Sexual abuse affects approximately 100,000 children each year in the United States.1 Although the sexual abuse of children has been recognized throughout the ages, professional attention was focused on this form of child maltreatment by Dr. Suzanne M. Sgroi,2 who in 1975 referred to child sexual abuse as the "last frontier" in child abuse work, and by Dr. C. Henry Kempe, who in a 1977 national address identified child sexual abuse as a hidden pediatric problem.3
Today, pediatric training programs include content related to the identification, reporting, and evaluation of children suspected as having been sexually abused.4"6 Additionally, as mandated reporters in all 50 states, physicians are required in good faith to report cases suspicious for the diagnosis of sexual abuse.7 Physicians also face sanctions if they fail to alert the appropriate authorities of possible cases of child sexual abuse.8 National curricula include training recommendations related to the evaluation of child sexual abuse, so pediatricians are expected, at a minimum, to be able to screen children competently and refer children and families appropriately for necessary abuse evaluations.5'9'10
The healthcare information obtained during a pediatric evaluation is central to understanding a child's experience. The medical history, physical examination findings, and laboratory tests represent important components of a comprehensive evaluation that is critical to protecting children when abuse allegations arise. This evaluation provides valuable information for children, their caregivers, and the agencies that investigate statutorily.
A distinction exists between the healthcare evaluation completed by the pediatrician and the investigation completed by law enforcement or the child protective services divisions of state human services departments.11 A pediatrician has specialized training in medical evaluation and is trusted by the child and family.12 The child and family should see the pediatrician as working with them to identify medical conditions, provide treatment modalities, and address health and wellness issues, including those stemming from the abuse.11'13 Skilled medical evaluations may provide considerable valuable information to the investigative process.
Investigators, in contrast, come from disciplines and agencies mandated by laws and regulations to explore allegations of suspected maltreatment.14' 15CPS, staffed by caseworkers typically trained in social work, plays an important role in the investigation of child abuse, focusing on the family's functioning and ability to protect the child. CPS agencies provide necessary social support services to families in need and ultimately may need to remove children from caregiving environments determined to be unsafe. Law enforcement officers, on the other hand, determine whether or not a crime has been committed and begin appropriate legal action toward holding the abuser responsible for his or her actions.16'17 These two types of agencies ideally operate hand-in-hand.18
Pediatricians may participate in community-based multidisciplinary teams that address the health and welfare of children. As a member of such a team, the pediatrician has the opportunity to better inform community agencies about the medical findings in a particular case and help team members understand the importance of medical evaluations. To complete a thorough medical evaluation and contribute effectively, the pediatrician must understand the components of the healthcare evaluation: the ever-increasing value of the history, the limitations of the physical examination, the clinical aspects related to the risk of sexually transmitted diseases (STDs), the process for collecting forensic evidence, and the need for meticulous documentation.11
All of these are important topics to review to update skills and knowledge. This article focuses specifically on the physical examination and the evolving literature surrounding anogenital physical findings in children, both abused and nonabused.
Any discussion of the physical examination in the evaluation of cases of suspected child sexual abuse should be linked intrinsically to a discussion of the history-taking process. The medical history increasingly is seen as the central component to the sexual abuse evaluation. Experience with rendering clinical care traditionally has focused attention on the value of the history as a guide to the physical examination process, as well as to the entire diagnostic process.19
However, obtaining a medical history when sexual abuse is suspected is not simple. Talking to children who may have experienced sexually inappropriate behavior is not intuitive and requires a special set of skills. Pediatricians must understand how children typically are engaged in sexually inappropriate activities, the importance of secrecy and the progression of activities over time, the disclosure process, and the potential for residual medical effects as a result of sexual contact. The medical history must be thorough, well-documented, and able to withstand scrutiny in an adversarial environment.
Child sexual abuse is very different from the sexual assault of an adult. Most children who are engaged in sexual activities participate without the use of physical force and restraint. The alleged perpetrator generally has little intent to harm the child physically because of a desire to reengage the child in the activities over time. The reluctance to use force and restraint, coupled with the likelihood that a child will not report the abuse immediately, means that few children present with either acute or healed diagnostic physical findings. Thus, the medical history becomes even more pivotal to the clinical evaluation and, ultimately, to the investigation of the sexual abuse allegation. Not uncommonly, the history of the abuse, provided by the child in his or her own words, may be the only diagnostic information that is uncovered during the evaluation.
