Interpretation of medical findings in suspected child sexual abuse: An update for 2023.

Health care professionals who examine children who may have been sexually abused need to be able to recognize, and photo-document any physical signs, and to have access to expert reviewers, particularly when signs concerning for sexual abuse are found. Although the general consensus among practitioners is that children will show few signs of sexual abuse on examination, there is considerable variability and rates of positive exam findings among practitioners of different professions, practice settings, and countries. This review will summarize new data and recommendations regarding the interpretation of medical findings and sexually transmitted infections (STIs); assessment and management of pediatric patients presenting with suspected sexual abuse or assault; and testing and treating patients for STIs. Updates to a table listing an approach to the interpretation of medical findings are presented, and reasons for changes are discussed.

Descripción del abuso sexual pediátrico a partir de hallazgos del examen físico / Description of pediatric sexual abuse based on physical exam findings

La comprensión de la frecuencia y el significado de diversos hallazgos médicos en niños sometidos a abuso sexual se modificaron con el tiempo. Antes de 1989, se pensaba que diversas variaciones en la apariencia de los tejidos genitales y anales se debían al abuso. Los estudios que describen en detalle la apariencia de los tejidos anales en niños seleccionados como no sometidos a abuso en 1989 y los hallazgos genitales en niñas no sometidas a abuso en 1990, mostraron que muchas de estas variaciones también se observaron en niños que no habían experimentado abuso. Las más comunes de estas variaciones se incluyeron en una lista de hallazgos anogenitales que también comprendían signos conocidos de lesiones agudas e infecciones de transmisión sexual, así como otros hallazgos físicos y de laboratorio cuya importancia con respecto al abuso se desconocía. Esta lista evolucionó a medida que se publicaban nuevos estudios y se procuraba llegar a un consenso entre los expertos en la evaluación del abuso sexual en niños en cuanto a la forma en que debían interpretarse los hallazgos de los exámenes médicos adicionales. La tabla de "interpretación de los resultados" evolucionó durante los 26 años siguientes, y la más reciente se publicó en 2018. Todavía hay hallazgos, en junio de 2020, respecto de los cuales no hay consenso entre los expertos en cuanto a cómo deben interpretarse en un niño evaluado por presunción de abuso sexual. Deberán revisarse los antecedentes de los cambios en la interpretación de los hallazgos genitales y perianales en niños con presunción de abuso sexual.

The understanding of the frequency and significance of various medical findings in sexually abused children has changed over time. Before 1989, several variations in the appearance of genital and anal tissues were thought to be due to abuse. Studies describing in detail the appearance of anal tissues in children selected for non-abuse in 1989, and genital findings in non-abused girls in 1990, showed that many of these variations were seen non-abused children as well. The most common of these variations were included in a listing of anogenital findings that also included known signs of acute injury and sexually transmitted infections, as well as other physical and laboratory findings for which the significance with respect to abuse was unknown. This listing evolved as new studies were published and efforts were made to reach consensus among experts in child sexual abuse evaluation as to how additional medical examination findings should be interpreted. The "Interpretation of Findings" table evolved over the next 26 years, with the most recent being published in 2018. There are still findings, as of June, 2020, for which no expert consensus exists as to how they should be interpreted in a child who is being evaluated for suspected sexual abuse. The history of the changes in the interpretation of genital and perianal findings in children with suspected sexual abuse will be reviewed.

Sexual Abuse in Children: What the General Practice Ob/Gyn Needs to Know.

The medical evaluation of a child who may have been sexually abused can be a challenge for physicians who are unfamiliar with the wide variation in normal genital anatomy in prepubertal girls. Signs of injury are rarely found, unless the child is examined within 72 hours of the event. This article will provide some history about how guidelines for medical care of these children have been developed, and list some of the findings that are normal or normal variants, caused by other conditions, or due to trauma or infection.

Interpretation of Medical Findings in Suspected Child Sexual Abuse: An Update for 2018.

