Self-induced carving and scarification of the forearms as a manifestation of sexual abuse in a 14-YEAR-old adolescent girl

Background: Numerous cutaneous abnormalities have been described in adolescent girls who have been sexually abused. These include bruising, bite marks, cuts, scratches, abrasions, edema, hematomas or other evidence of struggle. Victims frequently shower or bathe excessively in an effort to cleanse their skin following such an unwanted encounter. However, there is a paucity of information in the literature regarding the association of sexual abuse and removal of the superficial layers of the skin as a more desperate attempt by teenagers to rid themselves of the perpetrator. The purpose of this paper is to heighten awareness among practitioners that self-induced cutting and carving of the forearms with scarification may occur as a manifestation of sexual abuse in young women.Methods: A 14-year-old girl was seen in an adolescent medicine consultation setting during the spring of 1999 for evaluation of an anxiety disorder. During the interview the girl related that she had been under considerable stress and that she was having difficulty sleeping. She also had worsening of facial tics that had been previously noted in association with obsessive compulsive behaviors. She had been receiving psychotherapy and was being treated with fluoxetine, but the symptoms were becoming more severe. On examination she appeared very anxious and demonstrated numerous involuntary, repetitive facial grimaces. Similar twitching movements of the neck were also noted. In addition, she had several well healed scars over both forearms. The lesions were linear with a range of one half to one inch in width and three to four inches in length. The remainder of the general physical examination was entirely unremarkable.Results: The etiology of the scars was initially unknown. Upon further questioning the patient was asked directly about what had caused these marks. At that point she broke down and cried as she related that had been sexually assaulted several months earlier. She stated that she carved out tatoos on her arms to get rid of the skin that the perpetrator had touched when he forcibly held her down and raped her. She believed that the scars were "clean" as they were covered with newly regenerated skin. Her gynecologic exam was normal. Further psychiatric intervention was then obtained as it became very apparent that the patient had numerous unresolved emotional conflicts stemming from the attack. Conclusions: This paper documents that carving and scarification of the forearms may be due to self-induced injury in adolescent girls who have been the victims of a sexual assault. Clinicians who care for teens should be aware of this finding as it appears to be an important dermatologic manifestation of sexual abuse. Early recognition of this sign and prompt treatment of the underlying psychiatric issues are essential to an optimal outcome so that any further complications following such a traumatic event can be minimized.