Medical Evaluation of Pre-Pubertal Children w. Suspected Sexual Abuse - CPS Statement

Question 1

What is the age of consent for sexual activity in Canada?

Answer 1

16

Question 2

What are the “close in age” exceptions for sexual activity consent?

Answer 2

1) Youth 12 or 13 years old can consent to sexual activity with a partner as long as the partner is less than 2 years older

2) Youth 14 or 15 years old can consent as long as the partner is less than 5 years older

There is no “supervisory” role in relationship

Question 3

In the event of a disclosure of sexual abuse, what should happen first - the forensic interview or exam?

Answer 3

In both urgent and non-urgent cases, the child should be interviewed by child welfare and/or law enforcement authorities before their medical evaluation

Question 4

Within what timeframe of sexual abuse is an urgent medical assessment warranted?

Answer 4

If the abuse occurred less than 72 hours prior

Question 5

What information needs to be obtained on initial medical history for suspected sexual abuse?

Answer 5

Ano-genital pain, bleeding, discharge, or itching

Bowel and urinary symptoms

Abdominal pain

Changes in a child’s mood, behaviours, or fears

Current medications, allergies, and immunizations

Question 6

List the 5 categories of physical findings on the sexual abuse exam

Answer 6

1) Normal variant findings

2) Findings commonly caused by medical conditions other than trauma or sexual contact (e.g. erythema, labial adhesions)

3) Findings that can be mistaken for abuse which are caused by other conditions (e.g. lichen sclerosis)

4) Findings where there is no expert consensus regarding significance

5) Findings caused by trauma

Question 7

What are the 3 categories of infections when discussing a sexual abuse exam?

Answer 7

Infections unrelated to sexual contact (e.g., vaginitis with organisms transmitted by nonsexual means and genital ulcers caused by viruses)

Infections that can be spread by nonsexual as well as sexual transmission (e.g., molluscum contagiosum, HPV, HSV)

Infections caused by sexual contact (e.g., Neisseria gonorrhoeae, Chlamydia trachomatis, Trichomonas vaginalis, HIV)

Question 8

What are the two physical findings diagnostic of sexual contact?

Answer 8

1) Pregnancy
2) Semen identified in forensic specimens taken directly from a child’s body

Question 9

What are examples of “normal variant” findings on a sexual abuse exam?

Answer 9

Hymenal notches and bumps, intravaginal ridge, failure of midline fusion, partial dilatation of external anal sphincter

Question 10

What are examples of “findings where there is no expert consensus” on genitalia exam for sexual abuse?

Answer 10

Complete anal dilatation with relaxation of external and internal anal sphincter without predisposing factors

A notch or cleft nearly to the base of the hymen at or below the ‘3 o’clock’ or ‘9 o’clock’ position

Question 11

You see a child with a hymenal transection/complete hymen cleft – a defect in the hymen below the 3-9 o’clock location that extends to or through the base of the hymen. What category would you classify this as?

Answer 11

Genital findings caused by trauma

Question 12

What are 3 genital infections that can be caused by non-sexual as well as sexual transmission?

Answer 12

Molluscum contagiosum, HPV, HSV

Question 13

What is the ideal testing method for chlamydia and gonorrhoea for medico-legal purposes?

Answer 13

In pre-pubescent children, culture for NG and CT has been the preferred testing method for medical-legal purposes. However, NAATs may be acceptable if positive results are confirmed by a second set of primers or, in some cases, a second test sent to a different laboratory

Question 14

When is HIV PEP recommended?

Answer 14

HIV-PEP is recommended for prepubescent children following acute sexual abuse when any of the following high-risk factors are present:
1) The suspected offender is HIV-positive
2) Significant exposure has occurred (i.e., oral, anal, or vaginal penetration without condom use or condom status is unknown or suspect)

Question 15

What is the time frame for starting HIV PEP?

Answer 15

As soon as possible after exposure and within 72 hours, always needs to be discussed with an ID specialist

Question 16

What do you do when there is concern about possible exposure to HepB via sexual abuse?

Answer 16

Determine immunization status and consider initiating hepatitis B vaccine and possibly administering HBIG.

Collect serology for hepatitis B, C and syphilis.

Question 17

When should follow-up testing for HIV be done following a significant exposure?

Answer 17

Follow-up HIV testing should be completed at 6/12/and 24 weeks

Question 18

When should follow-up testing for HepC be done following a significant exposure?

Answer 18

Hepatitis C testing at 12 and 24 weeks following a significant exposure

Question 19

What are hymenal notch/cleft findings that could be normal variants?

Answer 19

1. Any notch/cleft above 9 - 3 is a normal variant
2. Any notch/cleft that does not extend to the base of the hymen below 9 - 3 could also be normal

Question 20

What are hymenal notch/cleft findings that have unknown significance?

Answer 20

1. Notch or cleft in the hymen rim, at or below the 3 o’clock or 9 o’clock location, which extends nearly to the base of the hymen, but is not a complete transection. This is a very rare finding that should be interpreted with caution unless an acute injury was documented at the same location
2. Complete cleft/suspected transection to the base of the hymen at the 3 or 9 o’clock location

Question 21

What are hymenal cleft findings that are indicative of trauma?

Answer 21

Healed hymenal transection/complete hymen cleft/defect in the hymen below the 3-9 o’clock location that extends to or through the base of the hymen, with no hymenal tissue discernible at that location