Most sexually abused children will not have signs of genital or anal injury, especially when examined nonacutely. A recent study reported that only 2.2% (26 of 1160) of sexually abused girls examined nonacutely had diagnostic physical findings, whereas among those examined acutely, the prevalence of injuries was 21.4% (73 of 340). It is important for health care professionals who examine children who might have been sexually abused to be able to recognize and interpret any physical signs or laboratory results that might be found. In this review we summarize new data and recommendations concerning documentation of medical examinations, testing for sexually transmitted infections, interpretation of lesions caused by human papillomavirus and herpes simplex virus in children, and interpretation of physical examination findings. Updates to a table listing an approach to the interpretation of medical findings is presented, and reasons for changes are discussed.

Understanding Medical Findings in Child Sexual Abuse: An Update For 2018.

When child sexual abuse is suspected, it is important for medical professionals to understand normal as well as abnormal features of the external genital and anal tissues in children. Physicians and other healthcare professionals who rarely perform a detailed examination of these areas may mistakenly interpret normal findings, or findings caused by conditions unrelated to abuse, as signs of injury due to sexual abuse. For this reason, it is important for all medical professionals to have a basic understanding of the appearance of the genital and anal tissues in children. Examples of normal and abnormal genital and anal findings are provided via annotated images. This review presents a research-based summary of how medical findings in children should be interpreted with respect to possible sexual abuse. Resources for obtaining expert review of medical findings are described.

Updated Guidelines for the Medical Assessment and Care of Children Who May Have Been Sexually Abused.

The medical evaluation is an important part of the clinical and legal process when child sexual abuse is suspected. Practitioners who examine children need to be up to date on current recommendations regarding when, how, and by whom these evaluations should be conducted, as well as how the medical findings should be interpreted. A previously published article on guidelines for medical care for sexually abused children has been widely used by physicians, nurses, and nurse practitioners to inform practice guidelines in this field. Since 2007, when the article was published, new research has suggested changes in some of the guidelines and in the table that lists medical and laboratory findings in children evaluated for suspected sexual abuse and suggests how these findings should be interpreted with respect to sexual abuse. A group of specialists in child abuse pediatrics met in person and via online communication from 2011 through 2014 to review published research as well as recommendations from the Centers for Disease Control and Prevention and the American Academy of Pediatrics and to reach consensus on if and how the guidelines and approach to interpretation table should be updated. The revisions are based, when possible, on data from well-designed, unbiased studies published in high-ranking, peer-reviewed, scientific journals that were reviewed and vetted by the authors. When such studies were not available, recommendations were based on expert consensus.

Anal findings in children with and without probable anal penetration: a retrospective study of 1115 children referred for suspected sexual abuse.

Interpreting the significance of anal findings in child sexual abuse can be difficult. The aim of this study is to compare the frequency of anal features between children with and without anal penetration. This is a retrospective blinded review of consecutive charts of children seen for suspected sexual abuse at a regional referral center from January 1. 2005 to December 31. 2009 Based on predetermined criteria, children were classified into two groups: low or high probability of anal penetration. The charts of 1115 children were included, 84% girls and 16% boys with an age range from 0.17 to 18.83 years (mean 9.20 year). 198 children (17.8%) were classified as belonging to the anal penetration group. Bivariate analysis showed a significant positive association between the following features and anal penetration: Anal soiling (p=0.046), fissure (p=0.000), laceration (p=0.000) and total anal dilatation (p=0.000). Logistic regression analysis and stratification analysis confirmed a positive association of soiling, anal lacerations and anal fissures with anal penetration. Total anal dilation was significantly correlated with a history of anal penetration in girls, in children examined in the prone knee chest position and in children without anal symptoms. Several variables were found to be significantly associated with anal penetration, including the controversial finding of total anal dilatation. Due to limitations in the study design, this finding should still be interpreted with caution in the absence of a clear disclosure from the child.

Diagnostic accuracy in child sexual abuse medical evaluation: role of experience, training, and expert case review.

