificity), but the sensitivity was low (1%-2%). Conclusion. Most hymenal measurements lack adequate sensitivity or specificity to be used to confirm previous penetration. Less than 1.0 mm of hymenal tissue at 6 o'clock was detected only in victims of abuse, but the usefulness of this test is limited by the rarity of this finding. Pediatrics 2002;109:228-235; sexual abuse, sexual assault, hymen, genitalia, measurements, anatomy., ABBREVIATIONS. CPH, Child Protective Health; UTMB, University of Texas Medical Branch. The examination of the external genitalia is a critical component in the evaluation of the sexually abused child. After [...]

Information is provided aimed at helping teachers identify typical characteristics of abused children and suggestions for addressing the subject of sexual abuse in classrooms.

The training of faculty and resident pediatricians in child sexual abuse evaluation during their three-year post-graduate program is perceived as inadequate and ineffective. A study on perceptions of faculty and resident pediatricians on training in child sexual abuse evaluation revealed that most were not satisfied with the quality of training. They also believe that preparation on conducting sexual abuse evaluation may be inadequate. These should prompt those responsible for training to ensure that faculty and resident physicians receive effective and well-organized information.

Latent infection of human papillomavirus (HPV) in children may be a poor screening test for sexual abuse. This virus has many forms, resulting in genital warts or non-symptomatic disease. Of 40 children with proven or suspected sexual abuse and no physical sign of genital warts, only two were positive for HPV 16. More than half had physical signs of abuse and 13% were positive for Chlamydia infection, another sexually transmitted disease. These low rates of HPV detection in this high-risk population suggest that this is not a justified screening test for sexual abuse., Objective. To evaluate for the presence of subclinical human papillomavirus (HPV) in cases of suspected sexual abuse in children. Design. Prospective data collection via interviews, physical examination, colposcopic examination, and tissue sampling by a surface swab technique. Setting. A total of 40 pediatric patients ranging in age from 1 to 16 years who were referred to the Special Assessment and Management Clinic at Cardinal Glennon Children's Hospital, St Louis, MO, for probable or confirmed sexual abuse. Interventions. In addition to colposcopic examination for physical signs of abuse, the patients were screened for evidence of sexually transmitted diseases, including syphilis, gonorrhea, and Chlamydia. At that time, surveillance sampling of the throat, vaginal introitus, and/or rectum by a simple, rapid surface swab technique was performed to detect the presence of HPV. Measurements. Template DNA was extracted from cotton swabs and analyzed using polymerase chain reaction analysis. Results. Human [Beta]-globin sequences were detected in 58 (83%) of 70 specimens obtained from 40 patients, indicating successful processing had occurred. Using a consensus L1 primer-probe set capable of detecting multiple HPV genotypes, 2 (3%) of 58 samples from 2 (5%) of 40 patients were positive for HPV 16. None of the other 56 specimens yielded evidence of HPV. Appropriate positive and negative controls were included in each assay. Conclusions. Our results suggest that subclinical HPV infection is possible, but not commonly associated with sexual abuse in children from St Louis, MO. In this group of children without condyloma, HPV 16 was the only type identified. Pediatrics 1998;101:43-47; human papillomavirus, condyloma, sexual abuse, child, polymerase chain reaction., ABBREVIATIONS. STD, sexually transmitted disease; HPV, human papillomavirus; PCR, polymerase chain reaction; SAM, Special Assessment and Management (Clinic); CDC, Centers for Disease Control and Prevention. Before 1970, sexual abuse of [...]

To increase their knowledge of the medical evaluation and reporting of child sexual abuse, medical students, pediatric resident physicians, fellows and attendings participated in an interdisciplinary team-based training program consisting of didactic: lectures, case discussions, videotapes and direct participation in patient evaluation. Content focused on the medical knowledge and skills needed for an assessment of the child's interview, anogenital examination and the indications for case reporting to child protection authorities. We evaluated the results of this training in our outpatient child abuse clinic located in a university-affiliated, municipal hospital using a survey which assesses knowledge of female genital anatomy, sexually-acquired diseases and case reporting in a nonrandomized control trial. Fifteen medical students and pediatric physicians participated and were compared to a reference group of 127 participants who did not receive this training and 15 others who randomly repeated the survey instrument during the study period. The results showed that resident physicians demonstrated increased mean total scores in the survey instrument. We conclude that an interdisciplinary team using patient care exposure increases physician knowledge in the evaluation of child sexual abuse. Key Words - Sexual abuse, Physician training, Survey.

