Childhood sexual abuse is a problem with very high prevalence. Recent studies have confirmed that ∼1 in 5 girls and 1 in 20 boys experience sexual abuse during childhood. Data from telephone surveys of adolescents in one study1 revealed that, by age 15, 16.8% of girls reported past sexual abuse, and by age 17, that number jumped to 26.6%. Many cases of sexual abuse are never reported, or come to light only when the child is ready, sometimes after years of keeping silent, to report the abuse to a trusted adult.
Physicians in many fields of practice may be called to evaluate a young child for possible abuse. A child and family may present to the physician due to a concern for abuse raised by the parent, a report of the child’s disclosure of abuse, an unusual examination finding, or an unexpected laboratory result. It is important for any physician who examines children to understand how to approach the medical examination, how to recognize normal variations in genital anatomy, and how to interpret any findings that are revealed during the evaluation.
There are several reasons why a child may not disclose to an adult that they are being sexually abused. When the abuser is a family member or trusted adult, a young child may be told that if they tell anyone, they will get in trouble, or no one will believe them, or the abuser will have to go away to jail. An older child may feel that what is happening is their own fault and feel too embarrassed and ashamed to tell anyone. A not uncommon scenario is the case of an older sibling only revealing their abuse after discovering that a younger sibling is now also being abused, and wants to stop that from happening. Young adolescent girls may be afraid to tell a parent what has happened because the abuse or assault occurred when she was engaging in high-risk behaviors that she had been warned about, or had gone somewhere unsafe without parent’s knowledge or approval. Shame, regret, and fear of parent’s anger may delay her disclosure for weeks or months.
In cases where the child has not disclosed abuse, the concern may be raised due to the girl’s complaints of genital pain or itching, or if the mother notices vaginal discharge, genital sores or warts or thinks the child’s vaginal opening looks “too big.” There are several conditions that the general practice gynecologist needs to be aware of and recognize when evaluating a young girl for these genital complaints.
In addition to common nonspecific vulvovaginitis, conditions such as lichen sclerosus, aphthous ulcers, bacterial vaginitis, common warts, molluscom contagiosum, genital warts, and genital herpes can also cause symptoms of itching, pain, redness, or bleeding. A close inspection of the external genitalia is important to sort out possible causes of these signs and symptoms. Unfortunately, physicians are not usually taught in medical school or residency to recognize variations the appearance of the labia minora, hymen, fossa, and posterior fourchette in girls before puberty.
When a young girl is brought to a physician for an examination, due to concerns about possible sexual abuse, parents may have some misconceptions about how the examination will be conducted and may think it can “prove” whether or not there has been sexual contact or penetration. One fear is that a young girl’s examination will be similar to that of an adolescent or adult woman, and worry that the child will be traumatized. An explanation that the examination will only involve taking a close look at the girls’ external genitalia, and that nothing will be inserted into her vagina, can be reassuring.
A medical evaluation and detailed genital inspection can be conducted in several ways. Young girls will likely want to have their mother or other accompanying family member in the room for the examination, to provide support and reassurance. Once the child has removed her underclothes and changed into a gown, she can be assisted to lie back on the examination table, with the head of the table elevated at a 45-degree angle. In this position, she will be able to see the physician and more easily be instructed on how to relax and allow the visual inspection of her genitalia. An article by Berkoff et al2 includes a diagram demonstrating 2 examination positions and 2 techniques for examining the genital area of a young girl. For very young girls, the child may be more comfortable on her mother’s lap. The mother is asked to sit on a chair with the child held on her lap. The child is instructed to bend her knees and put the soles of her feet together, with mother assisting, if necessary.
To visualize the labia majora, labia minora, and contents of the vestibule, 2 techniques can be used with the child in the supine position. First, the examiner gently spreads the labia majora apart, explaining that the doctor needs to take a close look. If the child is very reticent to have her genitalia touched, the child can be asked to use her own hands to spread the labia, with the doctor’s hands on top of her hands to guide the separation. If the vestibule and hymen are not clearly visualized, the examiner may use the labial traction technique. The labia majora are gently grasped with thumb and forefinger and spread slightly apart and pulled toward the examiner. Unless she has bruising or abrasions on the labia, this is not painful for the child.
