CM E

Evaluating
Child Sexual Abuse
A complete medical history and careful physical examination
are critical to both identification and investigation.

S
exual abuse affects approximately 100,000 children each year in the
United States.1 Although the sexual abuse of children has been rec-
ognized 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 rec-
ommendations related to the evaluation of
child sexual abuse, so pediatricians are
expected, at a minimum, to be able to
screen children competently and refer chil-
dren and families appropriately for neces-
sary abuse evaluations.5,9,10

Angelo P Giardino, MD, PhD; and Martin A Finkel, DO

Dr. Giardino is medical director, Texas Children’s Health Plan, Houston, TX. Dr. Finkel is profes-
sor and co-director, New Jersey Child Abuse Research Education and Service Institute, University
of Medicine and Dentistry of New Jersey School of Osteopathic Medicine, Stratford, NJ .
Address reprint requests to: Texas Children’s Health Plan, PO Box 301011, Mail Stop-NB-8391,
Houston, TX 77230-1011; or e-mail apgiardi@texaschildrenshospital.org.
The authors have no industry relationships to disclose.

382 PEDIATRIC ANNALS 34:5 | MAY 2005

 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 comprehen-
sive evaluation that is critical to protect-
ing children when abuse allegations arise.
This evaluation provides valuable infor-
mation for children, their caregivers, and
the agencies that investigate statutorily.
A distinction exists between the
healthcare evaluation completed by the
pediatrician and the investigation com-
pleted by law enforcement or the
child protective services di-
visions of state human
services departments.11
A pediatrician has spe-
cialized training in
medical evaluation
and is trusted by
the child and fam-
ily.12 The child and fam-
ily should see the pe-
diatrician as working
with them to identify
medical conditions, provide
treatment modalities, and
address health and wellness
issues, including
PEDIATRIC ANNALS 34:5 | MAY 2005
those stemming from the abuse.11,13 EDUCATIONAL OBJECTIVES
Skilled medical evaluations may provide 1. Explain the importance of
considerable valuable information to the a complete evaluation for
investigative process. suspected child sexual abuse
within the context of legal
Investigators, in contrast, come from
investigations into allegation.
disciplines and agencies mandated by
2. Review the essential connection
laws and regulations to explore allega-
between a well-done history
tions of suspected maltreatment.14,15CPS, and the physical examination for
staffed by caseworkers typically trained suspected child sexual abuse.
in social work, plays an important role in 3. Discuss the value of the physi-
the investigation of child abuse, focusing cal examination in the suspect-
on the family’s functioning and ability ed child sexual abuse evalua-
tion in view of data that confirm
to protect the child. CPS agencies pro- genital findings typically are not
vide necessary social support services to found on such examinations.
families in need and ultimately may
need to remove children
from care-
giving envi-
ronments
determined to
be unsafe. Law
enforcement
officers, on the
other hand, de-
termine whether
or not a crime has
been committed and
begin appropriate legal
action toward holding
the abuser respon-
sible for his
383
or her actions.16,17 These two types of
agencies ideally operate hand-in-hand.18
Pediatricians may participate in com-
munity-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 im-
portance of medical evaluations. To com-
plete a thorough medical evaluation and
contribute effectively, the pediatrician
must understand the com-
ponents of the healthcare
evaluation: the ever-in-
creasing value of the his-
tory, the limitations of
the physical examina-
tion, 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 evolv-
ing literature surrounding anogeni-
tal physical findings in children,
both abused and nonabused.
MEDICAL HISTORY
Any discussion of the
physical examination in the evalua-
tion of cases of suspected child sexual
abuse should be linked intrinsically to
a discussion of the history-taking pro-
cess. 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 exami-
nation process, as well as to the entire
diagnostic process.19
However, obtaining a medical history
when sexual abuse is suspected is not sim-
ple. Talking to children who may have ex-
384
perienced 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 his-
tory must be thorough, well-documented,
and able to withstand scrutiny in an ad-