Taking the medical history in cases of suspected child sexual abuse can be viewed as a several-step process that includes an introduction, the caregiver's history of the alleged concerns, the child's medical history with a detailed review of systems, the child's history obtained independent of the caregiver, and preparation of the child for the next component of the evaluation, the physical examination.11 Key information that can be obtained from the adult accompanying the child includes:
* Why sexual abuse is suspected and if there has been a disclosure from the child;
* To whom the child made the disclosure and under what circumstances;
* What the child said;
* What the adults witnessed;
* Changes in the child's behavior;
* Medical concerns (eg, pelvic pain, discharge, bleeding);
* Terminology the child uses to refer to his or her genitals;
* Who lives at home with the child and who cares for the child; and
* If the caregiver is not a parent, where the parents are and what role the parents play in the child's life.
Once this information and any additional details are obtained, the pediatrician is better prepared to talk with the child about what happened.
Taking the History from Children
As one might imagine, a child may experience a spectrum of sexually inappropriate activities. These may involve physical noncontact such as exposure to pornography, being photographed for pornography, or being coerced into observing sexual acts (eg, adults having sex or masturbating). Even noncontact experiences have the potential to result in significant psychological sequelae and may be preparatory for more intrusive activities. Contact activities may involve touching over the clothing or, more intrusively, genital fondling, oral copulation, cunnilingus, or genital or anal penetration with a digit, penis, or foreign body. All of the activities may be reciprocal with or without the use of physical force or restraint.
Children describe their experiences from their developmental perspective with age-appropriate understanding of the events and therefore may not reflect accurately what happened. This is most evident when children state that someone has put something inside of them. For example, when a 6-year-old child states, "He put his pee-pee in my peepee," she may be expressing a perceived experience accurately. A parent might interpret that statement as vaginal penetration, when most likely the contact was limited to placement of the penis between the labia or inside the vaginal vestibule, without penetrating into the vagina. Any genital-to-genital contact is inappropriate regardless of the degree of penetration, but determining whether penetration was limited to the vestibule or vaginal canal can be important from a cultural and legal perspective.
The same applies to anal penetration. Most perceived anal penetration involves rubbing of the convex side of the shaft of the penis between the gluteal cleft and over the external anal verge tissues, resulting in a downward pressure on the anal reggae perceived by children as "inside."
Regardless of the nature of the act or disclosure, eliciting an accurate and complete history from children of all ages remains a challenging task.20 Because stigma and shame so commonly accompany sexual victimization, children are reluctant to share details of their experience. Threats and intimidation by the abuser, as well as a sense of culpability on the part of the child, may contribute to the difficulties associated with a full disclosure.
The history typically is taken in a private, child-friendly area that is as free as possible from distraction.21 When a pediatrician creates an environment that is safe and supportive, children are more likely to share many details of their experience and frequently will provide idiosyncratic details that are age-appropriate and speak to the reality of their experience. However, clinicians also must consider other areas that can affect a child's ability to provide information accurately, including developmental influences, linguistic differences, suggestibility versus memory, the effects of multiple interviews, and the effects of trauma on a child's memory.22,23
When investigating the signs and symptoms that may be a result of sexual abuse, the clinician must remember that the goal of the interview is to maximize the amount and accuracy of the information while minimizing the stress to the child. Whenever possible, children with a developmental age of 3 or older should be interviewed alone.24 Children should be encouraged to ask questions of their own, or to ask for clarification if they don't understand a question. Saywitz et al.21 showed that, when confronted with difficult-to-comprehend questions regarding easily recalled information, children who were asked to tell the interviewer if they did not understand the question performed significantly better than children who did not receive those instructions. The study found children in the control group would try to answer the question anyway but were equally likely to give an incorrect answer as a correct one.
When interviewing a child, particular attention should be paid to the types of questions that are being asked. Ideally, the skilled pediatrician uses open-ended questions, such as the "W" questions (who, what, where, when, and how). Examples that might be used in the child sexual abuse evaluation include "What brings you here today?" or "What happened?" Follow-up, open-ended questions such as "Tell me more" or 'Then what happened?" are recommended and should be used until the child has nothing left to report.
