Interpretation of Medical Findings in Suspected Child Sexual Abuse: An Update for 2018

Abstract

Most sexually abused children will not have signs of genital or anal injury, especially when examined nonacutely. A recent study reported that only 2.2% (26 of 1160) of sexually abused girls examined nonacutely had diagnostic physical findings, whereas among those examined acutely, the prevalence of injuries was 21.4% (73 of 340). It is important for health care professionals who examine children who might have been sexually abused to be able to recognize and interpret any physical signs or laboratory results that might be found. In this review we summarize new data and recommendations concerning documentation of medical examinations, testing for sexually transmitted infections, interpretation of lesions caused by human papillomavirus and herpes simplex virus in children, and interpretation of physical examination findings. Updates to a table listing an approach to the interpretation of medical findings is presented, and reasons for changes are discussed.

Clinical practice: recognizing child sexual abuse—what makes it so difficult?

“…Although a child’s disclosure of CSA remains the most specific indicator of CSA [3], most children do not disclose spontaneously or only at a later stage, sometimes even adult age [17, 36]. Feelings of shame and guilt, fears for being blamed, or self-blame often withhold children from disclosing [17, 36].…”

“…Only few physical findings are highly suggestive of sexual abuse (even in the absence of a disclosure from the child, unless the child and/or caretaker provides a timely and plausible description of accidental anogenital injury, or past surgical interventions that are confirmed): acute laceration(s) or bruising of labia, penis, scrotum, or perineum; acute laceration of the posterior fourchette or vestibule, not involving the hymen; bruising, petechiae, or abrasions on the hymen; acute laceration of the hymen, of any depth, partial or complete; vaginal laceration; and perianal laceration with exposure of tissues below the dermis [3, 38]. …”

“…There is no consensus on the weight to be given, with respect to sexual abuse, for complete anal dilatation (in the absence of other predisposing factors such as constipation, encopresis, sedation, anesthesia, and neuromuscular condition), and hymenal notches or clefts at or below the three o’clock or nine o’clock location [3]. …”

“…The prevalence of sexually transmitted infections (STIs) among children is low [3] and in most cases of alleged CSA STI-tests are negative. Diagnosing a sexually transmitted infection (STI) in a child does not necessarily mean the child has been sexually abused.…”

“…The entire context needs to be taken into account. Some infections are not related to sexual contact, such as vaginitis caused by fungal infections, bacterial infections transmitted by non-sexual means (Streptococcus species, Staphylococcus sp., E. coli , Shigella, or other gram-negative organisms), or genital ulcers caused by viral infections such as Epstein Barr virus or other respiratory viruses [3]. …”