But diagnostic inconsistencies raise questions about the data.


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According to a study in JAMA Pediatrics, the annual number of ED admissions in the United States for confirmed cases of sexual abuse of children younger than 18 years increased from 5,138 in 2010 to 8,818 in 2016. Of the total number of admissions for sexual abuse during the seven-year period, 85.14% were girls and 44.75% were adolescents (ages 12 to 17).

Figure. A student in... - Click to enlarge in new windowFigure. A student in the sexual assault nurse examiner program at the Vanderbilt University School of Nursing uses a swab to collect evidence. Photo by Anne Rayner, Vanderbilt University.

The researchers cautioned that the upsurge in confirmed cases may be associated with an overall rise in the number of adolescents admitted to the ED during this period-from 44.37% of pediatric sexual abuse patients in 2010 to 57.36% in 2016. They also cite as potentially influencing factors a possible increase in the number of girls being subjected to sex trafficking, and greater awareness of sexual assault among clinicians.


Annie Lewis-O'Connor, founder of a clinic at Brigham and Women's Hospital in Boston to assist survivors of sexual violence and editorial board member of the Journal of Forensic Nursing, also urged caution in interpreting the statistical data. She noted that the study used diagnosis codes to identify sexual abuse admissions but that these can be misleading because of the many "gray" areas that affect diagnostic accuracy. With the exception of evidence such as sexually transmitted infections, the presence of vaginal or anal tears, pregnancy, witnesses (an older sibling, for example), or videotapes, child sexual abuse can only be definitively determined by the legal system.


"Physical findings have a lot of gray zones, and most kids don't have overt signs of sexual abuse," Lewis-O'Connor told AJN. "In addition, sometimes children are brought to the ED out of parental concern. Finally, as many clinicians are untrained in examining children and adolescents for sexual assault, they may interpret normal variants in the appearance of the hymen as signs of injury."


The authors of the JAMA Pediatrics study also express concerns about inadequate clinician training. The quality of care and the treatment of sexually abused children admitted to EDs, they write, may not consistently adhere to the recommendations for care endorsed by the American Academy of Pediatrics (AAP) and the Centers for Disease Control and Prevention. (To read the full AAP guidelines, go to https://pediatrics.aappublications.org/content/139/3/e20164243.)


A 2015 study published in Pediatrics found that only 44% of adolescents diagnosed with sexual assault in pediatric EDs received recommended testing for chlamydia, gonorrhea, and pregnancy, and even fewer, 35%, received recommended prophylaxis for sexually transmitted infections or, in cases of pregnancy, emergency contraception. Across all EDs, unadjusted rates of testing ranged from 6% to 89%, and prophylaxis ranged from 0% to 57%.


Pediatricians, ED physicians, and nurses "need significant training in order to properly evaluate and address child sexual abuse," said Lewis-O'Connor. "They must use the evidence collection kit and follow protocols." She added that some ED physicians view sexual abuse as "a social issue and leave these patients to nurses," highlighting the need for nurse training. Lewis-O'Connor also recommended that ED administrators develop systems to triage sexual abuse cases to properly trained personnel.-Dalia Sofer


Helton JJ, et al. JAMA Pediatr 2019 Nov 4 [Epub ahead of print].