The use of telemedicine in child sexual abuse evaluations.

OBJECTIVE: To describe the advantages, disadvantages and current status of child abuse consultations conducted through telemedicine networks. METHOD: The results of a telephone survey of seven statewide telemedicine networks are reported and discussed with respect to goals, funding, technical support and expertise, infrastructure, and extent of use. Quality assurance and liability issues concerning telemedicine child abuse consultations are also reviewed. RESULTS: The goals of telemedicine networks in child abuse are to provide (1) expertise to less experienced clinicians primarily in rural areas; (2) a method for peer review and quality assurance to build consensus of opinions particularly in sexual abuse cases; and (3) support for professionals involved in an emotionally burdensome area of pediatrics. Problems encountered by existing networks include: (1) funding for equipment and reimbursement for consultation; (2) consistent technical support: (3) clinician lack of technical expertise, knowledge, or motivation; and (4) lack of network infrastructure. Legal considerations include licensure exemptions for consulting across state lines, potential for malpractice, patient confidentiality and security of images forwarded over modem lines, and liability of the equipment, consulting site, and the consultant in criminal proceedings. CONCLUSIONS: Telemedicine consultations offer a unique opportunity to raise the standard of care in child abuse evaluations, but success depends on clinician motivation, appropriate infrastructure, and ongoing funding and technical support.

Measurement of cardiac output during exercise by open-circuit acetylene uptake.

Noninvasive measurement of cardiac output (QT) is problematic during heavy exercise. We report a new approach that avoids unpleasant rebreathing and resultant changes in alveolar PO(2) or PCO(2) by measuring short-term acetylene (C(2)H(2)) uptake by an open-circuit technique, with application of mass balance for the calculation of QT. The method assumes that alveolar and arterial C(2)H(2) pressures are the same, and we account for C(2)H(2) recirculation by extrapolating end-tidal C(2)H(2) back to breath 1 of the maneuver. We correct for incomplete gas mixing by using He in the inspired mixture. The maneuver involves switching the subject to air containing trace amounts of C(2)H(2) and He; ventilation and pressures of He, C(2)H(2), and CO(2) are measured continuously (the latter by mass spectrometer) for 20-25 breaths. Data from three subjects for whom multiple Fick O(2) measurements of QT were available showed that measurement of QT by the Fick method and by the C(2)H(2) technique was statistically similar from rest to 90% of maximal O(2) consumption (VO(2 max)). Data from 12 active women and 12 elite male athletes at rest and 90% of VO(2 max) fell on a single linear relationship, with O(2) consumption (VO(2)) predicting QT values of 9.13, 15.9, 22.6, and 29.4 l/min at VO(2) of 1, 2, 3, and 4 l/min. Mixed venous PO(2) predicted from C(2)H(2)-determined QT, measured VO(2), and arterial O(2) concentration was approximately 20-25 Torr at 90% of VO(2 max) during air breathing and 10-15 Torr during 13% O(2) breathing. This modification of previous gas uptake methods, to avoid rebreathing, produces reasonable data from rest to heavy exercise in normal subjects.

Early sexual experiences among pregnant and parenting adolescents.

One hundred sixty-six pregnant or parenting adolescent females completed a survey regarding early sexual experiences (wanted and unwanted), family dysfunction and violence, and health-risky behaviors occurring prior to age 18. Fifty-three percent had at least one unwanted sexual experience. Younger age at first unwanted sexual experience was associated with younger age at first wanted sexual experience. Adolescent females with an unwanted sexual experience, as compared to those without, were more likely to be victims of physical violence, to have run away, to be substance abusers, and to have family members with drug or alcohol problems. Four factors explained 39% of the variance in age at first pregnancy: presence of a family member with a drinking problem, age first got hit with a belt or other object by a family member, age first got drunk, and age at first wanted sexual experience. It was concluded that the prevention of teenage pregnancy entails a multifaceted approach that addresses family life, early sexual experiences, and health-risky behaviors.

Children with anogenital symptoms and signs referred for sexual abuse evaluations.

OBJECTIVE: To determine whether children referred to a sexual abuse clinic because of anogenital symptoms or signs have examination findings that are suggestive of or probable or definitive for sexual abuse. DESIGN: Case series of 157 patients. SETTING: Child and adolescent ambulatory care sexual abuse clinic. RESULTS: A medical records review of 3660 cases was done; 157 cases were identified for study. Most (75%) referrals were from medical clinics. Of 184 complaints, the most common presenting symptom or sign was anogenital bleeding or bruising (29.3%), followed by irritation or redness (21.7%), abnormal anogenital anatomy (20.7%), vaginal discharge (18.4%), lesions (6.5%), and "other" symptoms or signs (3.3%). We used a standardized classification system and determined that 25 patients (15%) had examination findings in the sexual abuse clinic that were suggestive of or probable or definitive for sexual abuse. Although 85 patients had examination findings that corroborated the presenting symptom(s), 70 had nonspecific examination findings or a diagnosis other than sexual abuse. Seventy-two patients had normal examination findings. Only patients with the presenting symptom of lesions had an increased likelihood of a sexual abuse diagnosis. Common examination findings included anogenital erythema, enhanced vascularity of the hymen or vestibule in prepubertal girls, labial adhesions, and culture-negative vaginitis. CONCLUSIONS: Few children are referred for sexual abuse evaluations based on physical signs or symptoms alone. Children with anogenital symptoms but without a disclosure or suspicion of sexual abuse are unlikely to have examination findings suggestive of abuse. The evaluation of children with anogenital symptoms and signs should include a consideration of alternative conditions and causes not directly related to sexual abuse.

