A family medicine physician refers a 19-year-old woman to you for abnormal findings during her well-woman examination. She emigrated to the United States with her family 6 years ago from West Africa. She is not sexually active at this time, but has had one partner 2 years ago. She has no history of sexually transmitted infections. She takes nitrofurantoin for recurrent urinary tract infections, but is otherwise healthy. She says she has not had any surgeries, but she remembers undergoing a special ceremony as young child in Africa. Lung, cardiac, breast, and abdominal examinations are within normal limits. On pelvic examination you note extensive scarring on the vulva, and the labia minora have been removed. The prepuce of the clitoris is missing and the clitoris is scarred over.
Which of the following is most likely a result of the procedure the patient had in Africa?
Female genital mutilation, also known as female circumcision or female genital cutting, is a genital alteration performed on girls and young women for nontherapeutic reasons. It is primarily practiced in Africa, but variations are also found in the Middle East and Southeast Asia. Reasons given by families who perform female genital mutilation include psychosexual reasons (ie, attenuation of sexual desire in women to ensure chastity and virginity before marriage), cultural reasons (ie, initiation of girls into womanhood), myths about enhanced fertility or promotion of child survival, and religious reasons. It is often performed by untrained practitioners in unsterile conditions with crude instruments and without anesthesia. It is performed predominantly on girls in early childhood through 14 years of age. The most common type of female genital mutilation involves the removal of the clitoris and partial or total excision of the labia minora. Many complications can occur, such as infection, tetanus, shock, hemorrhage, and death. Long-term complications include chronic infection, scar and abscess formation, sterility, obstetrical complications, and incontinence. Psychological problems related to sexual abuse may also be evident, such as anxiety, depression, and sexual dysfunction.
A 5-year-old girl is brought in to the emergency department by her mother. The mother is concerned that her daughter may have been sexually molested. She reports that her daughter has been complaining of abdominal pain, and has been particularly clingy. This morning, she noted some bloody discharge on her daughter’s underwear. The child lives at home with her mother, 1-year-old brother, maternal aunt, and 18-year-old cousin. The child’s father is dead, and her mother is not seeing anyone currently.
Which of the following is the most likely abuser?
Perpetrators of sexual abuse in children are usually male, and are often trusted adults or family members. Approximately 40% of cases of sexual abuse of a child involve a family member; approximately half of these cases are attributed to the father, and about 5% to the mother. Perpetrators often gain access to children through caretaking.
A mother brings in her 16-year-old daughter for an evaluation of chronic abdominal pain. You have seen the girl many times before for various vague complaints over the past year. She has regular cycles that last 4 days with medium to light flow. She reports no dysmenorrhea, gastrointestinal symptoms, or depression. She says she is not sexually active. The mother states that lately she has been doing poorly in school. She denies drug or alcohol use. Her mother thinks it may be related to recent changes at home since the mother’s boyfriend moved in. Your examination and laboratory tests are normal. A previous workup by a gastroenterologist was also negative.
Which of the following is the best next step in the management of this patient’s symptoms?
Children who have been abused may exhibit a variety of behaviors, including guilt, anger, behavioral problems, unexplained physical symptoms, poor school performance, and sleep disturbances. Physicians who evaluate patients with vague chronic pain syndromes that show no evidence of physical etiology should investigate sexual abuse as a possible contributor. Counseling should be offered as part of the treatment if abuse is encountered.
You are called to the pediatric emergency department to evaluate a 7-year-old girl for sexual assault.
As a health care provider taking care of this girl, which of the following are you required to do?
Whenever possible, this evaluation should be undertaken by a member of an experienced child abuse team in a nonemergent setting, such as a child advocacy center. In evaluating a child of suspected sexual assault, you should carefully obtain a history and allow the child to say what happened. A careful history, physical examination, and forensic evidence collection should be taken. Techniques of examining a rape victim should be employed (collection of cultures, clothing, hair samples, etc.). The police and child protective services should be notified. Any injuries should be treated, and the child should be hospitalized only if needed based on injuries. Appropriate antibiotic prophylaxis should be given and counseling should be scheduled. The child should be returned to the home only if it is deemed safe.
A 25-year-old G1P0 presents to your office for a routine return OB visit at 30 weeks. When you listen to the fetal heart tones, you notice that the patient has a number of bruises on her abdomen. You ask her what happened, and she tells you the bruises resulted from a fall she suffered several days earlier, when she slipped on the stairs. The patient returns to your office 3 weeks later for another routine visit, and you note that she has a broken arm in a cast. She says that she fell again. You question her about physical abuse, and the patient begins crying, and reveals a long-standing history of abuse by her husband.
Which of the following is the most likely reason for upper extremity injury in this patient?
IPV affects millions of women, regardless of age, ethnicity, economic status, religion, or sexual orientation. More than one in three women in the United States have experienced rape, physical violence, or stalking in their lifetime. There are 4.8 million incidents reported annually in the United States, but the true incidence is unknown, because victims are afraid to disclose their personal experience of violence. Physical abuse is common in pregnancy, occurring in up to 10% of pregnancies. In women who have been previously abused, about 20% will experience an increase in abuse during pregnancy. Abused women sometimes receive inadequate prenatal care and have more somatic complaints than those who have not been abused. Screening for IPV should be a core part of women’s health visits. It should be done at the first prenatal visit, once per trimester, and at the postpartum visit. Battering is frequently directed toward the breasts and abdomen. Other common sites of injury are the head, neck, chest, and upper extremities. An upper extremity may be fractured as the woman attempts to defend herself.
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