ED Exams Critical in Identifying Child Sexual Abuse

The U.S. Department of Health and Human Services reported 588,000 substantiated cases of child mistreatment, from neglect to sexual abuse, in 2021.

Gail Hornor, DNP, CPNP, SANE-P
Gail Hornor, DNP, CPNP, SANE-P

“These official numbers are only the tip of the iceberg,” said forensic nursing specialist Gail Hornor, DNP, CPNP, SANE-P, of the International Association of Forensic Nurses, who led the Thursday pre-session course “Child Sexual Abuse: Essentials for Emergency Nurse Practitioners.”

The forensic evidence collection and physical exams that happen in the emergency department play a critical role in identifying cases of child sexual abuse, which account for 10-12 percent of child mistreatment cases each year, Hornor explained.

According to the Centers for Disease Control and Prevention, 1 in 4 girls and 1 in 10 boys will be sexually abused before the age of 18.

“The number for boys is probably much closer to the number for girls,” Hornor said. “In our society, we socialize boys to be tough, to be strong, not to cry. This makes them less likely to tell. The majority of boys who are sexually abused were sexually abused by a male, and they have a fear of being perceived as gay. So, that also makes them less likely to disclose.”

An estimated 1 in 5 victims, regardless of gender, never disclose their mistreatment. Victims who share their experiences often do so years or months after the abuse occurs.

When concerns of child sexual abuse are brought to the ED, state laws and protocols affect the course of action taken. States allow the collection of evidence from 72 hours up to several days after the suspected incident of sexual abuse.

Indications supporting a medical forensic exam include the history given by the child; anogenital symptoms, such as bleeding, pain, discharge or bruising; caregiver concerns; and situational factors, such as sexual abuse observed by another individual, presence of a sexually transmitted infection or a confession by the perpetrator.

When gathering history, the child and caregiver should be separated to obtain the most accurate information from each one.

“You don’t want to put an idea in the child’s head, or you don’t want the parent or the caregiver’s concerns of sexual abuse to taint the history you obtain from the child,” Hornor said.

Questions should be open-ended, focusing on the who, what, where and when of a suspected incident.

“You want to know what is the sexual abuse concern and when was the last contact that this child had with the perpetrator, and that will give you an idea of whether or not you need to think about forensic evidence collection,” Hornor said.

The physical exam of a potential victim of child sexual abuse should be a head-to-toe assessment, not simply an anogenital assessment.

“These children may have health care that is sporadic. They may have previously undetected acute and chronic health concerns,” Hornor explained.

A U.S. study found that 26 percent of children and adolescents who received medical exams for physical and sexual abuse had medical or psychological issues that warranted intervention.

Medical forensic exams can also provide opportunities to reassure child sexual abuse survivors and their caregivers that the child is physically well.

“This is an important initial step towards healing,” Hornor said. “Ninety-nine percent of the time when I was doing an exam, I was providing reassurance to that child and that caregiver that their bodies were normal despite what had happened to their bodies.”

Horner also explained how ER nurses can apply the criteria for the interpretation of medical findings in suspected child sexual abuse developed by Joyce Adams. These include understanding the normal variants in hymen presentation. Hornor cautioned, though, that a normal anogenital exam does not negate suspected sexual acts, as this tissue typically heals quickly and without scarring.