The present study sought to increase current scientific knowledge about the controversial issue of subjectively reported childhood ritualistic abuse by addressing several key unresolved issues. In particular, the possibility that those reporting ritualistic abuse may be characterized primarily by the severity of their abuse histories or the severity of their present psychological symptoms, rather than the veridicality of the ritualistic events, was explored. Adult female outpatients reporting childhood sexual abuse with ritualistic features were compared with a second group of women who reported childhood sexual abuse without ritualism. Measures included characteristics of childhood sexual and physical abuse, current posttraumatic stress disorder (PTSD) diagnostic status and symptom severity, and severity of current dissociative experiences. Women reporting ritualistic features scored significantly higher on measures of childhood sexual and physical abuse. Neither PTSD diagnostic status nor severity for PTSD nor dissociative experiences were significantly different between the groups. While preliminary in nature, these results suggest that it may be helpful to conceptualize reported childhood ritualistic abuse as indicative of the need to assess carefully for severe abuse and its predictable sequelae within existing traumatic victimization conceptual frameworks. Key Words - Child abuse, Ritualistic abuse.

Objective: To determine if historical information influences residents' interpretation of physical findings in sexually abused children. Methodology: In a pediatric residency training program, all residents viewed 15 slides of children's genitalia (8 normal, 7 abnormal) with either a history specific for sexual abuse or one which was nonspecific. Three weeks later the same slides were viewed but with the alternate history scenario. The residents were asked if the physical findings were specific for sexual abuse. Results: Sixty-four percent of residents completed both surveys. Correct response rate did not vary by gender or year of training. Responses were most often correct when the slide and history were normal (87%). Responses were least accurate when normal historical information was presented with abnormal slides (49%). A logistic regression model demonstrated that residents were less accurate when history and physical did not agree (95% CI = .54-.78). Re-examination of the data using areas under the Receiver Operating Characteristic (ROC) curve confirmed that residents performed on a less accurate ROC curve when the slide and history were incongruent (p < .01). Conclusion: Incongruency between patient history and physical exam findings negatively affected this group of residents' ability to discriminate between abuse and nonabuse findings. Key Words - Sexual abuse, Patient history, Expectation bias.

Objective. To characterize third party payor types and rates of reimbursement for hospital costs in emergency department (ED) evaluations of preadolescents presenting as suspected victims of sexual abuse (SSA). Design and Methods. Retrospective chart review, comparing a set of 186 SSA patients with 623 evaluated for upper limb fracture and cumulative reimbursement and insurance data for all patients presenting to the ED during a 12-month period. Results. A greater percentage of SSA patients was uninsured (N = 96, 52%) as compared to patients with fractures (N = 9, 1%); 23% of all ED billing came from the uninsured. Of the 96 self-pay SSA patients' bills only 4% reimbursement was received. Of the insured, a greater percentage of the SSA patients was covered by publicly-funded plans (N = 59, 66%) as compared to fracture patients (N = 327, 52%). A lower percentage of insured SSA bill reimbursement was received from publicly-funded insurance than from commercial insurance (28% vs. 58%). Conclusions. Hospital costs of SSA patients are more often and to a greater degree underwritten by the hospital itself as a result of lower reimbursement and a higher percentage of uninsured and publicly-funded plans in that group, raising critical questions about how care for children with serious socially-based diagnoses is delivered and funded. Key Words - Insurance, Sexual abuse, Reimbursement.