"Why" questions such as "Why did you go in the bedroom with him?" should be avoided because they may carry connotations of blame. In addition, multiple-choice questions are particularly difficult for children because they may think that they have to choose an option, even if none applies.21 If a multiple-choice question seems necessary, it should have an open-ended choice. For example, the question "Were you in the bedroom or the bathroom?" forces the child to choose between two limited choices. A question phrased "Were you in your in your bedroom, in the bathroom, or somewhere else?" is a better option, although not ideal. The preferable question is always one that is openended and becomes more directed based on the child's response. Rather than suggest a place where a sexually inappropriate interaction might have occurred, the clinician might ask, "Could you tell me where you were when this happened?"
Leading questions or questions with a "tag line" such as "Didn't you go in the house with him?" or "You went into the house with him, didn't you?" should also be avoided because they may unduly influence the responses from an impressionable child, who typically wants to please a respected adult.25 Questions with negatives (eg, "Did you not see the woman in the video?") should be avoided as well; a study of children of all ages found they gave correct answers only 50% of the time when asked questions with negafives.26 When asked the question without the negative, the correct responses increased to between 70% and 100%.
From a developmental perspective, simple words and simple questions should be the rule. Between ages 1 and 6, children may acquire five to eight new words per day, often from a single exposure to a word.23,27,28 This means children have a large vocabulary before they understand the meaning of the words fully25 Additionally, more than 60% of children's responses to multipart questions such as "Where did he touch you and with what did he touch you?" may not be accurate.29 Multipart questions can be confusing and difficult to remember for the child. Simple questions such as "Can you tell me about the first thing that happened that was not okay?" are comfortable for children.
Whenever possible, the clinician should ask the child to explain how he or she felt during a sexually inappropriate experience, thoughts following the interaction, what was said, and how he or she responded. Throughout the history-taking process, the clinician must remain nonjudgmental, empathetic, and facilitating.
Education and Training
A 1982 study looking at the examination of genitalia in children referred to the failure to include the genital examination routinely in the pediatric physical examination as the "the remaining taboo in pediatrics."30 In that study, physicians examined the child's ears, heart, and abdomen more than 97% of the time regardless of age or sex, whereas male genitalia were examined 84% of the time and female genitalia only 39% of the time. Overall, female genitalia were examined half as frequently as male genitalia at all ages.
In a study of clinicians' perspectives on the prepubertal female genital examination, clinicians (including both pediatric residents and attending physicians) reported that the female genital examination was important and should be routine.31 Clinicians who were uncertain of their skills with this aspect of the physical examination identified their understanding of anatomical variants as problematic in distinguishing normal from abnormal exams. Pediatric residents reported they relied on the supervising physician for guidance in differentiating normal from abnormal prepubertal female genital examinations. Both studies concluded with a call for strengthened training in genital examination.30,31
Two studies using surveys of family practitioners, pediatricians, and surgeons demonstrated physician difficulty in correctly labeling and identifying basic genital structures on a photograph of a prepubertal child's genitalia.32,33 The hymen was correctly labeled 59% and 62% of the time in the respective studies. In a follow-up survey of pediatric chief residents to determine how accurately a group of recently trained physicians could identify and label prepubertal genital structures on two photographs, the hymen was correctly identified 64% of the time.34
An inability to identify basic anatomy on a photograph calls into question the ability of physicians to identify and interpret accurately findings related to sexual abuse or to other, nonabusive causes. While the outcome of child sexual abuse evaluation depends primarily on a child's disclosed detailed history, the physical examination is important and needs to be completed competently.35'36 At its most basic level, a competent physical examination begins with the ability of the examiner to identify anatomic structures correctly37,38
A 1997 survey evaluated physician agreement about female genital examination findings. Physicians of varying experience levels who rated themselves as skilled at evaluating children with suspected sexual abuse were compared with an expert physician panel.39 Findings demonstrated assessments often differed, with the most experienced physicians having the closest opinions to those of the expert panel. A related study evaluated whether clinical histories influenced physicians' interpretations of female genital findings.40 Diagnostic expectation resulting from the type of history provided was likely to influence the physicians' interpretation of genital findings as being abuse-related or not.