OBJECTIVES: (1) The purpose of this study was to assess the ability of clinicians who examine children for suspected sexual abuse to recognize and interpret normal and abnormal ano-genital findings in magnified photographs using an online survey format. (2) Determine which factors in education, clinical practice, and case review correlate with correct responses to the survey questions. METHODS: Between July and December 2007, medical professionals participated in a web-based survey. Participants answered questions regarding their professional background, education, clinical experience, and participation in case review. After viewing photographs and clinical information from 20 cases, participants answered 41 questions regarding diagnosis and medical knowledge. Answers chosen by an expert panel were used as the correct answers for the survey. RESULTS: The mean number of correct answers among the 141 first-time survey respondents was 31.6 (SD 5.9, range 15-41). Child Abuse Pediatricians (CAP) had mean total scores which were significantly higher than Pediatricians (Ped) (34.8 vs. 30.1, p<0.05) and Sexual Assault Nurse Examiners (SANE) (34.8 vs. 29.3, p<0.05). The mean total scores for Ped, SANE, and Advanced Practice Nurses (APN) who examine fewer than 5 children monthly for possible CSA were all below 30. Total score was directly correlated with the number of examinations performed monthly (p=0.003). In multivariable regression analysis, higher total score was associated with self-identification as a CAP, reading The Quarterly Update newsletter (p<0.0001), and with quarterly or more frequent expert case reviews using photo-documentation (p=0.0008). CONCLUSIONS: Child Abuse Pediatricians, examiners who perform many CSA examinations on a regular basis, examiners who regularly review cases with an expert, and examiners who keep up to date with current research have higher total scores in this survey, suggesting greater knowledge and competence in interpreting medical and laboratory findings in children with CSA. Review of cases with an expert in CSA medical evaluation and staying up to date with the CSA literature are encouraged for non-specialist clinicians who examine fewer than 5 children monthly for suspected sexual abuse.

Medical evaluation of suspected child sexual abuse: 2011 update.

The medical evaluation of children with suspected sexual abuse includes more than just the physical examination of the child. The importance of taking a detailed medical history from the parents and a history from the child about physical sensations following sexual contact has been emphasized in other articles in the medical literature. The examination is important, however, and medical providers who examine children need to be aware of published research on findings in nonabused children, studies of healing of injuries, and studies documenting the association between sexual contact and the diagnosis of sexually transmissible infections in children. This article reviews the current approach to interpreting findings in children who may have been sexually abused and why additional research is needed.

Links between sisters' sexual and dating victimization: the roles of neighborhood crime and parental controls.

This study examined the extent to which a sister's prior sexual and dating victimization is a risk factor for young women being similarly victimized and the possible factors underlying a co-occurrence. The sample involved 122 young adult Latina or African American sister pairs (244 women; ages 16-25) who resided in low-income, urban neighborhoods. Results indicated that women whose sisters had been victimized had increased risk of victimization even after controlling for neighborhood crime, parental controls, age and race-ethnicity (odds ratios were 4.0 for unwanted touching, 6.2 for a forced sex act, and 16.7 for dating violence). In high-crime neighborhoods, the presence of two adult parent figures in the home was associated with women's reduced likelihood of unwanted touching, and mothers' high monitoring during adolescence was associated with women's lower risk of dating aggression. Survival analysis results showed that the risk period of a second sister being victimized lasts between 7 and 10 years after a first sister's victimization. The prevention implications of study findings are discussed.

Changes in genital anatomy and microbiology in girls between age 6 and age 12 years: a longitudinal study.

STUDY OBJECTIVE: To study changes in genital anatomy and occurrence of human papillomavirus and Gardnerella vaginalis in girls resulting from growth and development. DESIGN: At age 11-12 years, an invitation was sent to 180 girls to attend a follow-up examination. All girls had previously participated in a study exploring anogenital anatomy and microbiology in children selected for non-abuse at age 5 and 6. The genital area was examined with a colposcope and microbiological samples for Gardnerella vaginalis (GV) and human papillomavirus (HPV) were collected. GV was identified by conventional criteria and HPV by a PCR method. RESULTS: Thirty-one girls were examined twice, at mean age 5.7 and 12.0 years. At first examination all were pre-pubertal. At second examination 21 girls were B2/P2 or above. Significantly more girls had developed a structure called a fossa groove. A thick and redundant hymen with a tendency of folding outward was more common at the second examination. Two girls had GV and one girl had HPV-16 identified. Another girl was classified to have a deep notch and a probable transection in her hymen, and this girl reported a painful insertion of a tampon. All girls denied sexual activity. CONCLUSION: The main genital finding in girls entering puberty is the hymen becoming thick and redundant with a tendency of folding out. In the study findings associated with sexual activity were discovered in two girls, and the possibility of alternative explanations is discussed.

