Am Fam Physician. 2014 May 15;89(10):830-832.
Key Points for Practice
Physicians should document all discussions of possible sexual abuse, regardless of whether these concerns are validated.
Physicians must have a very low threshold for reporting any suspected child abuse to appropriate authorities, especially if there are concerns about whether the child is safe to leave the office with the caregiver.
Physicians should personally interview verbal children and perform a complete physical examination with a chaperone present. Documentation of this examination is essential, keeping in mind that normal physical findings do not exclude abuse.
Children should be screened for STIs only if the abuser is a stranger, penetration is suspected, or the abuser has risk factors for STIs. However, all adolescents who may have been sexually abused should be screened for STIs.
—From the AFP Editors
Childhood sexual abuse is common and can lead to lifelong physical and psychological problems. The American Academy of Pediatrics (AAP) has released a report to assist physicians in evaluating children who may have been sexually abused, determining when to report the case, and counseling families.
Responding to Parental Concern About Possible Abuse
When parents bring up concerns about possible abuse, the child should be taken out of the room so that he or she is not influenced by the discussion. Sometimes, normal childhood sexual behavior or the parents' personal issues with caregivers can lead to unfounded concerns about sexual abuse. However, every concern should be approached objectively and with an open mind. Although it can be challenging to determine which cases warrant immediate intervention in the office and which cases require the involvement of outside entities, the physician should carefully document each case, including a detailed account of the factors leading to the parents' concerns.
If the physician has any question as to whether the child will be safe to leave the office with his or her parents, the appropriate child protective authorities should be alerted. If the child is not in imminent danger, the physician must decide when it is appropriate to contact authorities. In every state, health care professionals are mandated to report all cases of suspected child abuse or neglect. The physician must consider each case individually. The threshold for reporting is low, and it is the job of child protective services to investigate the validity of the claim.
In any case of possible sexual abuse, the patient should be evaluated for mental health problems. The initial disclosure of abuse can be stressful, and symptoms of posttraumatic stress disorder or depression may already be present. There also may be tensions between the patient and his or her family for disclosing the abuse. If a mental problem is identified, appropriate emergency mental health care should be initiated.
Physicians should be prepared to conduct a basic interview with a verbal child who may have been abused. However, the physician should keep in mind that it is a medical interview, and the child will probably be interviewed further by another professional experienced in evaluating children who have been abused. This initial interview can help determine whether referral is needed.
There are several guidelines to keep in mind when interviewing the child: (1) If the child spontaneously discloses abuse, the physician should respond by reassuring the child that he or she can talk to an adult about the abuse; (2) the physician should be supportive and respectful and should not appear shocked or dismissive; (3) the physician should establish trust with the child by discussing nonthreatening issues first, such as school or friends, and telling the child that it is the physician's job to keep the child healthy and it is okay to talk about uncomfortable issues; (4) it is important to avoid leading or suggestive questioning and to start with open-ended, general questions; (5) developmentally appropriate wording should be used, and a translator may be necessary if language is an issue; (6) there should be no expectation as to how much the child is required to tell the physician, and the child should not be coerced into talking or rewarded for a disclosure; and (7) any descriptions of abuse should be documented word for word using quotation marks, and the physicians opinions and impressions should be clearly indicated.
A physical examination should be performed to rule out injury, especially if genital or anal bleeding is reported. However, if the physician has not been specifically trained in examining a child who has been sexually abused, referral should be considered. If the abuse occurred in the distant past, the examination may be deferred and the child referred to a specialty center for further evaluation.
If the physician proceeds with the physical examination, a general assessment should precede the anogenital evaluation. The examination should be explained using appropriate language, and a chaperone must be present. If a parent is not available, a second medical staff member may be in the room to reassure the patient, assist in the examination, and act as the chaperone. Use of gowns and drapes can make the child feel more comfortable. The anogenital examination usually does not require instruments, and use of a speculum is contraindicated in prepubescent girls and should be used in adolescents only when warranted by signs and symptoms. In girls, separation of the labia while the child is supine and in the “frog-leg” position is often sufficient. If intravaginal trauma is suspected, vaginoscopy should be performed under anesthesia. In boys, the examination consists of inspecting the penis and scrotum. In girls and boys, the anal examination is usually performed by external inspection. Normal findings on the anogenital examination do not rule out abuse, and this should be noted on the assessment portion of the record.
Careful documentation of findings is important. Recommendations about the timing of forensic evidence collection vary, and physicians should be familiar with the protocol in their area. This should be performed at a clinic or emergency department equipped to collect evidence using a forensic evidence kit.
Sexually transmitted infections (STIs) are uncommon in children who have been sexually abused; therefore, screening is not needed in all patients. Screening should be considered if penetration occurred, the abuser is a stranger, the abuser is known to have an STI or is at high risk (e.g., intravenous drug users, men who have sex with men, persons with multiple sex partners), a sibling or other household member has an STI, the child has signs or symptoms, or the child has been previously diagnosed with an STI. Screening for all STIs is recommended in adolescents because the risk is higher than in younger children. Any child with a positive STI test result should prompt a careful investigation into risk factors and contacts, a medical examination and history, and evaluation for possible sexual abuse.
The family can be greatly affected when a child discloses abuse. Parents should be informed about the physician's requirement to report suspected abuse and encouraged to cooperate with investigators. Studies show that children have better long-term outcomes if their parents believe and support them, and the parents should be told that a calm and protective response is important. Parents should not try to independently question the child because the wrong type of questioning can be harmful.
Guideline source: American Academy of Pediatrics
Evidence rating system used? No
Literature search described? No
Guideline developed by participants without relevant financial ties to industry? Not reported
Published source: Pediatrics, August 2013
Coverage of guidelines from other organizations does not imply endorsement by AFP or the AAFP.
A collection of Practice Guidelines published in AFP is available at http://www.aafp.org/afp/practguide.
Copyright © 2014 by the American Academy of Family Physicians.
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