versarial environment.
Child sexual abuse is very differ-
ent from the sexual assault of an adult.
Most children who are engaged in sex-
ual activities participate without the use
of physical force and
restraint. The alleged
perpetrator generally
has little intent to
Talking to children who may have experienced
sexually inappropriate behavior is not intuitive
and requires a special set of skills.
harm the child
physically
because of a
desire to re-
engage 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 chil-
dren present with either acute or healed
diagnostic physical findings. Thus, the
medical history becomes even more piv-
otal to the clinical evaluation and, ulti-
mately, 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 caregiv-
er’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 physi-
cal examination.11 Key information that
can be obtained from the adult accompa-
nying 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 par-
ents play in the child’s life.
Once this information and any addi-
tional details are obtained, the pediatri-
cian 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 inap-
propriate activities. These may involve
physical noncontact such as exposure
to pornography, being photographed
for pornography, or being coerced into
PEDIATRIC ANNALS 34:5 | MAY 2005
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 intru-
sive 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 some-
one has put something inside of them.
For example, when a 6-year-old child
states, “He put his pee-pee in my pee-
pee,” she may be expressing a perceived
experience accurately. A parent might
interpret that statement as vaginal pen-
etration, 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 penetra-
tion. 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 tis-
sues, 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 Be-
cause stigma and shame so commonly
accompany sexual victimization, chil-
PEDIATRIC ANNALS 34:5 | MAY 2005
dren are reluctant to share details of their
experience. Threats and intimidation by
the abuser, as well as a sense of culpabil-
ity on the part of the child, may contrib-
ute to the difficulties associated with a
full disclosure.
The history typically is taken in a pri-
vate, 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 ex-
perience and frequently will provide
idiosyncratic details that are age-appro-
priate 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, sug-
gestibility 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 informa-
tion 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 in-
terviewer 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). Ex-
amples that might be used in the child
sexual abuse evaluation include “What
brings you here today?” or “What hap-
pened?” Follow-up, open-ended ques-
tions such as “Tell me more” or “Then
what happened?” are recommended and
should be used until the child has noth-
ing 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 particu-
larly difficult for children because they
may think that they have to choose an
option, even if none applies.21 If a mul-
tiple-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 bath-
room, or somewhere else?” is a better
option, although not ideal. The prefer-
able question is always one that is open-
ended and becomes more directed based
on the child’s response. Rather than sug-
gest a place where a sexually inappropri-
ate 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 impres-
sionable child, who typically wants to
please a respected adult.25 Questions with
negatives (eg, “Did you not see the wom-
an 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 nega-
385
 SIDEBAR. their skills with this aspect of the physi-
cal examination identified their under-
Strategies to Assist Children During the standing of anatomical variants as prob-
Sexual Abuse Examination lematic in distinguishing normal from
1. Help the child acclimate to the environment by providing play time in another area while abnormal exams. Pediatric residents
taking the history from the adult who has accompanied the child.
reported they relied on the supervising
2. Provide a calm and unhurried approach to the history and physical examination.
physician for guidance in differentiating
3. Whenever possible, provide choices for the child. Choices give the child a sense of power and normal from abnormal prepubertal fe-
control that was absent during victimization. Choices may be as simple as where to sit, what
gown to wear, who they want present, and offering the opportunity to watch the examination