Kellogg, Parra, and Menard41 studied patient records of children referred to a sexual abuse clinic because of anogenital signs or symptoms and found only 15% had examination findings that were suggestive, probable, or definitive for sexual abuse. The majority of the children had nonspecific examination findings; children without a disclosure or suspicion of sexual abuse were unlikely to have anogenital examination findings suggestive of abuse. The authors attributed the majority of physician referrals (for what turned out to be normal anatomic variants) to a lack of widespread knowledge and familiarity with normal genital anatomy. The study suggested physicians evaluating children for anogenital symptoms and signs should generate differential diagnoses that consider alternative conditions and causes not directly related to sexual abuse. Of course, this also requires physician familiarity with normal and abnormal genital anatomy.46
Stress During the Physical Examination
The healthcare setting in general can be a source of stress for children who may fear painful procedures and feel uncomfortable in a technical, adult-oriented environment.42 In cases of abuse, the child may be concerned and distressed about having painful injuries examined and manipulated. In child sexual abuse evaluations, the embarrassing nature of the abuse may be stressful, as may be the child's anticipation of having a genital examination.43"45 Studies of children have shown that the fear associated with a genital examination is greater than that associated with a regular office visit but that the evaluation is less traumatic when performed in a controlled setting by providers who are experienced and support the child psychologically.46,47
Healthcare providers have learned a great deal about how to help children cope with the stress they may feel related to the healthcare setting. Studies that determine the degree of a child's fear and feelings of distress towards medical procedures have opened the possibility of enhancing the child's coping strategies.42 Efforts to decrease the child's anxiety include establishing familiarity with the setting and communicating to the child in a friendly way what he or she can expect. The examiner should ask the caregiver if the child has expressed any worries or concerns, then anticipate age-appropriate anxieties associated with a visit to the doctor and address them with the child before the examination. For example, a 4-year-old may be worried about receiving a shot. Reassurance can go a long way toward reducing stress.
The examiner should also ask the whether the child has had a prior anogenital examination and how well the child has done during prior examinations. In addition, it is important to ask the child whether he or she wants a particular person to provide support during the examination.
The child should be told that the examiner's job is to understand what the child may have experienced and conduct a head-to-toe examination to make sure that his or her body is okay and to understand fully what may have happened. The children should be encouraged to let the examiner know about any worries and that he or she will have a chance to see a "listening doctor" (a psychologist) who will help, too. If the child is fearful of something happening again, reassurance should be provided. More specific strategies the examiner can use to assist the child in coping with what can be a stressful health care interaction are provided in the Sidebar (see page 386).48
CPS and Law Enforcement Involvement
When conducted appropriately, the medical examination should be therapeutic for the child. However, CPS and law enforcement, who may not understand the value of the examination, may think of it as traumatic to the child and therefore may be reluctant to refer anyone other than an acutely injured child. Steward et al.46 found that children were not traumatized by a colposcopie examination of the genital area and that the child's anxiety was lessened after completion of the examination.
Little data supports the idea that the examination is a form of revictimization to the child.43 An objective tool, the Genital Examination Distress Scale (GEDS), measures the emotional distress of a child during the anogenital component of the sexual abuse evaluation.44 The GEDS is used while the child undergoes the examination and may be useful to help compare different approaches to the examination.
Comparison of Abnormal Genital Findings in Children Referred for Possible Sexual Abuse
In addition, adolescents examined for concerns of sexual abuse with video colposcopy found a significant reduction in pre- and post-examination anxiety and generally viewed the examination as beneficial.49 Children usually respond well to the examination when someone talks with them about the purpose of the examination and what to expect during and after the evaluation.50
Use of Colposcopy in the Anogenital Examination
Colposcopy provides a noninvasive method for visualizing the anogenital structures and is a useful instrument for the detection and recording of genital injury.51 The colposcope also provides a means of generating excellent photographic documentation of the clinical findings. Technological advances allow the child to observe the genital examination via the videocolposcopy screen, demystifying the process and giving the child a sense of having more control over the situation.51 A study of children who underwent videocolposcopy found that children generally watched their evaluation and were cooperative and enthusiastic throughout the examination.52
Colposcopy provides magnification and an excellent light source that is helpful in identifying injuries while allowing a photograph or video to be taken simultaneously for documentation.51,53"55 Video images have advantages over still photography because the video allows for the easy viewing of the dynamic nature of the anogenital anatomy.56
Comparison of Abnormal Genital Findings in Children Referred for Possible Sexual Abuse
Documenting the Examination
Photography is an important component of documentation, memorializing findings that are diagnostic, allowing for expert consultation, and providing objective documentation should the examiner's interpretation of findings be challenged. If the interpretation of a finding is challenged and photographic documentation exists, the child will not need to undergo another examination; the challenging expert may simply review the documentation available. Experts can examine photographs after the examination is complete and render opinions for courtroom purposes. Photographic documentation also provides clinical case studies for the education of other clinicians.54
The technology underlying photography of injuries and genital anatomy is complex. Several types of camera systems work well to meet the standards needed for use of photos as evidence of the child's injuries.54 The experience of the examiner in photographing images can affect the quality of photographic documentation of examination findings.57'58 The examiner must take high-quality photographs that are clear, have adequate lighting, and include a planned composition of the parts of the body shown in the picture.56 The examiner documents any findings in the medical record, describing the findings in detail, and then supplements that documentation with photographs. Photographs must be taken of every injury, with a scale in the frame or with inclusion of anatomic landmarks to establish perspective. One overall image of the child to mark the beginning of the photographic set is recommended.
