Clinical and Experimental Pediatrics

The Korean Pediatric Society (대한소아청소년과학회)
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Clinacal investigation of child sexual abuse

소아 성폭력에 관한 임상적 고찰

  • Lee, Hyun Joo (Department of Pediatrics, National Police Hospital) ;
  • Han, Hye Jung (Department of Pediatrics, National Police Hospital) ;
  • Kim, Ji Hee (Department of Pediatrics, National Police Hospital) ;
  • Lee, Hye Sun (Department of Pediatrics, National Police Hospital) ;
  • Lee, In Sil (Department of Pediatrics, National Police Hospital)
  • Received : 2006.08.18
  • Accepted : 2006.09.20
  • Published : 2007.01.15
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Abstract

Purpose : Child sexual abuse is a significant and serious problem that affects public health and society. Pediatricians are responsible for preventing and detecting sexual abuse of children. The aim of this study was to examine clinical findings of child sexual abuse. Methods : The authors retrospectively studied 292 patients between the ages of 0 and 18 who were referred for evaluation of sexual abuse to the Emergency Department of the National Police Hospital from Oct 1, 2001 to May 5, 2005. Results : Sixty three (21.6 percent) of sexual abuse victims were younger than 6 years of age; 89 (30.5 percent) were 6-12 years of age; and 104 (47.9 percent) were 12-18 years of age. Attack time was the most common between noon and 6 pm. Victims were attacked in their home or nearby (51.4 percent). One hundred fifty six (53.6 percent) offenders were accquaitances, thirty nine (13.4 percent) of whom were family members. The disclosure of attack by parents with abnormal physical symptoms was more common in younger children than in adolescence. Eighty nine (30.5 percent) victims had no specific physical findings, 51 percent had injury to the hymen, 37.3% had injury to external genitalia, and 4 percent had anal injury. One case of gonorrhea and thirteen cases of chlamydia were found. Sperm was found in 19 cases and acid phosphatase was positive in 28 cases. The absence of physical findings and laboratory findings was more common in younger children than in those in adolescence. The time interval from attacks to hospital visits had a significant negative correlation with age. Conclusion : For younger victims, the time interval from attack to hospital visitis was more prolonged. Victims may have no physical evidence of sexual abuse. Therefore, a careful history should be obtained and a through physical examination should be performed. Pediatricians must play a leading role in evaluation and treatment of sexually abused children, considering children,s growth and development. Coordination with other professionals is necessary to provide consultation, medical treatment, and legal assistance for the sexually abused children and families.

목 적 : 성폭력 발생빈도가 증가하고 신고율이 높아지면서 사회문제로 관심이 커졌고 최근 성폭력과 관련되어 내원하는 소아가 증가하였다. 성폭력은 신체적 외상은 물론 정신적 충격으로 소아의 성장과 발달에 좋지않은 영향을 줄 수 있다. 본 연구에서는 18세 이하 성폭력 피해자의 임상적 소견을 관찰하였다. 방 법 : 2001년 10월 1일부터 2005년 5월 5일까지 국립경찰병원 학교 여성폭력 지원센터를 방문한 성폭력 피해자 중 18세 이하 292명의 임상 소견을 후향적으로 조사하였다. 결 과 : 1) 대상 환아의 연령은 6세 미만의 소아가 63명(21.6%), 6세 이상 12세 미만의 소아가 89명(30.5%), 12세 이상 18세 미만은 140명(47.9%)이었고 성별 분포는 여아가 288명(98.6%), 남아가 4명(1.4%)이었다. 2) 범행 시각은 12:00-18:00시(44.6%)에 가장 많이 발생하였고, 피해 장소는 피해자 집과 집근처에서 범행이 있었던 경우가 150례(51.4%), 학교, 유치원, 놀이방에서 발생한 경우가 39례(13.4%), 가해자의 집에서 발생한 경우가 34례(11.6%)였다. 3) 가해자는 평소 알고 있었던 사람인 경우가 156례(53.6%)였고 그 중 39례는 친인척이었으며 모르는 사람인 경우가 135례(46.4%)였다. 나이가 어릴수록 가해자가 평소 알고 있었던 사람인 경우가 많았다(P<0.05). 4) 병원에 내원하게 된 동기는 201례(69.8%)가 본인의 호소에 의한 경우였으나 의사 표현이 충분하지 않은 6세 미만의 소아에서는 증상과 징후로 부모에 의해 발견된 경우가 36례(12.5%)였다. 5) 신체 검진시 정상 소견을 보인 경우는 89례(30.5%)이었고 처녀막 주위에 이상 소견을 보인 경우가 149례(51.0%), 기타 외음부에 이상 소견을 보인 경우가 109례(37.3%), 항문부위에 이상 소견을 보인 경우가 12례(4.1%)였고 나이가 어릴수록 정상 소견을 보인 경우가 더 많았다(P<0.05). 6) 질에서 채취한 검체로 시행한 검사상 성병 감염 빈도는 임균감염이 1례(0.3%), 클라미디아 13례(4.5%)였다. 질 분비물내 정충이 발견된 경우는 19례(6.5%)였고 산성 인산효소 양성반응은 보인 경우는 28례(9.6%)였다. 나이가 많을수록 정자가 발견되거나, 산성 인산효소 양성, 클라미디아 배양율이 더 높았다(P<0.05). 7) 사건후 내원까지 걸린 시간은 72시간 이내인 경우가 174례(62.6%), 72시간이상 지연된 경우는 104례(37.4%)에 해당하였고 이는 피해자의 나이가 적을수록 걸린 시간이 증가하였다(P< 0.05). 결 론 : 나이가 어릴수록 성폭력 피해 사실을 발견하는 시간이 지연되고 신체검진상 정상소견을 보일 가능성이 있기 때문에 주의 깊은 관찰과 면담이 필요하고 이를 통해 만성적이고 지속적인 피해를 줄일 수 있다. 피해자와 가족에 대한 상담, 의학적 진료, 법적인 조치를 위한 전문팀이 구성되어야 하고 이에 소아과 의사의 적극적인 참여가 요구된다.