male genital examinations. Both studies
on a video monitor. concluded with a call for strengthened
4. Talk about less-threatening subjects with the child, such as asking about likes and dislikes, training in genital examination.30,31
before addressing the issues at hand. Remember that children are likely to avoid topics that Two studies using surveys of fam-
cause discomfort. Only when the trauma that a child may have experienced is addressed will ily practitioners, pediatricians, and sur-
there be an opportunity for the child to put the experience to rest.
geons demonstrated physician difficulty
5. Allow older children to participate throughout the examination so as to impart a sense of in correctly labeling and identifying ba-
control.
sic genital structures on a photograph of
6. Whenever possible, use the child’s descriptive words and do not introduce age-inappropriate
a prepubertal child’s genitalia.32,33 The
language that the child may misunderstand or misinterpret. Most children simply want to
know if their body is okay. If they were previously injured, knowing that their injury has healed hymen was correctly labeled 59% and
and that their body is fine is sufficient for most children. Adolescents may need to be assured 62% of the time in the respective studies.
that their experience will not, from a medical perspective, affect their ability to have children In a follow-up survey of pediatric chief
when older or to have appropriate consensual sexual interactions.
residents to determine how accurately
a group of recently trained physicians
tives.26 When asked the question without process, the clinician must remain non- could identify and label prepubertal
the negative, the correct responses in- judgmental, empathetic, and facilitating. genital structures on two photographs,
creased to between 70% and 100%. the hymen was correctly identified 64%
From a developmental perspective, PHYSICAL EXAMINATION of the time.34
simple words and simple questions An inability to identify basic anato-
should be the rule. Between ages 1 and Education and Training my on a photograph calls into question
6, children may acquire five to eight new A 1982 study looking at the examina- the ability of physicians to identify and
words per day, often from a single ex- tion of genitalia in children referred to interpret accurately findings related to
posure to a word.23,27,28 This means chil- the failure to include the genital exami- sexual abuse or to other, nonabusive
dren have a large vocabulary before they nation routinely in the pediatric physical causes. While the outcome of child sex-
understand the meaning of the words examination as the “the remaining taboo ual abuse evaluation depends primarily
fully.25 Additionally, more than 60% of in pediatrics.”30 In that study, physicians on a child’s disclosed detailed history,
children’s responses to multipart ques- examined the child’s ears, heart, and the physical examination is important
tions such as “Where did he touch you abdomen more than 97% of the time and needs to be completed competent-
and with what did he touch you?” may regardless of age or sex, whereas male ly.35,36 At its most basic level, a compe-
not be accurate.29 Multipart questions genitalia were examined 84% of the tent physical examination begins with
can be confusing and difficult to remem- time and female genitalia only 39% of the ability of the examiner to identify
ber for the child. Simple questions such the time. Overall, female genitalia were anatomic structures correctly.37,38
as “Can you tell me about the first thing examined half as frequently as male A 1997 survey evaluated physician
that happened that was not okay?” are genitalia at all ages. agreement about female genital exami-
comfortable for children. In a study of clinicians’ perspectives nation findings. Physicians of varying
Whenever possible, the clinician on the prepubertal female genital exami- experience levels who rated themselves
should ask the child to explain how he or nation, clinicians (including both pedi- as skilled at evaluating children with
she felt during a sexually inappropriate atric residents and attending physicians) suspected sexual abuse were compared
experience, thoughts following the inter- reported that the female genital exami- with an expert physician panel.39 Find-
action, what was said, and how he or she nation was important and should be rou- ings demonstrated assessments often
responded. Throughout the history-taking tine.31 Clinicians who were uncertain of differed, with the most experienced phy-

