Personal values and sexual decision-making among virginal and sexually experienced urban adolescent girls.

PURPOSE: To guide the development of an intervention to reduce the incidence of sexually transmitted diseases (STDs) in urban, adolescent girls, we investigated such girls' reasons for deciding to have or not to have sexual intercourse. METHODS: Consecutive girls >or=14 years of age attending an urban adolescent clinic were invited to complete an anonymous survey about sexual decision-making. In this pilot study, girls were asked: (a) whether they agreed with a statement that they had or had not had sexual intercourse "because of my values and beliefs"; and (b) to select from a list one or more specific reasons why they had or had not had intercourse. The girls were categorized by self-report as either "virgins," "currently inactive" (no intercourse in the preceding 3 months), or "currently active" (had intercourse during the preceding 3 months). RESULTS: Usable surveys were obtained from 197 adolescents whose age (18.2 +/- 2.6 years) and race (69% black) were comparable to those of clinic attendees in general. Forty girls (20%; age 16.1 +/- 2.1 years) were virgins, 25 girls (13%; age 17.8 +/- 2.3 years) were inactive, and 132 girls (67%; age 18.9 +/- 2.5 years) were currently active. "Values and beliefs" were cited as the reason for decisions about sexual behavior by 53% of the virgins, but only by 24% of the sexually inactive and 24% of the sexually active girls (p = .002). Virgins were more likely than inactive girls to cite three specific reasons for not having sex: "not the right thing for me now" (82% vs. 50%, p = .007), "waiting until I am older" (69% vs. 8%, p = .001), and "waiting until I am married" (67% vs. 38%, p = .02). The reason "against my religious beliefs" was cited by 23% of virgins and 13% of inactive girls (p = not significant). Personal values were implicit in the two specific reasons for having sex that active girls chose most frequently, namely, "I like/love the person" (86%) and "I like having sex" (37%), although only 24% of these girls had explicitly cited "values and beliefs" as their reason for having sex. CONCLUSIONS: Our data indicate that urban girls, both those who have had sexual intercourse and those who have not, view their sexual behavior as being based on personal (although infrequently religious) values. Many of the virginal urban, adolescent girls we surveyed hold abstinence as a personal value. The sexually active adolescents perceive the decision to have sexual intercourse as being based affirmatively on their personal values rather than on the chance occurrence of opportunities to have intercourse. These data may be useful in the development of new strategies for reducing urban adolescent girls' risk of acquiring sexually transmitted diseases.

Current concepts in preventing sexual abuse.

Most efforts to prevent sexual abuse have focused on teaching school children to resist abuse after it starts and to report it promptly to trusted adults. These programs increase children's knowledge and skills and the likelihood that children will disclose sexual victimization but have not been shown to reduce the incidence of abuse. A recent, unique approach to prevention is a Vermont social marketing campaign that encouraged sexual offenders to seek treatment. During the campaign, 50 persons voluntarily sought treatment for sexual offending or sexual behavior problems, and eight offenders presented themselves voluntarily to state attorney offices. Recent evidence indicates that many sexual offenders were themselves molested and that lack of family support about that molestation is an important risk factor for sexual offending. However, the number of treatment programs for "sexually reactive" children and adolescent sexual offenders in the United States declined from more than one thousand in 1994 to 337 in 2000. In nine states, no adolescent treatment program is currently available. There is an urgent need for methodologically sound research aimed at delineating the causes of sexual deviance and at measuring and improving the efficacy of treatment for sexual offenders.

Influence of the history on physicians' interpretations of girls' genital findings.

