Practice Guideline Briefs

AAP Report on Assessment of Sexual Abuse in Children



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Am Fam Physician. 2005 Dec 1;72(11):2387-2388.

The American Academy of Pediatrics (AAP) has released recommendations for the recognition of possible sexual abuse in children, the need for diagnostic testing for sexually transmitted diseases (STDs) in these children, and determination of the need to inform child protective services. The full report, “The Evaluation of Sexual Abuse in Children,” was published in the August 2005 issue of Pediatrics and is available online at http://www.pediatrics.org/cgi/content/full/116/2/506.

Children who have been sexually abused—defined as engaging a child in sexual activities (including noncontact activities such as voyeurism) that are beyond his or her comprehension and developmental preparation—may present with a variety of nonspecific symptoms such as sleep disturbances, abdominal pain, phobias, or bed wetting. Inappropriate or excessive sexual behavior, such as mouth-genital contact, asking to engage in sex acts, or imitating intercourse, also may indicate abuse, although many children who have been abused do not display increased sexual behavior.

If alleged abuse has occurred within 72 hours or if the child has an acute injury, an immediate physical examination is necessary. Generally, however, physicians should first take a clinical history, including behavioral symptoms and signs of abuse, past incidences of abuse, suspicious injuries, and menstrual history. Physical and laboratory findings usually are absent, and diagnosis may be made from the history alone.

A physical examination should be performed. Findings that may indicate sexual abuse include: abrasions or bruising of genitalia; tearing (new or healed) in the posterior aspect of the hymen; decreased hymenal tissue; injury to or scarring of the fourchette, fossa navicularis, or hymen; and anal lacerations or bruising. Physicians also should assess the child’s sexual maturity and evaluate for signs of physical abuse, neglect, and self-injury. Abnormal findings, defensively incurred bruises on the arms and legs, and signs of trauma should be documented. Detailed records will be useful if legal action is taken.

The AAP recommends testing for STDs depending on various factors (e.g., age, type of contact, signs or symptoms of disease, community prevalence of disease). Gonorrhea, syphilis, human immunodeficiency virus infection, and Chlamydia trachomatis infection are diagnostic for sexual abuse and warrant a report to the appropriate agency. Trichomonas vaginalis is highly suspicious, and Chlamydia acuminata infection or herpes simplex virus lesions in the genital area also should be reported.

Children who have been sexually abused should be assessed by a physician and mental health professional. At follow-up examination, physicians should assess the healing of injuries, presence of STDs, and emotional recovery. The AAP guidelines for reporting sexual abuse are provided in the accompanying table. For legal requirements by state, the AAP refers physicians to the National Clearinghouse on Child Abuse and Neglect Information Web site at http://www.childwelfare.gov. The AAP report emphasizes that the primary responsibility of the physician is to protect the child. Any lack of parental support or belief in the child should be reported to child protective services.

Guidelines for Reposting Sexual Abuse of Children

Findings Response
History Behavioral symptoms* Physical examination Diagnostic tests

Clear statement

Present or absent

Normal or abnormal

Positive or negative

High concern; report

None or vague

Present or absent

Normal or nonspecific

Positive test for Chlamydia trachomatis, gonorrhea, Trachomatis vaginalis, human immunodeficiency virus, syphilis, or herpes†

High concern; report

None or vague

Present or absent

Worrying or diagnostic findings

Negative or positive

High concern; report

Vague or history from parent only

Present or absent

Normal or nonspecific

Negative

Indeterminate concern;refer when possible

None

Present

Normal or nonspecific

Negative

Intermediate concern; possible report, ‡ refer, or follow


*—In children two to 12 years of age, abnormal behaviors may include putting the mouth on genitals, asking to engage in sex acts, imitating intercourse, inserting objects into the vagina or anus, and touching animal genitals.

†—If nonsexual transmission is unlikely or excluded.

‡—If behaviors normally are rare or unusual in children.

Adapted with permission from Kellogg N; American Academy of Pediatrics Committee on Child Abuse and Neglect. The evaluation of sexual abuse in children. Pediatrics 2005;116:510.

Guidelines for Reposting Sexual Abuse of Children

View Table

Guidelines for Reposting Sexual Abuse of Children

Findings Response
History Behavioral symptoms* Physical examination Diagnostic tests

Clear statement

Present or absent

Normal or abnormal

Positive or negative

High concern; report

None or vague

Present or absent

Normal or nonspecific

Positive test for Chlamydia trachomatis, gonorrhea, Trachomatis vaginalis, human immunodeficiency virus, syphilis, or herpes†

High concern; report

None or vague

Present or absent

Worrying or diagnostic findings

Negative or positive

High concern; report

Vague or history from parent only

Present or absent

Normal or nonspecific

Negative

Indeterminate concern;refer when possible

None

Present

Normal or nonspecific

Negative

Intermediate concern; possible report, ‡ refer, or follow


*—In children two to 12 years of age, abnormal behaviors may include putting the mouth on genitals, asking to engage in sex acts, imitating intercourse, inserting objects into the vagina or anus, and touching animal genitals.

†—If nonsexual transmission is unlikely or excluded.

‡—If behaviors normally are rare or unusual in children.

Adapted with permission from Kellogg N; American Academy of Pediatrics Committee on Child Abuse and Neglect. The evaluation of sexual abuse in children. Pediatrics 2005;116:510.



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