Kindergynäkologische Aspekte des sexuellen Missbrauchs

Abstract

Genital findings in sexually abused prepubertal girls. Childhood sexual abuse is defined as the involvement of dependent, developmentally immature children and adolescents in sexual activities that they do not fully comprehend, to which they are unable to give informed consent or that violate the social taboos of family roles. Essential to the diagnosis of sexual abuse is an awareness of the problem and acknowledgement of its manifestations. The evaluation of the sexually abused girl usually is performed in a pediatric and adolescent gynecology outpatient department. Thus, the gynecologist will be part of a multidisciplinary approach to the problem and will need to be competent in the basic skills of history taking, physical examination, selection of laboratory tests und differential diagnosis. Findings secondary to sexual abuse are often subtle. Acute tears or bruisings are rare, because force is seldom part of sexual acts committed against a child. A vaginal opening of greater than 5 mm is not common and may indicate vaginal penetration. An intact hymen not necessarily exclude vaginal intercourse. Lack of physical evidence never rules out abuse because sexual acts may leave no physical findings.

A Pregnant Adolescence with an Intact Hymen

“…If a hymenal rim does not admit anything bigger than a finger, it is considered intact [13], but a greater than 5 mm vaginal opening is not considered normal and raises doubts of penile, solid object, or finger penetration [14,15]. On the other hand, an intact hymen cannot preclude penetration [14].…”

Anogenital Warts in Childhood – Always a Marker for Sexual Abuse?

“…The clearance rate was between 73 % for children and 91 % for adolescents. However, only 13 % of the legal proceedings resulted in conviction of the perpetrator [26][27][28]. In addition to these known criminal offences against the sexual selfdetermination of children and adolescents, the estimated number of unreported cases is thought by experts to be 10-20 times higher [29][30][31][32].…”

“…The suspicion of sexual abuse can arise in various ways. Direct or indirect statements by the child, abnormal behaviour, physical signs on the child, observations of caregivers or disturbed family interaction can lead to the suspicion of sexual abuse [26,30,31,33,34]. The symptoms noticeable in the paediatric gynaecological examination are only rarely pathognomonic of sexual abuse having taken place.…”

“…Sexual abuse can be demonstrated by physical examination in less than 10 % of children [26,[33][34][35][36][37]. Circumstances providing clear evidence of sexual abuse, even without a statement by the child, include acute trauma of the anogenital tract (lacerations, haematomas, deep perineal tears) without clear evidence of accidental aetiology, infections with gonococci, syphilis and HIV after ruling out perinatal transmission, trichomoniasis after the 1st year of life, a chlamydia-trachomatis infection after the 3rd year of life, as well as evidence of spermatozoa on the childʼs body and pregnancy [26,33]. Thus, in most cases, the suspicion is based on a combination of non-specific individual symptoms [21].…”