OBJECTIVE: Because physicians customarily obtain histories before examining children in cases of possible sexual abuse, and because the resulting diagnostic opinions can influence important social and legal decisions, we investigated whether clinical histories influence physicians' interpretations of girls' genital findings. DESIGN: In mailed questionnaires, 1387 randomly selected Fellows of the American Academy of Pediatrics and all 802 members of four professional groups concerned with child abuse or pediatric gynecology were asked to interpret seven simulated cases. Respondents were asked to interpret seven additional cases in separate questionnaires mailed 4 months later. Both sets of cases involved the same seven photographs of girls' external genitalia. However, in six of the seven case pairs, the histories in the two questionnaires differed in the extent to which they suggested sexual abuse. In the remaining (control) pair, the same history was presented in both questionnaires. RESULTS: Of 2189 physicians, 1114 (50.9%) responded. Responses from 604 physicians (54.2%) were eligible for analysis. Overall, the genital findings were interpreted most consistently by the most experienced physicians and least consistently by the least experienced physicians. The proportion of physicians whose interpretations of a photograph reversed in the direction suggested by the change in the associated history from "no indication of abuse" to "probable abuse," or vice versa, ranged for experienced physicians from none to 5.6%; for moderately experienced physicians from 1.6% to 19.8%; and for inexperienced physicians from 3.6% to 27.2%. This difference between the experience groups was statistically significant in four case pairs. Mean interpretation scores for genital findings changed significantly when the histories changed in two case pairs for the experienced physicians, in five pairs for the moderately experienced physicians, and in all six pairs for the inexperienced physicians. CONCLUSIONS: In some cases and especially for less experienced physicians, diagnostic expectation appears likely to influence physicians' interpretations of girls' genital findings. Physicians should be alert to the possibility of diagnostic expectation bias and its potentially serious social and legal consequences.

Boston HAPPENS Program: a model of health care for HIV-positive, homeless, and at-risk youth. Human immunodeficiency virus (HIV) Adolescent Provider and Peer Education Network for Services.

The Boston HAPPENS [Human immunodeficiency virus (HIV) Adolescent Provider and Peer Education Network for Services] Program is a project supported by Special Projects of National Significance (SPNS) Program, HIV/AIDS Bureau, Health Resources and Services Administration, which provides a network of care for homeless, at-risk, and HIV-positive youth (ages 12-24 years), involving eight agencies. The program has provided services to 1301 youth, including 46 who are HIV-positive. Boston HAPPENS provides a citywide network of culturally and developmentally appropriate adolescent-specific care, including: (a) outreach and risk-reduction counseling through professional and adult-supervised peer staff, (b) access to appropriate HIV counseling and testing support services, (c) life management counseling (mental health intake and visits as part of health care and at times of crisis), (d) health status screening and services needs assessment, (e) client-focused, comprehensive, multidisciplinary care and support, (f) follow-up and outreach to ensure continuing care, and (g) integrated care and communication among providers in the metropolitan Boston area. This innovative network of youth-specific care offers a continuum from street outreach to referral and HIV specialty care that crosses institutional barriers.

Assessments of girl's genital findings and the likelihood of sexual abuse: agreement among physicians self-rated as skilled.

OBJECTIVES: To measure agreement about genital examination findings among physicians who rate themselves as skilled in evaluating children for suspected sexual abuse, to compare these physicians' descriptions and interpretations with consensus standards developed by an expert panel, and to investigate the effects of physician and case characteristics on agreement. STUDY DESIGN: Questionnaires including 7 simulated cases, each consisting of a brief history and 1 photograph of a girl's genitalia, were mailed to random samples of 2 groups: the members of 4 physician organizations concerned with child abuse or pediatric gynecology, and pediatricians at large. Among the surveyed physicians who rated their own skill in evaluating cases of suspected sexual abuse as higher than average, we measured agreement, both overall and between those with the most and with less clinical experience, and assessed their conformity with consensus standard descriptions and interpretations. RESULTS: We received responses from 548 (50.9%) of 1076 physicians; 414 responses (75.5%) were analyzable. Two hundred six physicians (50%) rated themselves as skilled in assessing children for sexual abuse. On average, 45% of these physicians' descriptions and 72.6% of their interpretations conformed with the consensus standards. In 4 cases, between 5% and 20.7% of these physicians described genital findings that the expert panel had considered absent from the photographs. Conformity with standard interpretations tended to be higher in cases with photographs concordant with the accompanying, unambiguous histories (P=.06). The most experienced physicians resembled the expert panel more closely than did the less experienced self-rated skilled physicians in interpreting 3 simulated cases (P< or =.001). CONCLUSIONS: Assessments of girls' genital findings by physicians who rate themselves as skilled in examining children for suspected sexual abuse often differ. In some cases, among physicians who all rate themselves as skilled, assessments made by very experienced physicians may conform more closely to consensus standards than do assessments made by less experienced physicians.

