In this issue of American Family Physician, Lahoti and colleagues1 provide a useful approach to the medical evaluation of the child victim of alleged sexual abuse. Over the past 20 years, much has been learned about the presentation of sexual abuse. The vast majority of children who are sexually abused do not have severe injuries of the genitalia or anus; therefore, the examination does not reveal specific signs of injury. Studies of nonabused children have reported that many of the variations in appearance of the hymen and the anus initially believed to be associated with abuse are, in fact, normal or nonspecific findings.2–5
The most common error made by physicians who are not used to examining children's genitalia and anal areas with magnification is to call normal or nonspecific findings abnormal or suspicious for abuse. If the child has given no history of sexual abuse and is being examined for another reason, the misdiagnosis of sexual abuse can be extremely traumatic and sometimes tragic for everyone involved. A recent study6 presented a review of cases in which the child gave no history of sexual abuse, but the physician thought the genital or anal examination findings were suspicious for abuse. Only 14 percent of these children were found by the experts at the sexual abuse evaluation center to have findings that were concerning for abuse: the remainder of the evaluations were within normal limits, or the child had some other condition that was unrelated to abuse.
Table 1 in the article1 represents an abbreviated version of a new classification system that I have published and revised several times since 1992. In the past, an “enlarged hymenal opening” had been considered concerning for sexual abuse; however, this was removed from that category in my last classification scale. A lack of studies of nonabused children of various ages, using different examination techniques and incorporating accurate measurement techniques, does not allow us to know what size of hymenal opening should be considered “enlarged.” In my study7 of sexually abused girls who had described penile-vaginal penetration and whose perpetrators had confessed or pled guilty to sexual abuse, the mean diameter of the hymenal opening was not significantly larger than that in nonabused girls of the same age.
The finding of genital warts or condylomata acuminata in a child older than two years who gives no history of sexual contact is listed in my revised classification scale as indicating “possible” abuse. New studies using DNA hybridization to identify human papillomavirus DNA have reported that this virus is much more ubiquitous than was previously known, and it is likely that it can be transmitted by means other than sexual contact, regardless of age.
A new study by Berenson and colleagues8 compared the genital findings in magnified photographs from two distinct groups of girls between three and eight years of age. The first group included children who had given a history of digital or penile-vaginal penetration and were examined at a sexual abuse evaluation center. The second group, recruited to obtain age- and race-matched controls, were children from a well-child clinic who were thoroughly screened by child interview, parent interview and behavioral questionnaires, and who gave no indication of past sexual abuse. Few differences in the physical findings were evidenced between these two groups; an equal number of girls from each group had clefts in the posterior hymen extending up to 50 percent of the hymenal width.
So, what is the family physician to do? If a child relates a history of being sexually abused, a report to child protective services and a law enforcement agency must be made. If a child gives no history of abuse but is found to have signs of acute trauma to the genital or anal area with bruising and/or bleeding, this child should be referred to a subspecialist who is experienced in the evaluation of children for sexual abuse—if one is available.
A child who has a vaginal discharge should have cultures obtained to test for gonorrhea, Chlamydia and trichomonas infections. Until the culture results are available, a report to protective services need not be made if the child gives no history suggesting abuse (unless, of course, a parent or caretaker reports a history of sexual abuse). Most cases of vaginal discharge are not caused by sexually transmitted infections. If the examining physician evaluates a child and believes that the genital or anal area looks unusual or abnormal, but the child gives no history of sexual abuse, the physician should refer this patient to a local subspecialist for evaluation before a report of suspected sexual abuse is made.
Every family physician who examines children needs to know where to refer a child who should be evaluated by a subspecialist in child sexual abuse medical evaluation. Many times, this physician is based at an academic medical center, a children's hospital or a free-standing child advocacy center.
An accurate diagnosis of injuries from sexual abuse trauma is vitally important, not only as far as the legal system is concerned, but also for the child and family. Most children will not have physical injuries, and many children with unusual genital or anal findings will not have a history of sexual abuse. It is the responsibility of the family physician to assure that children with questionable diagnoses are referred to a subspecialist before the specter of sexual abuse is unnecessarily raised.