The prone knee-chest position is very helpful when trying to get a clear look at the hymen or to look inside the vagina without the use of any instrumentation. Asking the child, in the prone position, to lift her bottom up in the air, with tummy towards the table “like a kitty cat” can facilitate positioning for this examination method. The examiner then uses her/his thumbs to lift up the lower portion of the labia majora, allowing a clear view of the hymen and into the vagina.
The next task of the examining physician is to understand what the examination reveals. Until the early 1990s, there was very little research on the details of normal variations in the appearance of genital tissues in prepubertal girls, and many things thought to be due to abuse were later shown to be found in nonabused girls as well. Between 1989 and 1993, 3 studies describing genital or anal findings in nonabused children were published. McCann and colleagues3,4 described anal findings and genital findings among a group of prepubertal children who were carefully screened and found to have no suspicion of sexual abuse. Another study, describing the appearance of the hymen in newborn infants, provided additional important normative data.5 Data from these studies helped the physicians examining children to understand and recognize all of the normal variations in genital and anal anatomy.
In 2005, a group of physician specialists in child abuse evaluation worked to incorporate the data from research studies and recommendations from the American Academy of Pediatrics into a set of guidelines for the medical evaluation of suspected sexual abuse and interpretation of physical examination findings.6 The guidelines were updated in 20157 and 2017.8
As the guidelines have been updated, so, too has a table listing medical examination findings and results of laboratory tests, categorized as to their possible correlation with child sexual abuse. The sections of the table are under the following headings: (1) findings documented in newborns or commonly seen in nonabused children, (2) findings commonly caused by medical conditions other than trauma or sexual contact, (3) conditions mistaken for abuse, (4) findings with no expert consensus regarding the degree of significance with respect to abuse, and (5) findings caused by trauma and/or sexual contact.
Physicians who rarely examine girls for suspected abuse often expect to find signs of injury if a child has reported what sounds like penetration of the vagina or anus. However, most children who are evaluated for suspected sexual abuse will not have signs of injury or infection.9,10 Minor injuries heal rapidly, and if the child is not examined within days of the assault, the examination findings will likely be normal. Another reason for a lack of injury in prepubertal children is that the most common types of abuse; touching, fondling, oral-genital contact do not cause injury.
Young girls do not really have a concept of what “in” means, with respect to their external genitalia. This misunderstanding was partially explained in a recent study,9 where girls presenting for evaluation of suspected sexual abuse were routinely asked, by a social worker at intake, the question: “When you wipe after you go pee, do you wipe on the inside or outside of your (private part, or whatever word the child uses for her external genitalia)?” Of the 533 children in the study who answered the question, 41% said “inside,” 35% said “outside,” and 23% said “both inside and outside.”
The girls were not wiping inside the vaginal canal, but more girls under age 12 years (69%) answered “inside” or “both” than girls aged 13 or over (55%). With pubertal development, the adolescent girls had a clearer idea of “inside,” so more reported that the wiping was on the “outside” of the external genitalia. For the data analysis, when the child answered “inside,” or both inside and outside, the contact was described as “penetration,” if she answered “outside,” the contact was described as “contact.”
Overall, only 64 of 502 female patients (12.7%) had diagnostic signs of genital penetration. Within this group of 64 girls with injuries, 58 (91%) had described penetration (inside), and only 6 (9%) had described contact (outside). Another recent study, by Smith et al,10 reviewed the records of 3569 children evaluated for suspected sexual abuse.
Signs of acute trauma, such as bruising, abrasions, and lacerations were rare in children who were examined >72 hours after the abuse. The authors found that abnormal genital findings were significantly more common in adolescent girls (13.9%) than among girls under 12 years of age (2.2%). The timing of the examination was also a factor, and among girls who were examined within 72 hours of the last episode of abuse, acute genital injuries were seen in 14.2% of children, compared with 4.5% of children examined >72 hours following the abuse.