A camera attached to a colposcope allows for uncomplicated and predictable photo documentation without the potential intrusiveness of a handheld camera pointed at the child's genitalia. In additon, children who have experienced pornography may find the use of a handheld camera a disturbing reminder of one aspect of their victimization.
Digital photography is an excellent way to take photos and then transmit them to colleagues for peer review.59 The use of digitized images, however, should be considered only after consultation with law enforcement officials and prosecutors because they can be manipulated easily. Many digital cameras now have encrypting devices to prove whether the image has been altered or is the original.
If photographs must be shared because of legal mandates, it is important to maintain an unbroken chain of evidence and to have policies in place for handling the release of photographs.54,55 When pictures are kept in the medical records department of a hospital, precautions must be taken to prevent destruction of the pictures at microfilming.
The prepubertal hymen has a variety of orifice configurations, described as annular, crescentric, fimbriated, cribriform, or septate.51 The most common shapes of the hymenal orifice are crescentric and annular.59 The diameter of the hymenal orifice is easy to describe, while thickness and degree of elasticity are more difficult to quantify.
Estrogen affects the hymen, as it does all periurethral tissue. Maternal estrogen affects the appearance of the newborn hymen by causing a thick and redundant appearance.60 This effect changes after 2 to 3 months and then reappears again as the child approaches puberty. Estrogen creates a thicker and paler appearance to the hymen.61 The prepubertal, unestrogenized hymen has an appearance of involuted tissue and tends to appear more vascular and reddened.61
The appearance of the normal hymen in both prepubertal and postpubertal children is variable.62,63 Normal hymenal appearance varies; it can be thick and elastic or thin and nonelastic.64 The range of normal variants is wide, and the examination techniques and positioning of the child can affect what the examiner sees.65 Studies have found that both "normal"-appearing genital tissues and nonspecific findings are seen in children known to be sexually abused.66"68
The appearance of the hymen changes depending on the degree of relaxation of the child and the examination position. Prepubertal children can benefit from an examination of the hymen in both the supine frog-leg position and the knee-chest position. Although some children find the knee-chest position awkward, any "diagnostic" finding observed in the supine frog-leg position should be confirmed in the knee-chest position. The hymen may appear quite different in this position. Abnormal findings in the adolescent should be confirmed in the knee-chest position.
Optimal visualization of the hymen and the component parts of the external genitalia in girls requires the technique of labial separation and mild traction. The hymen and its orifice generally can be visualized with positioning and gentle traction only. Traction is applied by grasping the labia majora between the thumb and forefinger and gently applying traction downward and lateral, taking care to not induce injury.51,69
The hymenal membrane of the prepubertal child is innervated and can be sensitive to touch.51 Various techniques have been described to achieve gentle manipulation of the delicate hymenal tissues, including a moistened cotton applicator, an inflated foley catheter balloon, and warm saline irrigation to assist in fully visualizing the hymen.70,71 A vaginal speculum is used rarely with children who have not reached puberty.67 In prepubertal children, a speculum examination, if indicated, must be done under sedation or anesthesia and only as required. Indications include unexplained bleeding or other unusual findings that may need further evaluation. A nasal speculum typically is not helpful for the genital examination. Instead, an excellent light source, a gentle and sensitive manner during the examination, and careful observation will reveal the most findings.72
The Table (see page 388) compares the rates of abnormal examinations finding during sexual abuse evaluations that have been reported in 13 studies conducted during more than 2 decades of peer-reviewed literature. The genital examinations of children who have been sexually abused often are found to be either "normal" or "nonspecific."67,68,73 For example:
* Heger and colleagues68 evaluated 2,384 children for suspected sexual abuse and found that, overall, 96.3% had "normal" physical examinations. Most of the examinations with abnormal findings were among children sent to the referral center by their healthcare provider for evaluation of a suspected finding; only 8% of these had an "abnormal" examination. In other words, 92% of suspected abnormal exams were deemed normal when assessed by the expert team.