386 PEDIATRIC ANNALS 34:5 | MAY 2005

sicians having the closest opinions to
those of the expert panel. A related study
evaluated whether clinical histories in-
fluenced 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 sug-
Studies of children have shown that the fear
associated with a genital examination is greater
than that associated with a regular office visit.
gestive, probable, or definitive for sexual
abuse. The majority of the children had
nonspecific examination findings; chil-
dren without a disclosure or suspicion
of sexual abuse were unlikely to have
anogenital examination findings sug-
gestive of abuse. The authors attributed
the majority of physician referrals (for
what turned out to be normal anatomic
variants) to a lack of widespread knowl-
edge and familiarity with normal genital
anatomy. The study suggested physi-
cians evaluating children for anogenital
symptoms and signs should generate dif-
ferential diagnoses that consider alterna-
tive 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 un-
comfortable in a technical, adult-orient-
ed environment.42 In cases of abuse, the
PEDIATRIC ANNALS 34:5 | MAY 2005
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 geni-
tal 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 trau-
matic when performed in a
controlled setting by provid-
ers who are experienced
and support the child
psychologically.46,47
Healthcare pro-
viders 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 commu-
nicating 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 as-
sociated 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 ano-
genital examination and how well the
child has done during prior examina-
tions. In addition, it is important to ask
the child whether he or she wants a par-
ticular person to provide support during
the examination.
The child should be told that the ex-
aminer’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 chil-
dren 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, re-
assurance should be
provided. More spe-
cific 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 thera-
peutic for the child. However, CPS and
law enforcement, who may not under-
stand the value of the examination, may
think of it as traumatic to the child and
therefore may be reluctant to refer any-
one other than an acutely injured child.
Steward et al.46 found that children were
not traumatized by a colposcopic exami-
nation of the genital area and that the
child’s anxiety was lessened after com-
pletion of the examination.
Little data supports the idea that the
examination is a form of revictimiza-
tion to the child.43 An objective tool,
387
 TABLE 1.
Comparison of Abnormal Genital Findings in Children Referred for Possible Sexual Abuse
Investigator Orr74 Teixeria75 Rimsza*76 Cantwell†77 Emans‡78 Hobbs & Dubowitz††80
Wynne**79
Year 1979 1981 1982 1983 1987 1987 1992
Number 100 33 311 83 119 337 99
girls = 86 girls = 33 girls = 268 girls girls girls = 243 girls = 82
boys = 14 boys = 43 boys = 94 boys = 17
Age (years) Younger Younger Younger Younger Younger Younger Younger
than 16 than 10 than 18 than 13 than 15 than 15 than 12
mean 9.2 mean 9.2 mean 5.6 mean 8.0 mean 6.0
Findings (%) Boys Girls
Normal/nonspecific 77% 85% 39% 16% 70% 17% 42% 62%
Suspicious/abnormal 23% 15% 61% 84% 30% 83% 58% 38%
Vaginal (total)
Normal/nonspecific 65% 85% 39% 16% 70% 42% 62%
Suspicious/suggestive 55% 16% 84% 10%
Definitive 35% 15% 48% N/A 30% 58% 28%
(penetration) (penetration) (penetration) (6% trauma)
Anal (total) Boys Girls
Normal/nonspecific N/A 17% 75% 65%
Suspicious/abnormal N/A 5.4% 83% 25% 35%
STDs 7% N/A 11.50% N/A 2.5% 3.2% N/A
N/A = not reported.
*85% in 72 hours window
†Hymeneal opening as criteria; used hymenal diameters.
‡Scars attenuated hymen, tears, abrasions, and condyloma.
**Erythema, abrasions, edema, discharge, scars, adhesions, anal tone, tears, and venous dilatation.
††Adhesions, hymenal scarring asymmetry, discontinuity, rounding, enlarged hymenal opening, anal scarring, fissures, and gaping.
‡‡Used Adams classification scheme.
***Acute trauma, deep notches, transections, or perforations of hymen.

the Genital Examination Distress Scale
(GEDS), measures the emotional dis-
tress of a child during the anogenital
component of the sexual abuse evalua-
tion.44 The GEDS is used while the child
undergoes the examination and may
be useful to help compare different ap-
proaches to the examination.
In addition, adolescents examined for
concerns of sexual abuse with video col-
poscopy 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 photo-
graphic documentation of the clinical
findings. Technological advances allow
the child to observe the genital exami-
nation 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 evalua-
tion and were cooperative and enthusias-
tic throughout the examination.52
Colposcopy provides magnification
and an excellent light source that is help-
ful in identifying injuries while allowing
a photograph or video to be taken si-
multaneously for documentation.51,53-55
Video images have advantages over still
photography because the video allows