After the onset of puberty in girls, the hymen becomes thicker and able to stretch without tearing during intercourse. This was shown definitively in a study by Kellogg et al,11 who reviewed the appearance of the hymen in adolescent girls who were pregnant. Only 2 of 36 pregnant girls had nonacute genital findings indicative of previous vaginal penetration. These results are important to understand since the lack of physical findings of intercourse should never be used to discount a young woman’s disclosure of being sexually assaulted.
The most common medical findings that are mistaken for signs of sexual abuse include redness of the genital or anal tissues (many causes); the appearance of a “dilated” hymen, urethra, or anal opening felt by caretakers to be “too big”; a concern for an “absent” hymen due to a relatively narrow posterior rim of hymen when labial traction is applied in a well-relaxed child; mistaking the presence of labial adhesions as “scars” in the genital area; mistaking the irregular appearance of the pectinate line as scars or tears of the anus, and mistaking the blue coloration around the anus caused by venous congestion for anal bruising.
A recent textbook and atlas12 review the medical assessment of suspected child sexual abuse and contains photographs of many of the genital and anal anatomic features described above. Annular and crescentic are the 2 most common variations in hymen appearance in prepubertal girls. Remembering that the hymen is a remnant of tissue left when the solid vagina hollows out during embryological development, it is not surprising that this remnant may have varying shapes and sizes.
Occasionally, a rare condition such as the congenital failure of midline fusion, or perineal groove, hemangiomas of the hymen or labia, urethral prolapse, lichen sclerosus, and lesions in the genital or anal area caused by conditions such as Crohn disease or Bechet disease can also be confused with signs of sexual contact or trauma. Examples of these findings are shown in Chapters 2, 8, and 10 in the textbook mentioned earlier.12
For physicians who are not familiar with the detailed appearance of the genital and anal tissues in children, distinguishing normal from abnormal findings can be difficult. There is a tendency to conclude that an unusal finding must be a result of abuse. In an online survey of medical professionals who examine children for suspected sexual abuse, findings on genital and anal photographs were more likely to be incorrectly attributed to sexual abuse among those who examined <5 children per month for sexual abuse.13
Physicians who do not routinely perform magnified examinations of children’s genital and anal tissues are advised to develop a procedure to obtain high-quality digital images of any physical finding that is thought to be related to sexual abuse. These images can then be shared with an expert in child sexual abuse medical evaluation to obtain a second opinion as to whether or not a concern for sexual abuse should be raised.
University-affiliated Children’s Hospitals often have specialists in Child Abuse Pediatrics who are trained to perform the examinations of sexually abused children. These physicians could also be a resource for medical providers in the community and may be willing to offer a second opinion regarding a case in which an examination finding is suspected of being related to sexual abuse. No one wants to miss a case of child abuse, but neither should the question of possible abuse be raised unnecessarily.
Given that the overall rate of abnormal genital findings in girls under age 12 years evaluated for sexual abuse, as reported by Smith and colleagues was only 2.2%, even in specialty centers where physicians may examine an average of 500 children per year for suspected sexual abuse, only 10 or 11 of those children would have signs of injury. The data show that while child sexual abuse is a widespread problem, children examined for suspected sexual abuse will most likely not have signs of injury or infection. Rates of injury are higher in adolescent girls than in prepubertal girls. Child sexual abuse is not rare; abnormal genital findings in abused children are rare unless the child is examined within 72 hours of the last episode of abuse.
The American Academy of Pediatrics Committee on Child Abuse and Neglect published, in 2012, recommendations for providers in primary care when evaluating a child who may have been sexually abused.14 The recommendations could also be helpful for general practice gynecologists as well when a child presents with a concern for possible sexual abuse.
Recognizing the prevalence of sexual abuse, being alert to signs and symptoms that can be associated with abuse, and understanding how to best evaluate young children are important for all health care professionals who care for children and adolescents, even those who do not regularly do so, such as general obstetricians and gynecologists.
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