Physical symptoms in very young children assessed for sexual abuse: a mixed method analysis from the ASAC study

Abstract

So far, a recognizable pattern of clinical symptoms for child sexual abuse (CSA), especially in young male children, is lacking. To improve early recognition of CSA, we reviewed physical complaints, physical examination, and tests on sexually transmitted infections (STIs) in confirmed victims (predominantly preschool boys) of CSA from the Amsterdam sexual abuse case (ASAC). We retrospectively analyzed the outcomes of the primary assessment using mixed methods: descriptive analysis of physical complaints, physical exams, and STI tests from medical files and a qualitative analysis on expert’s interpretations of physical complaints and children’s behavior during physical examination. We included 54 confirmed CSA victims, median age 3.2 (0–6) years, 43 boys (80%), and 11 girls (20%). Physical complaints were reported in 50%, of which gastrointestinal and anogenital complaints were most common. None of the children showed CSA-specific genital signs at physical examination. Most prominent finding during physical examination was a deviant behavioral response (anxiety, withdrawal, too outgoing) in 15 children (28%), especially in children who experienced anal/vaginal penetration. Testing for STIs was negative. Conclusion: Physical complaints and physical signs at examinations were non-specific for CSA. Deviant behavioral reactions during physical examination were the most prominent finding. Precise observation of a child’s behavior during physical examination is needed. What is known • Child sexual abuse (CSA) affects many children on both the short and the long term but remains unrecognized in most cases. • So far, there is a lack of studies on symptom patterns of CSA in male, preschool children. What is new • None of the children showed CSA-specific findings at physical and anogenital examination; STIs were not found in the confirmed victims of CSA. • The most prominent finding was the deviant behavioral response of the children examined, especially in children who experienced anal/vaginal penetration; therefore, precise observation of a child’s behavior during physical examination is a crucial part of the evaluation of suspected CSA. Electronic supplementary materialThe online version of this article (10.1007/s00431-017-2996-7) contains supplementary material, which is available to authorized users.

Sexual abuse in very young children: a psychological assessment in the Amsterdam Sexual Abuse Case study

“…The ASAC is unique owing to its large scale, the young age of the victims, the large proportion of boys involved (all abused under similar circumstances), the strong evidence, and the detailed documentation available about the abuse. The current study is part of the larger ASAC study (Lindauer et al, 2014; Vrolijk-Bosschaart et al, 2017a, 2017b). It reports on the first follow-up (T 1 ), carried out in 2013, 3 years after the case was disclosed.…”

“…Yet, studies on CSA outcomes generally focus on older, female victims, because female prevalence rates are higher (Stoltenborgh et al, 2011). The detection of CSA in very young children is also complicated by the absence of CSA-specific signs in most victims (Vrolijk-Bosschaart et al, 2017a). …”

Forensic medical evaluation of children who present with suspected sexual abuse: How do we know what we know?

“…The only significant finding in this group of children was behavioural difficulties (termed ‘deviant behavioural responses’) noted by the examiners when the children had their genital examination, particularly those who experienced penetrative assault …”

“…In the Amsterdam ASAC study, none of 11 girls confirmed to have been sexually abused, including some with known vaginal penetration, had genital findings considered 'diagnostic' of penetrative abuse when examined months to years later. 34 Furthermore, only 2 of 36 children in this cohort had any history of bleeding -1 had constipation and was known to have experienced anal penetration; in the other child, the origin of the blood loss was unclear. 34 The only significant finding in this group of children was behavioural difficulties (termed 'deviant behavioural responses') noted by the examiners when the children had their genital examination, particularly those who experienced penetrative assault.…”

Clinical practice: recognizing child sexual abuse—what makes it so difficult?

“…We need to emphasize that CSA-specific findings are only found in a minority of CSA victims (4–5%) when examined over 72 h after the last abuse [1, 2, 21, 22, 38, 49], due to the rapid healing of mucous tissue. Accordingly, in 95%, there are no physical findings at anogenital examination in children examined 48 h or more after the abuse [1, 2].…”