The Committee on Child Abuse and Neglect of the American Academy of Pediatrics (AAP) has updated the 1991 guidelines for the evaluation of children in whom sexual abuse is suspected. The guidelines are published in the January 1999 issue of Pediatrics. The following highlights the content of the guidelines.
The guidelines describe various circumstances in which children who are sexually abused may present to physicians. They may be seen for a routine physical examination or for care of a medical illness or behavioral condition that may or may not be related to sexual abuse. They also may be brought to the physician's office by social service or law enforcement professionals for evaluation of possible sexual abuse. Alternatively, they may be seen in an emergency department for evaluation and crisis management, including collection of evidence, after a suspected episode of sexual abuse.
Children who are victims of sexual abuse may present with nonspecific symptoms, such as sleep disturbances, abdominal pain, enuresis, encopresis or phobias, or with symptoms specific enough to raise a suspicion of sexual abuse. Among the more suspicious signs are rectal or genital bleeding, sexually transmitted diseases and developmentally unusual sexual behavior. The guidelines recommend that physicians at least consider the possibility of sexual abuse if such findings are present. If no other diagnosis is apparent to explain such findings, the appropriate child protection agency should be notified.
Obtaining the History and Interviewing the Child
To minimize repeated questioning of the child, the guidelines recommend that investigative interviews be conducted by the agency designated to carry out such an investigation. The guidelines note that this does not preclude the physician from asking questions to obtain relevant information about the child's history and review of systems.
Children may occasionally make statements about the abuse during the history and physical examination. If so, the physician should not react by displaying strong emotions such as shock or disbelief. Instead, questions can be asked using a “tell me more” or a “then what happened next” approach.
Physical Examination and Laboratory Data
The child may be anxious about history taking, being examined or having procedures performed, and time should be allotted for allaying the child's anxiety. The guidelines state that a supportive adult should be present during the physical examination. The child's behavior during the examination should be noted. As different areas of the body are examined, the child may be asked to demonstrate anything that may have occurred at a particular area.
The protocol for child sexual assault victims should be followed if the alleged sexual abuse occurred within 72 hours of presentation or if bleeding or other signs of acute injury are noted. Forensic studies should be performed if the examination takes place within 72 hours of acute sexual assault or sexual abuse. An emergency examination is generally not required if more than 72 hours has elapsed since the alleged episode of sexual abuse.
The examination should include brief assessments of the child's developmental, behavioral, mental and emotional status, with special attention paid to growth parameters and sexual development. During physical examination, instruments that magnify and illuminate the genital and rectal areas should be used to examine these areas thoroughly. If signs of trauma are found, they should be carefully documented by drawing detailed diagrams of the abnormalities or by photographing them. Special attention should be paid to the mouth, breasts, genitals, perineal region, buttocks and anus.
The genital examination of females should include inspection of the medial aspects of the thighs, labia majora and minora, clitoris, urethra, periurethral tissue, hymen, hymenal opening, fossa navicularis and posterior fourchette. Speculum or digital examination should not be performed on the prepubertal girl. In males, the thighs, penis and scrotum should be examined for bruises, scars, chafing, bite marks and discharge.
In both males and females, the rectal area should be examined for the presence of bruises around the anus, scars, anal tears (especially those that extend into the surrounding perianal skin) and anal dilation. While the child may be asked to demonstrate any events that may have occurred to the area, care should be taken not to suggest answers to the questions.
As far as the need for obtaining cultures and serologic tests for sexually transmitted diseases, the guidelines cite several factors to consider when making this decision: the possibility of oral, genital or rectal contact; the local incidence of sexually transmitted diseases; and whether the child has symptoms of sexually transmitted disease.
The guidelines note that physical findings are often absent in sexually abused children. Findings that would raise a concern about sexual abuse but in isolation would not be diagnostic of sexual abuse include abrasions or bruising of the inner thighs and genitalia; scarring or tears of the labia minora, and enlargement of the hymenal opening. Findings that would raise more concern about the possibility of sexual abuse include scarring, tears or distortion of the hymen; a decreased amount of or absence of hymenal tissue; scarring of the fossa navicularis; injury to or scarring of the posterior forchette, and anal lacerations.
Records and Legal Issues
The guidelines explain that the more detailed the reports and the more explicit the physician's opinion, the less likely the physician will need to testify in civil court proceedings. In all likelihood, though, the physician's testimony will be required in criminal court.
Legal issues also include mandatory reporting and the risk of medical liability if a physician fails to diagnose sexual abuse. Similarly, liability is a risk if the physician mistakenly renders a diagnosis of sexual abuse when some other condition is responsible for the abnormalities thought to be caused by sexual abuse. The guidelines encourage physicians to discuss cases of possible sexual abuse with child abuse consultants or local agencies for child protective services.