Keywords

References

  1. Kempe CH. Sexual abuse, another hidden pediatric problem. Pediatrics 1978;62:382-9
  2. Adams JA. Medical evaluation of suspected child sexual abuse. J Pediatr Adolesc Gynecol 2004;17:191-7 https://doi.org/10.1016/j.jpag.2004.03.044
  3. Heger A, Ticson L, Velasquez O, Bernier R. Children referred for possible sexual abuse: medical findings in 2384 children. Child Abuse Neglect 2002;26:645-59 https://doi.org/10.1016/S0145-2134(02)00339-3
  4. Finkelhor D. Epidemiological factors in the clinical identification of child sexual abuse. Child Abuse Negl 1993;17:67-70 https://doi.org/10.1016/0145-2134(93)90009-T
  5. Bowen K, Aldous MB. Medical evaluation of sexual abuse in children without disclosed or witnessed abuse. Arch Pediatr Adolesc Med 1999;153:1160-4 https://doi.org/10.1001/archpedi.153.11.1160
  6. Frank WP. Ten-year research update review: child sexual abuse. J Am Acad Child Adolesc Psychiatry 2003;42:269-78 https://doi.org/10.1097/00004583-200303000-00006
  7. Dube SR, Anda RF, Whitfield CL, Brown DW, Felitti VJ, Dong M, et al. Long-term consequences of childhood sexual abuse by gender of victim. Am J Prev Med 2005;28:430-8 https://doi.org/10.1016/j.amepre.2005.01.015
  8. Hymel KP, Child JC. Child sexual abuse. Pediatr Rev 1996;17:236-50 https://doi.org/10.1542/pir.17-7-236
  9. Finkelhor D. Current information on the scope and nature of child sexual abuse. Future Child 1994;4:31-53 https://doi.org/10.2307/1602522
  10. Gorey K, Leslie D. The prevalence of child sexual abuse. Child Abuse Negl 1997;21:391-8 https://doi.org/10.1016/S0145-2134(96)00180-9
  11. Johnson CF. Sexual abuse in children. Pediatr Rev 2006;27: 17-27 https://doi.org/10.1542/pir.27-1-17
  12. Ministry Health & Welfare National Child Protection Agency. The report of child sexual abuse in the whole country 2005;1-6
  13. Sobsey D, Randall W, Parrila R. Gender differences in abused children with and without disabilities. Child Abuse Negl 1997;21:707-20
  14. Cheung PC, Ko CH, Lee HY, Ho LM, To WW, Ip PL. Correlation of colposcopic anogenital findings and overall assessment of child sexual abuse. Hong Kong Med J 2004;10:378-83
  15. Browning DH, Boatman B. Incest: Chilren at risk. Am J Psychiatry 1977;134:69-72 https://doi.org/10.1176/ajp.134.1.69
  16. Hong KE, Kang BG, Kwack YS. A survey of intrafamilial child sexual abuse by physicians, reports. Korean J Child Adol Psychiatr 1998;9:138-47
  17. Gold SN, Hughes DM, Swingle JM. Characteristics of childhood sexual abuse among female survivors in therapy. Pediatrics 1996;20:323-5
  18. Kellogg N. The evaluation of sexual abuse in children. Pediatrics 2005;116,506-12 https://doi.org/10.1542/peds.2005-1336
  19. Muram D. Genital tract injuries in the prepubertal child. Pediatr Ann 1986;15:616-20
  20. Muram D. Childs sexual abuse: relationship between sexual acts and genital findings. Child Abuse Negl 1989;13:211-6 https://doi.org/10.1016/0145-2134(89)90007-0
  21. Lahoti SL, McClain N, Girardet R, McNeese M, Cheung K. Evaluating the child for sexual abuse. Am Fam Physician 2001;63:883-92