Minimum criteria for reporting child abuse from health care settings.

We evaluated how consistently clinicians of two hospitals reported child abuse and neglect, and the utility of specific, operational criteria for assessing hospital clinicians' compliance with the child abuse reporting laws. To evaluate clinicians' compliance, we audited the medical records of 85 children who had been reported to a child protective service (CPS) agency by clinicians at either of two hospitals and who had been seen at that hospital at least once before the index report of abuse. The time elapsed from first hospital visit to index abuse report among the 85 children averaged 4.3 years. In the children's records, we identified 28 earlier reports to the CPS agency and four episodes that met criteria we developed but that had not been reported. Thus, application of specific criteria resulted in the finding that 28 (88 percent) of 32 suspected abuse episodes were actually reported to the CPS agency (95 percent confidence interval: 76 to 99 percent). In a second phase of the study, we compared the content of 45 reported episodes of child abuse (4) index reports and four earlier reports) to the criteria in order to evaluate their utility. Thirty-five episodes (78 percent) met one of the criteria. Review of the remaining 10 episodes led to the development of one new criterion. We conclude that, although it has been estimated that hospital personnel nationwide report to CPS agencies only 69 percent of the child abuse cases they identify, clinicians at the hospitals we studied reported 88 percent of documented episodes of suspected abuse. We also conclude that specific, operational criteria can help in the assessment of hospital clinicians' compliance with their obligation to report child abuse and neglect.

Emergency diagnosis and management of physical abuse and neglect of children.

Injuries due to child abuse have continued to attract the attention of investigators. There was new evidence to show that cardiopulmonary resuscitation is a rare cause of rib fracture and that posterior rib fractures without a history of significant trauma are highly suggestive of abuse. An autopsy study examined ocular nerve sheath hemorrhage in deaths caused by abuse. The incidence and characteristics of abuse and neglect were studied for drowning victims. Female circumcision was well described, and physicians need to familiarize themselves with this cultural practice. The American Academy of Pediatrics published policy statements on sudden infant death and shaken baby syndrome. They stressed the need for protocols to deal with unexpected childhood deaths and to obtain autopsies in such cases. Reviews of fractures of abuse and retinal hemorrhages were enlightening. Reporting abuse and coping with violence remained topics of interest.

Screening for mental health using adolescent-reported parenting.

BACKGROUND AND OBJECTIVES: Little is known in primary care practices about the relationship between parenting and adolescent mental health. In addition, current parenting measures have a narrow focus or do not lend themselves to clinical intervention. This study examined the clinical utility of a new instrument measuring adolescent-reported parenting, the Parenting Assessment Scale (PAS), to predict adolescent mental health. METHODS: A total of 147 adolescents regularly attending an inner-city clinic were asked to complete the Youth Self Report (YSR), a standard scale measuring mental health, and a PAS for each biological parent. Global scores on the PAS and YSR summarized the reported parenting quality and the adolescents' mental health status. RESULTS: Receiver Operating Characteristics and discrimination analyses showed that the global parenting index was highly predictive of mental health using a z score of .73 (sensitivity = 92.3%, specificity = 88.9%). CONCLUSIONS: The PAS may be useful as a screening tool in older, black adolescent females, although further research is needed to clarify its role in the clinical setting.

Behavior, family function, school performance, and predictors of persistent disturbance in sexually abused children.