* Berenson et al.86 performed a casecontrolled study comparing 192 prepubertal girls with a history of being sexually abused to 200 girls thought not to be victims of sexual abuse. The study found examination results of abuse victims rarely differed from those of nonabused children.
* Kellogg et al.87 found that of 36 adolescents who were pregnant at the time of or shortly before a sexual abuse exam, 82% had a normal examination. Eleven percent were suggestive of abuse, and 7% were definitive for penetrating trauma.
As these results show, a lack of physical findings should not be seen as ruling out sexual abuse but rather as the finding in a given case at the time of the physical examination. The word "normal" does not mean that the child's examination does not support the concern that something inappropriate happened but rather reflects no anatomic sequelae from the contact. Three studies of the healing process in the anogenital area consistently have reported that most injuries resulting from sexual abuse heal relatively quickly.70,88,89 Injuries in sexual encounters may be fresh and visible to the examiner if the examination is done near to the time of the contact (typically thought to be within hours of the alleged contact). However, this is often not the case in episodes of sexual abuse because of the typical delayed disclosure of the sexual contact. In these children, it is the history of injury or discomfort that is important.
Other factors that contribute to the relative paucity of definitive physical findings in cases of sexual abuse include the types of sexual contact that the perpetrator may have engaged the child in during the abuse, the length of time between the occasions of abuse, the time between disclosure and subsequent presentation to the healthcare setting for evaluation, and the relatively rapid healing observed in the mucous membranes that comprise a child's anogenital tissues.35,68'89 Despite the expectation of few findings, a complete examination is necessary, as the child and family may have significant concerns about possible injury and findings that might suggest a nonsex-related condition.
The lack of physical findings also reinforces the need for a comprehensive healthcare evaluation that goes beyond the physical examination and forensic evidence collection. A comprehensive evaluation searches for other possible indicators of abuse, such as specific historical information, nonspecific physical complaints, and nonspecific behavioral complaints that are common in the setting of sexual victimization.90
Types of Injuries
When abnormal results are found during physical examination, the findings can involve the genitalia, anus, oral cavity, extragenital sites, or any combination of the above. Injuries that children incur can be described broadly as either primarily superficial (healing by regeneration of labile cells) or deep and penetrating (healing by repair by secondary intention). The appearance of any given injury is attributable primarily to the time between the last contact and when the examination is being conducted. The greater the time interval, the less likely the extent of the initial injury will be appreciated.
Also, because the anus can enlarge to large diameters to pass bowel movements, sequelae of penetration into the anal rectal canal are infrequent. If the perpetrator engages the child in anal penetration without force and with the use of lubrication, the potential for residual effects is minimal.
When children present with acute genital or anal trauma, however, the differential diagnosis is rather limited. The injuries are either accidental crush, impaling, or inflicted. Clearly, a child who has a witnessed fall on play equipment such as a jungle gym and presents with a unilateral crush injury of the labia is not a child whose clinical history would suggest sexual abuse. When a child presents with acute genital trauma, occasionally there will be a presenting history of accidental impalement. When this is the case, the history is paramount in determining whether an injury is accidental or inflicted, as the pattern of trauma may not be distinctive enough to differentiate. If accidental impalement is being considered, it is critically important for law enforcement to conduct a scene investigation to determine the plausibility of the explanation.
In prepubertal girls, the most common injuries are superficial abrasions of the inner aspects of the labia minora, the periurethral area, and the posterior four-chette. If an object such as a finger has penetrated through the hymenal orifice, an interruption of integrity of the hymenal edge may occur. This interruption or laceration may extend to the base of the attachment of the hymen to the posterior portion of the vagina, or may extend through the fosse navicularis and, in more serious blunt force trauma, onto the perineum.
When a child presents with significant blunt force penetrating trauma, it is best to complete the examination under anesthesia to identify intravaginal trauma. No congenital defects mimic a posterior transection of the hymen. If the child presents without acute injuries and a transection of the hymen is observed, the history should be focused on determining the etiology of this healed injury.