Children who are sexually abused may often have normal genital and anal tissues. Researchers studied 215 girls and 21 boys who were sexually abused. Genital and anal photographs taken during post-abuse medical examinations were assessed for abnormalities. In girls, results revealed normal genitals in 28%, inconclusive genital findings in 49%, suspicious findings in 9%, and abnormalities in 14% of patients. Abnormal findings were more common in girls examined within three days of molestation and in those with a history of bleeding during the molestation. In boys and girls, normal anal tissues were observed in 31%, inconclusive findings in 62%, suspicious findings in 6% and abnormal findings in 1% of patients. Evidence of sexual abuse may depend on a child's verbalization of molestation rather than anal or genital abnormalities., Background. Studies of alleged victims of child sexual abuse vary greatly in the reported frequency of physical findings based on differences in definition of abuse and of "findings." This study was designed to determine the frequency of abnormal findings in a population of children with legal confirmation of sexual abuse, using a standardized classification system for colposcopic photographic findings. Methods. Case files and colposcopic photographs of 236 children with perpetrator conviction for sexual abuse, were reviewed. The photos were reviewed blindly by a team member other than the examiner, and specific anatomical findings were noted and classified as normal to abnormal on a scale of 1 to 5. Historical and behavioral information, as well as legal outcome was recorded, and all data entered into a dBase III program. Correlations were sought between abnormal findings and other variables. Results. The mean age of the patients was 9.0 years (range 8 months to 17 years, 11 months), with 63% reporting penile-genital contact. Genital examination findings in girls were normal in 28%, nonspecific in 49%, suspicious in 9%, and abnormal in 14% of cases. Abnormal anal findings were found in only 1% of patients. Using discriminant analysis, the two factors which significantly correlated with the presence of abnormal genital findings in girls were the time since the last incident, and a history of blood being reported at the time of the molest. Conclusions. Abnormal genital findings are not common In sexually abused girls, based on a standardized classification system. More emphasis should be placed on documenting the child&apos;s description of the molestation, and educating prosecutors that, for children alleging abuse. "It&apos;s normal to be normal." Pediatrics 1994;94: 310-317; child sexual abuse, genital findings.

This study investigated how 99 children who were examined for suspected sexual abuse (SSA) perceived their own medical evaluation experiences. Each child was interviewed about the degree of pain and fear associated with the experience, the kindness of the doctor, general fear of doctor visits, and degree of fear associated with a hypothetical second examination. The majority of children did not perceive their SSA examination to be strongly negative. However children di report greater fear associated with the SSA evaluation compared to an ordinary doctor visit. Using multiple regression, general fear of doctor visits and fear and pain associated with the SSA examination contributed to the prediction of intensity of fear about a hypothetical second SSA evaluation. Perceived kindnes of the doctor, patient sex and age, and physician sex and age did not contribut to the regression equation. The relatively low reported rate of intense distres associated with medical evaluation of SSA suggests that fear and pain can be minimized and effectively managed for many children. The results of the regression analysis suggest that previous negative medical experiences may play an important role in determining how a child interprets the experience of an SS medical evaluation.

The recent increase in request for genital examinations in girls who may have been sexually abused has necessitated detailed information not previously available on normal anatomy of the prepubertal girl. This study was undertaken to document the genital anatomy of 211 girls between the ages of 1 month and 7 years who presented for well child care or nongynecologic complaints and who had no history of sexual abuse. Each child&apos;s genitalia was examined and photographed, with findings reported reflecting those observed photographically The study population consisted of 36% blacks, 33.6% white non-Hipanics, 29% Hispanics, and 0.5% Asians. Subjects had a mean age of 21 [+ or -] 20.6(SD) months. Extensive labial agglutination sufficient to obscure the hymen was noted in 5% (10/11) and partial agglutination in an additional 17% (35/211). A significant difference was noted in hymenal configuration by age, with a fimbriated hymen the most common type (46%) in infants aged 12 months or younger and a crescentic hymen the most common (51%) in girls older than 24 months (P [less than or equal to].001. No significant difference was noted in hymen configuration by race. Hymenal bumps (mounds) were observed in 7%, hymenal tags in 3%, vestibular bands in 89%, longitudinal intravaginal ridges in 25%, and external ridges in15% of subjects in whom the anatomy under study could be visualized. Hymenal notches (clefts) occurred superiorly and laterally on the hymenal rim but none were found inferiorly on the lower half of the hymen. A narrow rounded hymenal ring with a transection was observed in only 1 (0.5%) of 201 subjects and was not considered a normal finding. Transverse hymenal openings measured only in annular and crescentic hymens had a mean which ranged from 2.5 [+ or -] 0.8 tp 3.6 [+ or -] 1.2 mm and varied significantly with age (P = .003). normal hymenal findings must be recognized by medical professionals so that posttraumatic findings can be diagnosed appropriately. Pediatirics 1992;89:387-394; hymen, hymenal configuration, sexual abuse.