Child sexual revictimization by multiple perpetrators.

OBJECTIVE: The objectives of this study were to describe feelings, disclosure characteristics, family dysfunction, and health risky behaviors in those adolescents having unwanted sexual experiences (USE; any kind of sexual touching that was bad, uncomfortable, or forced) with multiple perpetrators and to compare these parameters with those adolescents having USE(s) with single perpetrators. METHOD: A cross-sectional survey of consecutive waiting room patients from four clinic sites was done in 538 adolescents and young adults; 76% of the study population were Hispanic and over half were poor. One hundred sixty-one subjects with single perpetrator USE(s) were compared with 97 subjects who had USE(s) with more than one perpetrator. RESULTS: Victims of multiple perpetrators were more likely than victims of single perpetrators to react with self-blame and delay disclosure of USE due to shame. When compared with victims of single perpetrators, those with multiple perpetrators were more likely to disclose their USE to protect self or others or because they became weary or intolerant of the abuse. Although family violence and substance abuse were common in both victims of single and multiple perpetrators of USE, these factors appeared to potentiate the likelihood of repeated victimization in childhood. Prevalence of health risky behaviors did not differ between the two groups. CONCLUSIONS: The findings indicated that sexual revictimization by multiple perpetrators is not uncommon and suggest that abused children should be questioned about this possibility. Children and teenagers who have USE(s) with more than one perpetrator may have more difficulties with psychological recovery due to increased shame and self-blame.

Unwanted and illegal sexual experiences in childhood and adolescence.

Three hundred forty-two anonymous surveys regarding unwanted sexual experiences (USE) were filled out in three clinic sites: a pediatric sexual abuse clinic, family practice clinic, and family planning clinic. In the latter two clinics, 40% of females and 16% of males had at least one unwanted sexual experience prior to turning 18 years old. Only 91% of the sexual abuse clinic patients indicated their experience was unwanted. In addition, 27% of the subjects had wanted sexual experiences that were illegal and underreported: These experiences involved a partner at least 4 years older or younger. While feelings of victimization were most common, self-blame and naivete about the abuse were also frequently reported, especially in those who had an USE with a peer. Ambivalence, self-blame, and peer pressure were associated with a lower tendency to disclose one's USE. Although unwanted and illegal sexual experiences were less common in Hispanic females, feelings of self-blame and ambivalence regarding their USE were more frequent in comparison with White females. These findings have important investigative and therapeutic implications for professionals who encounter victims of sexual abuse.

Unwanted sexual experiences in adolescents. Patterns of disclosure.

More than 300 patients who presented consecutively to a sexual abuse clinic, a family planning clinic, and a family practice clinic filled out an anonymous survey regarding unwanted sexual experiences. In the family planning and family practice clinics, 40% of females and 16% of males reported having at least one unwanted sexual experience prior to their 18th birthday. Although 85% had disclosed their unwanted sexual experience, time to disclosure was prolonged (mean 2.3 years, median 5 to 6 months). Fear and embarrassment were the most common reasons for delay or lack of disclosure. The most common reasons for disclosure reflected internal rather than external or environmental influences. Increased awareness of unwanted sexual experiences and pattern of disclosure may enhance detection and treatment in children and adolescents.

Repair of a recto-vaginal fistula as a result of sexual assault.

A thorough and careful examination should always be performed for a child with a presenting complaint of sexual abuse. Rarely will a child suffer extensive injuries requiring surgical repair. This case study is of a 4-year-old girl who sustained severe penetrating trauma of the vagina and rectum resulting in a recto-vaginal fistula. She presented 2 months after the assault and required anogenital reconstruction with a temporary colostomy. Initial and long-term surgical management of this case is discussed.

Sexual abuse of children.

Sexual abuse of children is a pervasive and growing problem, which has demanded the attention of several professional groups. Because most children never reveal the abuse, understanding the psychodynamics involved is fundamental to the detection of these victims. Physicians should be aware of the masked clinical and behavioral indicators of sexually abused children that signal the need for further questioning. Through appropriate inspection of genitalia and anus in routine examination of the child, the physician can establish rapport and a foundation of trust critical for disclosure of abuse. The history the child gives is the most important evidence and is most credible when spontaneous, consistent, and detailed. Physicians must report any suspicion of child abuse to the Texas Department of Human Services (TDHS) and/or law enforcement agencies. Finally, physicians can help prevent such sexual abuse by providing anticipatory guidance for parents and caretakers of children.

Chlamydia trachomatis infections in children evaluated for sexual abuse.

The purpose of this study was to elucidate the conditions under which children evaluated for sexual abuse should be tested for Chlamydia trachomatis. Children were seen in an outpatient sexual abuse clinic over a nine-month period. Eight patients, ranging from 1.5 to 14.5 years of age, had positive C. trachomatis cultures. The records of these patients were examined for historical information and physical findings suggestive of rectal or vaginal penetration. Neither historical information of abuse nor physical findings were helpful in predicting the C. trachomatis infections. These results suggest that all children being evaluated for sexual abuse should be cultured for C. trachomatis.