The adolescent patient presents a different set of diagnostic challenges. Some adolescents present with a long history of sexual victimization that began when they were prepubertal and has continued through puberty. Others present with either a disclosure of sexual abuse that began and progressed during adolescence or with an acute sexual assault.
When an adolescent presents for a nonacute examination with a history of vaginal penetration, it is less likely (when compared with the prepubertal child) that diagnostic findings will be present. This difference is due to the effect of estrogen on the hymen. The pubertal hymen is elastic and distensible as a result of estrogen; thus, it is more likely that the introduction of a foreign body into the vagina will not cause injury to the hymen.
Nonspecific findings such as erythema and vaginal discharge may be seen in either the prepubertal or pubertal child and must be correlated with the history. Superficial abrasions of the mucosa may be either nonspecific or specific, depending on whether the child's history details how he or she incurred the injury. Extragenital trauma is infrequent and reflects the use of force and restraint to engage the child in the activity. When extragenital trauma is present, oral, genital, or anal trauma is more likely to be present.
Children and adolescents may contract STDs as a result of inappropriate sexual contact. When a child has an STD, the working assumption is that the child had to have come in contact with infected genital secretions. Contact with infected secretions does not require genital-to-genital contact directly but may simply involve a perpetrator fondling a child with infected secretions on his or her hand. Vertical transmission must be considered in children younger than one. Guidelines for STD evaluation have been developed by the American Academy of Pediatrics (AAP)248 and the Centers for Disease Control and Prevention.91
FORENSIC EVIDENCE COLLECTION
Most pediatricians have limited experience collecting and preserving forensic evidence. Although the examining physician will only infrequently need to collect evidence, it is important to do so appropriately. Forensic evidence assists law enforcement in identifying perpetrators of a crime and is most important in rape and sexual assault cases. Most children and adolescents who experience sexual abuse can identify the alleged perpetrator, so forensic evidence may be less crucial in those cases.
The AAP recommends forensic evidence collection if the evaluation is within 72 hours of the sexual abuse.24 During that time period, the examination may focus on both the search for physical findings and the collection of forensic specimens that may still be present on or in the child's body, clothing, or other environmental materials, such as linens or upholstery. Because there is a lower probability of finding traces of forensic evidence when the abuse is suspected or known to have taken place more than 72 hours before the time of the physical examination, the focus shifts from forensic evidence collection to the identification of possible physical findings. This is based on experience with adult sexual assault victims and the likelihood of finding useful forensic evidence during those examinations. Christian et al.92 found that more than 90% of prepubertal children with positive forensic evidence found on their bodies were seen within 24 hours of the assault.
When there is reason to believe evidence of trace elements and seminal products may be present, the examiner uses a forensic evidence collection kit, sometimes called a "rape kit."62,92 It is essential that only practitioners who have experience in the collection and preservation of forensic evidence use a rape kit. Any evidence must be collected and packaged appropriately because it will be evaluated in a crime lab and may be used as evidence in legal proceedings. Training in forensic evidence collection typically is available via continuing medical education offerings at regional child abuse referral centers and at national pediatric meetings; best practice can be reinforced via reference texts.92
When conducting a forensic evaluation, it is important to collect the child's clothing and place it in a paper bag. If the child is not wearing the same clothing, instruct parents not to wash the clothes that were worn during the assault, and to store them in a paper bag, not plastic.
In 2000, Christian and colleagues93 evaluated forensic evidence in pre-pubertal victims of sexual assault. Forensic evidence was found for 25% of children, all of whom were evaluated within 44 hours of assault. Sixty-four percent of evidence was found on clothing and linens. However, only 35% of children in the study had their clothing collected for analysis. No swabs from a child's body were positive for blood after 13 hours or for semen after 9 hours.
We have learned much about the medical evaluation of suspected child sexual abuse during the past 2 decades. The physical examination still holds an important place in the evaluation but is secondary to a well-performed history. As the evolving literature increases our understanding, the relevance of various anatomic appearances of the prepubertal and pubertal genital examination will certainly become even clearer. The physical examination rarely is diagnostic by itself, with more than 92% of cases failing to demonstrate either acute or chronic signs of injury.68 Thus, the 1994 quote by Adams and colleagues,67 "It's normal to be normal," continues to ring true, now supported by a growing body of pediatric literature.
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Comparison of Abnormal Genital Findings in Children Referred for Possible Sexual Abuse
Comparison of Abnormal Genital Findings in Children Referred for Possible Sexual Abuse