A variety of anal or genital diseases in children may have an appearance that suggests the child was sexually abused. It is essential that a careful physical examination be performed and the possibility of causes other than child abuse be considered. There are serious consequences for the child, the family and the suspected person when a diagnosis of child abuse is made. Sexual abuse may be confused with congenital defects, infections, injuries and skin disorders. Seven cases are presented in which the child was referred for evaluation of possible child abuse, however the observed condition was due to other causes. A review of the literature on conditions mistaken for child abuse injuries is presented. Various skin disorders and symptoms such as erythema (redness) and excoriations (abrasions) may be caused by conditions other than child abuse. Congenital abnormalities of the genitals may be mistaken for genital or anal scars; it is advised to be cautious in diagnosing midline lesions of the genitals or anus, as these may actually be congenital malformations. Accidental injury may be mistaken for child abuse. In African and Middle Eastern children where female circumcision is performed, there may be unusual genital scarring. When genital infections are present it is necessary to obtain a detailed history in order to distinguish innocent actions from sexual abuse. Urethral conditions that involve bleeding may have causes other than child abuse, such as urethral prolapse, hemangioma, and polyps. It is important for physicians to be aware of other potential diagnoses when these abnormalities are discovered. (Consumer Summary produced by Reliance Medical Information, Inc.)

The increased incidence of reported childhood sexual abuse has resulted in a demand for improved methods of evaluating the abused child. Studies within the past 20 years have described the physical findings in children suspected of being sexually molested. However, in many cases, physical findings may be absent or difficult to detect. Thus, several examination techniques have been developed to visualize soft tissues and identify microtrauma, or very small sites of injury, which are difficult to detect. Technical developments have been made in methods of examination and the use of magnifying devices and cameras to record the results. The correct interpretation of findings requires understanding of the normal physical structure of the genitals in non-abused children who have not reached puberty. Hence, the normal anatomy or physical characteristics of the genitals of non-abused, prepubertal children was studied to provide a comparison of results obtained by different examination methods. One hundred and forty-four girls, aged 10 months to 10 years, were screened for onset of puberty and undetected child abuse, and 93 girls who had not reached puberty and had no evidence of sexual abuse were chosen. Each child was examined using three different examination methods; the results were assessed by age group and examination technique. The physical findings are described in detail and the effectiveness of the examination methods is reviewed. (Consumer Summary produced by Reliance Medical Information, Inc.)

THE ARTICLE by McCann et al (1) in this issue of Pediatrics Electronic Pages provides additional information on the natural course of hymenal injuries in both prepubertal and pubertal girls. [...]

For many years, dolls have been used as a part of play therapy. Within the last 10 years, anatomically correct dolls have been created for use in the diagnosis and treatment of children who may have been sexually abused; a review of research on this topic is presented. Using these dolls, a significant difference in play behavior has been noted between sexually abused and nonabused children. It has been suggested that for normal children, exposure to anatomically correct dolls is not threatening or sexually stimulating, nor does it promote aggression; however the sample size of this particular study was small. There is controversy in both the courts and the field of child psychiatry over the use of anatomically correct dolls in evaluating whether children have been sexually abused. It is believed by some that dolls can be used in assessment but that they do not prove or disprove sexual abuse. Others feel that use of these dolls prompts talk about sex and may plant new information that changes currently stored memory and thus ruins the child as a witness. There are many variables that may influence a child's play behavior with these dolls; these factors need to be explored further. The interviewer must be trained and the format of the interview must be standardized. The child's background needs to be taken into consideration, as well as the child's comfort level with the interviewer and the setting. It is concluded that these dolls may be helpful tools when used by trained professionals. (Consumer Summary produced by Reliance Medical Information, Inc.)

