Evaluating the Child for Sexual Abuse
Am Fam Physician. 2001 Mar 1;63(5):883-893.
Child victims of sexual abuse may present with physical findings that can include anogenital problems, enuresis or encopresis. Behavioral changes may involve sexual acting out, aggression, depression, eating disturbances and regression. Because the examination findings of most child victims of sexual abuse are within normal limits or are nonspecific, the child's statements are extremely important. The child's history as obtained by the physician may be admitted as evidence in court trials; therefore, complete documentation of questions and answers is critical. A careful history should be obtained and a thorough physical examination should be performed with documentation of all findings. When examining the child's genitalia, it is important that the physician be familiar with normal variants, nonspecific changes and diagnostic signs of sexual abuse. Judicious use of laboratory tests, along with appropriate therapy, should be individually tailored. Forensic evidence collection is indicated in certain cases. Referral for psychologic services is important because victims of abuse are more likely to have depression, anxiety disorders, behavioral problems and post-traumatic stress disorder.
It is estimated that by the age of 18, 12 to 25 percent of girls and 8 to 10 percent of boys have been victims of sexual abuse.1 With this high prevalence, it is likely that primary care physicians will encounter child victims of abuse in their practice. Because the diagnosis of sexual abuse often has significant psychologic, social and legal ramifications, evaluating children who allegedly have been sexually abused can be anxiety provoking for physicians, as well as for patients and their families. It is important that the physician be knowledgeable about the basic evaluation of children for sexual abuse and cognizant of the resources available in the community.
Definition
Sexual abuse is defined as any sexual activity that a child cannot comprehend or give consent to, or that violates the law.2 The sexual activity may include fondling, oral-genital, genital and anal contact, as well as exhibitionism, voyeurism and exposure to pornography. Sexual abuse must be differentiated from “sexual play” or age-appropriate behavior. In sexual play, the developmental level of the participants should be similar, and the activity should occur without coercion. For example, preschool children viewing each other's genitalia without force is considered to be “normal,” while a developmentally more mature child engaging a young child in sexual behavior warrants investigation. Perpetrators may be relatives or nonrelatives and are most frequently male.3 Adolescent perpetrators are not uncommon, and many have a personal history of sexual and/or physical abuse.4
Presentation
Concern about possible sexual abuse should be raised when children exhibit behavioral changes or have anogenital or other medical problems. Behavioral changes include sexual acting out, aggression, problems in school, regression (e.g., return to thumb sucking, use of a security blanket), sleep disturbances, depression and eating disturbances. Sexual acting-out behavior is the most specific indicator of possible sexual abuse.5 Medical problems include anogenital trauma, bleeding, irritation or discharge, dysuria, frequent urinary tract infections, encopresis, enuresis (especially after continence has been achieved), pregnancy, diagnosis of a sexually transmitted disease (STD) and oral trauma. Children may present with somatic complaints such as recurrent abdominal pain or frequent headaches resulting from the psychologic stress.
Interviewing the Child
Even in legally confirmed cases of sexual abuse, most children do not have physical findings diagnostic of sexual abuse. Therefore, the child's disclosure is often the most important piece of information in determining the likelihood of abuse. Investigative interviewing should be performed by the appropriate agencies and, if possible, by forensic interviewers. In addition, physicians should ask questions relevant to medical diagnosis and treatment. The child should be interviewed, preferably alone, using open-ended questions such as “Has anyone ever touched you in a way that you didn't like or in a way that made you feel uncomfortable?” It is important to keep a neutral tone of voice and manner when the child responds and to ask the child to elaborate in a nonleading manner. The medical interview may be admissible in court as an exception to hearsay; thus, careful documentation of questions and responses is critical. Questions and answers should be recorded verbatim.6
Physical Examination
The physician should maintain a gentle and calm demeanor and be considerate of the apprehensive child. It is helpful to explain the examination beforehand to the patient and caretaker. A complete physical examination, including careful documentation of any lacerations, ecchymoses or petechiae, is critical. Physical examination of the oral cavity includes inspection of the hard and soft palate for bruising or petechiae, and inspection of the frenulum for any lacerations that can result from forced oral penetration.
If the sexual assault has occurred within 72 hours of the physical examination, forensic evidence collection should be conducted. Rape evidence collection kits are available in the emergency department of most hospitals. Evaluation of acute sexual assault may be conducted in an emergency department setting or, if available, at a children's advocacy center. In nonacute cases, the office of the family physician has the benefit of being a familiar location for the patient.
Magnification and illumination are essential when examining the genitalia. An otoscope or, if available, a colposcope can be used. Demonstration of the instruments before use can be helpful in alleviating a child's fears about the examination. Colposcopy allows enhanced illumination and magnification as well as photographic documentation. If photographic documentation is unavailable, diagrams can be used to illustrate abnormalities.
PHYSICAL EXAMINATION OF PREPUBERTAL AND PUBERTAL GIRLS
Examination of the genitalia of the prepubertal girl is best performed with the child in the frog-leg, frog-leg while sitting on caretaker's lap or prone knee-chest position (Figures 1a,1b and 1c). In the frog-leg position, the child is supine with the knees apart. If the child is anxious, the examination may be performed while the child is sitting on the caretaker's lap. In the knee-chest position, the child is prone, with knees, chest and head in contact with the table, and the back is in lordosis. It is necessary to perform an examination in the prone knee-chest position to confirm or exclude abnormalities of the posterior aspect of the hymen.7 Pubertal girls can be examined in the lithotomy position.
FIGURE 1A.
Frog-leg position for examination of the external genitalia.
FIGURE 1B.
Frog-leg position with patient on caretaker's lap.
FIGURE 1C.
Prone knee-chest examination position.
Because the examination position can influence findings, it is important to document the position in which the child was examined.8 The use of labial traction can greatly enhance visualization of the hymen. The labia majora are gently retracted between the thumb and forefinger with force applied downward and outward (Figure 2). When performing the anogenital examination, it is important to be familiar with pre-pubertal anatomy and normal variants. The most common hymenal configurations are crescentic, annular, cuff-like, septate (Figures 3a,3b,3c and 3d) and fimbriated.
FIGURE 2.
Changes in the examination position can affect the appearance of the hymen. (Top) An 11-year-old girl examined in the supine frog-leg position. (Bottom) The same child examined in the prone knee-chest position. Note that the irregularities resolve in the knee-chest position.
FIGURE 3.
Normal variants of the hymen: (A) crescentic, (B) annular/cuff, (C) collar/cuff-like, (D) septate.
Locations of abnormalities should be described as on a clock face with the urethra in the 12-o'clock position and the anus at the 6-o'clock position. In prepubertal girls, use of the speculum is reserved for unexplained bleeding and may require an examination with sedation. In pubertal girls, estrogen causes the hymenal tissue to become thicker and more compliant; therefore, detection of trauma can be more challenging (Figure 4). The use of a moistened cotton swab to gently move the hymen may be helpful in viewing all aspects of a fimbriated or redundant hymen. Another method of improving visualization of the pubertal hymen requires the use of a Foley catheter. The catheter is inserted into the vagina, the balloon is inflated and, with mild retraction, the hymen is stretched (Figure 5).
FIGURE 4.
Estrogen changes the appearance of the hymen. (Left) Annular hymen in a prepubertal girl. (Right) Annular hymen in a pubertal girl.
FIGURE 5.
Foley catheter technique for examination of the pubertal hymen. A Foley catheter is inserted, the balloon is inflated and slight retraction is given. This method allows better visualization of the redundant areas of the hymen.
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