388 PEDIATRIC ANNALS 34:5 | MAY 2005

 documentation of examination findings.57,58
The examiner must take high-quality
photographs that are clear, have adequate
Adams‡‡81 Kellog‡‡82 Palusci‡‡83 Bowen‡‡84 Pugno†85 Berenson***86 lighting, and include a planned composi-
tion of the parts of the body shown in
1994 1998 1999 1999 1999 2000 the picture.56 The examiner documents
236 157 497 385 1058 192 any findings in the medical record, de-
girls = 215 girls = 151 girls = 388 girls = 325 girls girls scribing the findings in detail, and then
boys = 21 boys = 6 boys = 109 boys = 60 supplements that documentation with
Younger Younger Younger Younger Younger Younger photographs. Photographs must be taken
than 17 than 14 than 17 than 18 than 11 than 8 of every injury, with a scale in the frame
mean 9.0 mean 4.6 mean 7.4 mean 7.1 or with inclusion of anatomic landmarks
to establish perspective. One overall im-
77% 85% 83% 88% 65% 97.5% age of the child to mark the beginning of
23% 15% 17% 8.3% 35.2% 2.5% the photographic set is recommended.
A camera attached to a colposcope
77% 85% N/A N/A 64.7% 97.5%
allows for uncomplicated and predict-
able photo documentation without the
9% 12%
potential intrusiveness of a handheld
14% 3% N/A N/A N/A N/A
camera pointed at the child’s genitalia.
n = 213 n=6
In additon, children who have experi-
enced pornography may find the use of a
93% 100%
handheld camera a disturbing reminder
7% 0% of one aspect of their victimization.
N/A 3.1% 0% 0.7% N/A 0% 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 consul-
tation with law enforcement officials
and prosecutors because they can be ma-
nipulated easily. Many digital cameras
now have encrypting devices to prove
whether the image has been altered or is
for the easy viewing of the dynamic na- view the documentation available. Ex- the original.
ture of the anogenital anatomy.56 perts can examine photographs after If photographs must be shared be-
the examination is complete and render cause of legal mandates, it is important
Documenting the Examination opinions for courtroom purposes. Pho- to maintain an unbroken chain of evi-
Photography is an important compo- tographic documentation also provides dence and to have policies in place for
nent of documentation, memorializing clinical case studies for the education of handling the release of photographs.54,55
findings that are diagnostic, allowing other clinicians.54 When pictures are kept in the medical
for expert consultation, and provid- The technology underlying photog- records department of a hospital, precau-
ing objective documentation should the raphy of injuries and genital anatomy is tions must be taken to prevent destruc-
examiner’s interpretation of findings complex. Several types of camera sys- tion of the pictures at microfilming.
be challenged. If the interpretation of a tems work well to meet the standards
finding is challenged and photographic needed for use of photos as evidence of Anogenital Examination
documentation exists, the child will not the child’s injuries.54 The experience of The prepubertal hymen has a variety
need to undergo another examination; the examiner in photographing images of orifice configurations, described as
the challenging expert may simply re- can affect the quality of photographic annular, crescentric, fimbriated, cribri-