Imperforate hymen diagnosed beyond the newborn period may present a dilemma for the physician. Three case studies are reviewed in which children with the diagnoses of imperforate hymen presented for evaluation of suspected sexual abuse. Clear descriptions of genital anatomy documented at well-child visits may be critical to later interpretations of findings encountered during examinations for suspected sexual abuse. Pediatrics 2001; 108(3). URL: http://www.pediatrics.org/cgi/content/ full/108/3/e53; sexual abuse, imperforate hymen, congenital anomaly.

Objective: This study examined the utility of sexual behavior problems as a diagnostic indicator of sexual abuse. The hypothesis was that sexual behavior problems are multiply determined and consequently are variably related to sexual abuse in a clinical sample. Method: A sample of 247 children evaluated for sexual abuse at a multidisciplinary forensic child abuse evaluation clinic were included. Results from the Child Behavior Checklist (CBCL) and the Child Sexual Behavior Inventory (CSBI) were analyzed and compared to the results of a structured abuse assessment performed independent of these scores. Results: The forensic team assessment found evidence of sexual abuse in 25% of cases, and no evidence in 61%. Children in this sample exhibited an elevated level of both sexual and nonsexual behavior problems. However, considerable variability was noted in sexual behavior problem scores. Thus, in this study a high score or a low score had no relationship to the diagnosis of sexual abuse. Indeed, nonsexually abused children were just as likely to have high CSBI scores as sexually abused children. Conclusions: This study found no significant relationship between a diagnosis of sexual abuse and the presence or absence of sexual behavior problems in a sample of children referred for sexual abuse evaluation. The finding suggests that community professionals should use caution in relying on sexual behavior problems as a diagnostic indicator of abuse. [C] 2001 Elsevier Science Ltd. All rights reserved. Keywords: Child sexual abuse; Sexual behavior

Objective. The American Academy of Pediatrics recommends forensic evidence collection when sexual abuse has occurred within 72 hours, or when there is bleeding or acute injury. It is not known whether these recommendations are appropriate for prepubertal children, because few data exist regarding the utility of forensic evidence collection in cases of child sexual assault. This study describes the epidemiology of forensic evidence findings in prepubertal victims of sexual assault. Methods. The medical records of 273 children [is less than] 10 years old who were evaluated in hospital emergency departments in Philadelphia, Pennsylvania, and had forensic evidence processed by the Philadelphia Police Criminalistics Laboratory were retrospectively reviewed for history, physical examination findings, forensic evidence collection, and forensic results. Results. Some form of forensic evidence was identified in 24.9% of children, all of whom were examined within 44 hours of their assault. Over 90% of children with positive forensic evidence findings were seen within 24 hours of their assault. The majority of forensic evidence (64%) was found on clothing and linens, yet only 35% of children had clothing collected for analysis. After 24 hours, all evidence, with the exception of 1 pubic hair, was recovered from clothing or linens. No swabs taken from the child&apos;s body were positive for blood after 13 hours or sperm/semen after 9 hours. A minority of children (23%) had genital injuries. Genital injury and a history of ejaculation provided by the child were associated with an increased likelihood of identifying forensic evidence, but several children had forensic evidence found that was unanticipated by the child&apos;s history. Conclusions. The general guidelines for forensic evidence collection in cases of acute sexual assault are not well-suited for prepubertal victims. The decision to collect evidence is best made by the timing of the examination. Swabbing the child&apos;s body for evidence is unnecessary after 24 hours. Clothing and linens yield the majority of evidence and should be pursued vigorously for analysis. Pediatrics 2000;106:100-104; child abuse, sexual abuse, forensic evidence, sperm, semen., The American Academy of Pediatrics recommends an immediate examination and forensic evidence collection when sexual abuse has occurred within 72 hours, or when there is bleeding or acute injury.[1] This [...]