OBJECTIVE: Although sexual abuse is widely considered to have severe sequelae, most studies of children's status after sexual abuse have had major limitations, including retrospective design, small sample sizes, selective enrollment of subjects, no comparison groups, and lack of information about potentially confounding characteristics of studied children. The aim of this study was to clarify the impact of sexual abuse on children's psychological well-being. METHODS: We prospectively studied 154 children who were brought to urban, university-affiliated hospitals for assessment of recently disclosed sexual abuse and compared them with a control group of 53 demographically similar children not known to have been sexually abused. RESULTS: In comparison with the control children, fewer of the sexually abused children had health insurance and more had received psychiatric care unrelated to the sexual abuse. Most initial ratings of behavior, maternal psychiatric status, family function, and school performance were less favorable among the sexually abused than among the control children (P < .05). At follow-up 6 months later, the psychiatric status of the mothers of the abused children apparently improved, but the children's difficulties largely persisted. Baseline characteristics of the abused children significantly or suggestively associated with persisting problematic behavior were older age (P = .04), lower maternal educational attainment (P = .06), poorer maternal psychiatric status (P = .04) and lower family integration (P < .001). These four factors accounted for 31% of the variance in the children's behavior at 6-month follow-up (P < .001). Unexpectedly, characteristics of the children's sexual abuse experiences did not predict their later behavioral status. CONCLUSIONS: These findings suggest that preexisting, long-standing adverse psychosocial circumstances may contribute importantly to persistently problematic behavior and school performance among sexually abused children. The findings also suggest that it is children's preexisting psychosocial circumstances, rather than the abuse, that determine, at least in part, the nature of their functional outcomes.

The medical evaluation of the sexually abused child.

The diagnosis of suspected sexual abuse is nearly always based on a description of abuse provided by the child. The physician should invite a child to describe his or her sexual victimization in detail if such a "disclosure" interview has not already occurred, if the child seems ready to describe the abuse, and if a child protective services worker has not yet been notified of the suspected abuse. If an allegedly abused child has already been carefully interviewed, however, the physician should instead obtain information from the child's parents or other appropriate adults to determine how best to address the questions being raised. Nonspecific behavioral or somatic complaints unaccompanied by a specific description of sexual abuse should generate a differential diagnosis for further investigation. The goals of the physical examination of the sexually abused child are to identify abnormalities that warrant further diagnostic efforts or treatment, to obtain specimens to screen the patient for sexually transmitted infections, and to make observations and take specimens that may corroborate the patient's history of victimization. These goals should be met in the context of a standard, complete physical examination. The advisability of postcoital contraception should be discussed with every postmenarcheal victim seen within 72 hours after a rape. Because gonorrhea and chlamydial infections are the most prevalent STDs seen after sexual abuse and are often asymptomatic, universal screening for these infections is recommended. Parents of all abused children should be given an opportunity to make an informed choice about HIV screening. Because the risk of acquiring STDs is low, routine antibiotic prophylaxis is not recommended for sexually abused children. Physicians must report all cases of suspected sexual abuse to states' child protective services agencies. Failure to do so can incur legal penalties. Reporting sexual assaults of children to local law enforcement officials is strongly advised. The long-term impact of sexual abuse on children's psychological adjustment is unpredictable. In the short term, children's circumstances vary widely. Some show no evidence of psychological distress. Others have severe, pervasive difficulty. Office counseling by the empathetic and knowledgeable primary care physician, short-term crisis counseling, a more formal psychological evaluation, and longer-term psychotherapy may be recommended for individual children, depending on the nature and severity of each child's symptoms, his or her parents' preference, and the availability of services in the child's community.

Substantiation of sexual abuse charges when parents dispute custody or visitation.

Recent news reports have implied that charges of sexual child abuse during parental separation or divorce are often deliberately falsified. Such a conclusion could be harmful if it biased practitioners faced with such allegations in clinical practice. To investigate this concern, sexual abuse cases in a hospital-based consecutive series and in one author's clinical practice were reviewed. Abuse allegations with and without a concomitant custody or visitation dispute were compared. A custody or visitation dispute occurred in 12 (39%) of 31 sexual abuse complaints lodged against a parent. Allegedly abused children whose parents contested custody or visitation were significantly younger than those for whom custody or visitation was not an issue (5.4 v 7.8 years, P = .02). Sexual abuse allegations were substantiated less frequently when there was concomitant parental conflict (67% v 95%, nonsignificant) but were nevertheless substantiated more than half of the time.