PEDIATRIC ANNALS 34:5 | MAY 2005 389

form, or septate.51 The most common
shapes of the hymenal orifice are cres-
centric 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. Es-
trogen creates a thicker and
paler appearance to the hy-
men.61 The prepubertal, un-
estrogenized hymen has an
appearance of involuted tis-
sue and tends to appear more
vascular and reddened.61
The appearance of the nor-
mal hymen in both prepubertal
and postpubertal children is
variable.62,63 Normal hy-
menal appearance var-
ies; it can be thick
and elastic or thin
and nonelastic. 64
The range of normal variants is wide,
and the examination techniques and po-
sitioning 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 chil-
dren 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 su-
pine frog-leg position and the knee-chest
position. Although some children find the
knee-chest position awkward, any “di-
agnostic” 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. Ab-
normal findings in the adolescent should
be confirmed in the knee-chest position.
390
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 gen-
tle traction only. Traction is applied by
grasping the labia majora between the
thumb and forefinger and gently apply-
ing traction downward and lateral, tak-
ing care to not induce injury.51,69
The hymenal membrane of the pre-
pubertal child is innervated and can
be sensitive to touch.51 Various
techniques have been described
to achieve gentle manipula-
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.
tion of the delicate hymenal
tissues, including a moist-
ened 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 puber-
ty.67 In prepubertal children, a speculum
examination, if indicated, must be done
under sedation or anesthesia and only
as required. Indications include unex-
plained bleeding or other unusual find-
ings that may need further evaluation. A
nasal speculum typically is not helpful
for the genital examination. Instead, an
excellent light source, a gentle and sen-
sitive manner during the examination,
and careful observation will reveal the
most findings.72
EXAMINATION FINDINGS
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 ab-
normal 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 abnor-
mal exams were deemed normal when
assessed by the expert team.
● Berenson et al.86 performed a case-
controlled study comparing 192 pre-
pubertal 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 ado-
lescents who were pregnant at the time
of or shortly before a sexual abuse
exam, 82% had a normal examina-
tion. Eleven percent were suggestive
of abuse, and 7% were definitive for
penetrating trauma.
As these results show, a lack of physi-
cal 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
PEDIATRIC ANNALS 34:5 | MAY 2005
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 re-
ported 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 de-
layed 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 per-
petrator may have engaged the child in
during the abuse, the length of time be-
tween the occasions of abuse, the time
between disclosure and subsequent pre-
sentation to the healthcare setting for
evaluation, and the relatively rapid heal-
ing observed in the mucous membranes
that comprise a child’s anogenital tis-
sues.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 re-
inforces 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 his-
torical information, nonspecific physical
complaints, and nonspecific behavioral
complaints that are common in the set-
ting of sexual victimization.90
Types of Injuries
When abnormal results are found
PEDIATRIC ANNALS 34:5 | MAY 2005
during physical examination, the find-
ings 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 conduct-
ed. 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 move-
ments, 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 re-
sidual effects is minimal.
When children present with acute
genital or anal trauma, however, the dif-
ferential diagnosis is rather limited. The
injuries are either accidental crush, im-
paling, 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 pres-
ents with acute genital trauma, occasion-
ally there will be a presenting history of
accidental impalement. When this is the
case, the history is paramount in deter-
mining whether an injury is accidental
or inflicted, as the pattern of trauma may
not be distinctive enough to differenti-
ate. If accidental impalement is being
considered, it is critically important for
law enforcement to conduct a scene in-
vestigation to determine the plausibility
of the explanation.
In prepubertal girls, the most com-
mon 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 hy-
menal edge may occur. This interruption
or laceration may extend to the base of
the attachment of the hymen to the pos-
terior portion of the vagina, or may ex-
tend 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 an-
esthesia 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 determin-
ing the etiology of this healed injury.
The adolescent patient presents a dif-
ferent 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 ef-
fect of estrogen on the hymen. The pu-
bertal 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 in-
jury to the hymen.
Nonspecific findings such as erythe-
ma 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, depend-
ing on whether the child’s history details
how he or she incurred the injury. Extra-
391
genital trauma is infrequent and reflects
the use of force and restraint to engage
the child in the activity. When extrageni-
tal trauma is present, oral, genital, or
anal trauma is more likely to be present.
Children and adolescents may con-
tract 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 gen-
ital-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 expe-
rience collecting and preserving forensic
evidence. Although the examining phy-
sician will only infrequently need to
collect evidence, it is important to do so
appropriately. Forensic evidence assists
law enforcement in identifying perpetra-
tors of a crime and is most important in
rape and sexual assault cases. Most chil-
dren 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 evi-
dence collection if the evaluation is with-
in 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
392
72 hours before the time of the physi-
cal examination, the focus shifts from
forensic evidence collection to the iden-
tification of possible physical findings.
This is based on experience with adult
sexual assault victims and the likelihood
of finding useful forensic evidence dur-
ing 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 evi-
dence 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 na-
tional pediatric meetings; best practice
can be reinforced via reference texts.92
When conducting a forensic evalua-
tion, 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-pu-
bertal 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 lin-
ens. 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.
SUMMARY
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 prepuber-
tal and pubertal genital examination
will certainly become even clearer. The
physical examination rarely is diagnos-
tic by itself, with more than 92% of cas-
es 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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