  22. McCann J, Voris J, Simon M. Genital injuries resulting from sexual abuse: a longitudinal study. Pediatrics 1992;89:307-17
  23. McCann J. The appearance of acute, healing and healed anogenital trauma. Child Abuse Negl 1998;22:605-15 https://doi.org/10.1016/S0145-2134(98)00035-0
  24. Ingram DM, Everett VD, Ingram DL. The relationship between the transeverse hymenal orifice diameter by the separation technique and other possible markers of sex abuse. Child Abuse Negl 2001;25:1109-20
  25. Siegel RM, Schubert CJ, Meyers PA, Shapiro RA. The prevalence of sexually transmitted diseases in children and adolescents evaluated for sexual abuse in Cincinnati: rationale for limited STD testing in prepubertal girls. Pediatrics 1995;96:1090-4
  26. American Academy of Pediatrics Committee on Child Abuse and Neglect. Guidelines for the evaluation of sexual abuse of children. Pediatrics 1999;103:186-91 https://doi.org/10.1542/peds.103.1.186
  27. Ricci LR, Hoffman SA. Prostatic acid phosphatase and sperm in the post-coital vagina. Ann Emerg Med 1982;11:530-4 https://doi.org/10.1016/S0196-0644(82)80424-1
  28. Schumann GB, Badawy S, Peglow A, Henry JB, Hammerschlag MR. Prostatic acid phosphatase. Am J Clin Pathol 1976;66:944-52 https://doi.org/10.1093/ajcp/66.6.944
  29. Freyd JJ, Putnam FW, Lyon TD, Becker-Blease KA, Cheit RE, Siegel NB. The science of child sexual abuse. Science 2005;308:501 https://doi.org/10.1126/science.1108066
  30. Koss MP, Koss PG, Woodruff WJ. Deleterious effects of criminal victimization of women's health and medical utilization. Arch Intern Med 1991;151:342-7 https://doi.org/10.1001/archinte.151.2.342
  31. Kimerling R, Calhoun K. Somatic symptoms, social support, and treatment seeking among sexual assault victims. J Consult Clin Psychol 1994;62:333-40 https://doi.org/10.1037/0022-006X.62.2.333
  32. Swanston HY, Tebbutt JS. Sexually abused children 5 years after presentation. Pediatrics 1997;100:600-8 https://doi.org/10.1542/peds.100.4.600
  33. Drach KM, Wientzen J. Ricci LR. The diagnosic utility of sexual behavior problems in diagnosing sexual abuse in a forensic child abuse evaluation clinic. Child Abuse Neglect 2001;25:489-503 https://doi.org/10.1016/S0145-2134(01)00222-8
  34. Forbes F, Duffy JC, Mok J, Lemvig J. Early intervention service for non-abusing parents of victims of child sexual abuse: Pilot study. Br J Psychiatry 2003;183:66-72 https://doi.org/10.1192/bjp.183.1.66
  35. Weinstein D, Staffelbach D, Biaggio M. Attention-deficit hyperactivity disorder and posttraumatic stress disorder: differential diagnosis in childhood sexual abuse. Clin Psychol Rev 2000;20:359-78 https://doi.org/10.1016/S0272-7358(98)00107-X
  36. Swanston HY, Tebbutt JS, O,Toole BI, Oates RK. Sexually abused children 5 years after presentation: a case control study. Pediatrics 1997;100:600-8 https://doi.org/10.1542/peds.100.4.600
  37. Melisa MH, Heidi SR. Follow-up of sexual assult victims. Am J Obstet Gynecol 1998;179:336-42 https://doi.org/10.1016/S0002-9378(98)70361-8