Probability of vaginal foreign body in girls with genital complaints.

We used Bayes' theorem to evaluate the probability of vaginal foreign bodies in girls with genital complaints. The prevalence of vaginal foreign bodies in outpatient girls under 13 years of age with gynecologic disorders was found to be 4%. Review of the charts of 17 pre-menarcheal girls who had foreign bodies on 19 occasions and of 28 girls with infectious or nonspecific vaginitis demonstrated that patients with foreign bodies reported vaginal bleeding more frequently than discharge (14 and two of 15 symptomatic cases, respectively), while in contrast, patients with infectious or nonspecific vaginitis reported vaginal discharge more often than bleeding (23 and five of 28 symptomatic controls, respectively). Bayes' theorem indicates that, in populations resembling the one we studied, approximately 18% of preteenage girls with vaginal bleeding with or without discharge and 50% of those with bleeding and no discharge will prove to have vaginal foreign bodies.

Social relevance of genital herpes simplex in children.

The charts of children younger than 13 years with culture-proved genital herpes simplex virus (HSV) were reviewed to determine how acquisition of the infection was documented and whether sexual abuse had been investigated. Six children (four girls and two boys) had genital HSV infection: five had type 1 HSV and one had type 2 HSV. None had serologic evidence of syphilis or culture-proved gonorrhea. Sexual abuse was documented in four of six patients. We concluded that genital HSV in children is frequently sexually transmitted and should always be considered a possible indicator of child abuse. Confirmation of HSV infection by culture is important to substantiate suspicious circumstances, since it may occur in the absence of either a history of sexual abuse or of other sexually transmitted diseases.

Intranasal administration of RA 27/3 rubella virus vaccine. A clinical trial in young adults.

Of the vaccines and inoculation routes studied for the prevention of rubella, only the RA27/3 vaccine, administered intranasally, has the ability to stimulate a humoral antibody pattern very similar to that evoked by wild rubella infection. Because information about intranasal (IN) vaccination has only been obtained using the RA 27/3 vaccine manufactured in Europe, we conducted a trial of IN vaccination among young adults using Meruvax II which is manufactured in the USA. Of 597 family planning clinic patients screened in 1980-1981, 71 (11.9%) were susceptible to rubella; forty-one subjects were randomly assigned to receive IN or subcutaneous (SC) vaccine. All 20 SC vaccinees, but only 8/21 (38%) IN vaccinees, were successfully immunized. We conclude that standard doses of commercially available RA 27/3 vaccine are insufficient for IN immunization against rubella. Additional study of the dose-response relationship is needed if IN vaccination is to be recommended.

Vulvovaginitis in premenarcheal girls: clinical features and diagnostic evaluation.

Fifty-four premenarcheal patients (median age 5.8 years) with symptoms or signs of vulvovaginitis were studied, and the results of cultures of vaginal secretions were compared with those from an age-matched control group. Vaginal discharge was found on examination in 24 of 42 patients with a complaint of discharge, and in two of 12 patients without a complaint of discharge. Convincing evidence of bacterial or monilial infection was found in 14 of the 26 patients with discharge on examination, but in none of the 28 patients without discharge (P less than .001). In the latter group pinworm infestation was present in one patient. Moniliasis occurred exclusively in girls who were pubertal (P less than .001). Four patients were found to have gonorrhea. No patient appeared to have symptoms or signs caused by Bacteroides sp, Chlamydia trachomatis, viruses, or Trichomonas vaginalis. Noninfectious causes were identified in four patients with and 13 without discharge (P less than .025); the most common cause was poor hygiene, implicated in six patients. Bubble bath use was implicated in only one patient. In 22 patients, no specific cause could be identified. All patients with poor hygiene as the only cause, and most with no demonstrable etiology, recovered after being advised to institute improved perineal hygiene. Patients with vaginal discharge are likely to have specific infections, and therefore cultures should be taken, in particular for Neisseria gonorrhoeae. Genital pruritus in prepubertal girls has little or no etiologic specificity, but in pubertal girls with vaginal discharge it suggests the presence of monilial vaginitis.