Guidelines for medical care of children evaluated for suspected sexual abuse: an update for 2008.

PURPOSE OF REVIEW: Child sexual abuse is a common problem in our society and medical professionals who provide evaluations of children who may have been abused need to be updated as to recent research findings and recommendations for conducting examinations and interpreting results. RECENT FINDINGS: Research studies have provided important new information regarding the qualifications of examiners, the recovery of forensic evidence in children, the frequency of abnormal findings in children and adolescents, the healing of genital injuries, and the interpretation of medical findings and sexually transmissible infections with respect to abuse. SUMMARY: The recommendations for the timing and type of examinations for prepubertal children, in contrast to adolescent sexual assault victims, may need to be changed. Studies showing that partial tears of the hymen, as well as abrasions and contusions, may heal to leave very little or no sign of previous injury emphasize the importance of urgent evaluations. There is a need for standardization of the training of medical professionals who perform child sexual abuse evaluations to ensure continuing competence.

Guidelines for medical care of children who may have been sexually abused.

BACKGROUND: Children who may have been sexually abused are examined in many different settings by medical providers with variable levels of education and experience in this special area of practice. Therefore, there is a need for a consistent evidence-based approach that is agreed upon by medical experts. OBJECTIVES: To develop and provide guidelines and recommendations for performing and interpreting findings of the medical evaluation of children referred for sexual abuse medical evaluations, and to provide guidelines for the education, oversight, and peer review process for clinicians who provide assessments for suspected child sexual abuse. METHODS: Participation from medical providers was solicited through postings on the Internet list-serves administered by Cornell University (Special Interest Group in Child Abuse), and by the Ray E. Helfer Society, an honorary society for physician specialists in child abuse diagnosis and treatment. The guidelines were developed through review and critique of published research studies, discussions in focus group meetings at child abuse medical conferences, and ongoing communication leading to revision of draft documents. RESULTS: Groups of 10 to 40 physician experts met at child abuse conferences between January 2002 and January 2005 to revise the table summarizing the interpretation of physical and laboratory findings in suspected child sexual abuse and to develop guidelines for medical care for sexually abused children. Between January and December 2005, the guidelines were expanded and revised. CONCLUSIONS: The guidelines presented here reflect the current knowledge, recommended clinical approaches, and required competencies in the field of child sexual abuse medical evaluation.

Differences in hymenal morphology between adolescent girls with and without a history of consensual sexual intercourse.

OBJECTIVE: To compare the morphology of the hymen in adolescent girls who have and have not had sexual intercourse involving penile-vaginal penetration. SUBJECTS: Female patients aged 13 to 19 years, recruited from an urban adolescent medicine practice. METHODS: Subjects were interviewed in private after completing detailed questionnaires and then underwent a physical examination. External genital inspections were performed using a colposcope with an attached 35-mm camera to document the appearance of the hymen. The presence of notches or clefts was recorded during the examination, and photographs taken at x10 magnification were used to take measurements of the width of the posterior hymenal rim. RESULTS: Posterior hymenal notches and clefts were more common among girls admitting past intercourse (13/27 [48%]) than in girls who denied intercourse (2/58 [3%]; P =.001), but the mean width of the posterior hymenal rim was not significantly different between the 2 groups (2.5 mm vs 3.0 mm; P =.11). Two subjects who denied intercourse but had posterior hymenal clefts described a painful first experience with tampon insertion. CONCLUSIONS: Deep notches or complete clefts in the posterior rim of the hymen were rare in girls who denied intercourse. Subjects who admitted past intercourse still had nondisrupted, intact hymens in 52% of cases.