The history is often most important to make a diagnosis of sexual abuse. An ED physician may ask questions as necessary for the medical evaluation of the patient. However, forensic interviews should be performed by professionals trained in interviewing children for possible sexual abuse.
A pubertal female can be examined in the supine position with feet in stirrups. A prepubertal female should be examined in the supine frog-leg position (hips and knees bent; soles of feet touching) and can be examined on the examination table or while sitting on a caregiver’s lap. Gentle even labial traction will allow visualization of the vulva and the hymen. Attention should be paid to all areas, but special attention should be given to the hymen and posterior fourchette, the most common sites of injury in cases of sexual abuse. Use the clock-face designation when documenting locations around the hymen. A cotton-tipped applicator can be used in the postpubertal female to unfold and examine the edges of the hymen. The prepubescent hymen is sensitive to touch. A speculum is never used in the examination of a prepubertal girl; the only time a speculum is used in this population is during examination under anesthesia.
A male patient can be examined in the supine position, with care to inspect the penis and scrotum in entirety. The anus can be examined in the prone or lateral decubitus position. A colposcope can be used, if available, to magnify the genital and anal areas to look for injury.
Management and Disposition
When patients with a concern of sexual abuse present to the ED, Social Work should be notified. If sexual abuse is suspected, a report of alleged sexual abuse should be made to child protective services and law enforcement.
All children who are seen in the emergency room for acute sexual assault should receive a complete physical examination including genital and anal examination. Any injuries or skin lesions concerning for injuries on the body should be described in detail with the aid of full body diagrams and, when available, photodocumentation. When performing a genital examination, a chaperone (hospital personnel) should be present at all times.
Evidence collection should be performed if the contact occurred within the last 72 hours (for all males and prepubertal females), and can be considered up to 96 hours in pubertal females, as there is the potential for the recovery of trace forensic evidence.
In most cases, an anxious patient will cooperate fully with the examination if a parent or other support person remains for the examination. Reassurance and distraction techniques are helpful. Sedation is rarely needed and can be ineffective. An examination should never be forced upon an unwilling patient. When an examination is deemed medically necessary (ie, vaginal bleeding without a known source, and the patient is not cooperative), examination under anesthesia should be considered.
Sexual assault can coincide with intentional or covertly administered substance use. Do not begin the evidence collection or genital/anal examination until the patient is coherent and can consent or assent to the process and examination.
A normal examination does not exclude the diagnosis of sexual abuse, and a normal examination is the most likely finding, even in abused children. Examination findings (genital and anal) specific for sexual abuse are found in only a small percentage of patients who report a history of sexual abuse.
The shape and appearance of the prepubertal hymen is variable. Crescentic and annular configurations are most common. Hymens can also be sleeve-like, septate, imperforate (which eventually requires surgical opening), and cribriform (multiple small openings).
The inner edge of the prepubertal hymen is usually smooth and uninterrupted. Notches at the 3- and 9-o’clock positions are normal. Minor irregularities are most likely insignificant.
Presumptive treatment for gonorrhea and chlamydia is not recommended for a prepubertal patient because of the very low incidence of infection in these patients and also because of the low risk of ascending infection (infection is a lower-tract disease in prepubertal females) and the need for confirmatory testing.
A history of sexual abuse is strongly associated with increased risk of suicidal thinking and suicide and self-harm attempts among older children and adolescents. All patients evaluated for sexual abuse should be carefully assessed for current suicidal or self-harm thoughts.
Before the patient is discharged from the ED, it is necessary to also determine what access the alleged perpetrator has to the patient, family, or other individuals and to ensure a safe discharge plan.
Labial Traction Examination Technique. Position the child in a supine position with her knees out and soles together. Hymenal inspection in prepubertal girls is best accomplished when lateral (1) and posterior (2) traction to the labia is applied as shown here. (Adapted from Giardino AP et al. A Practical Guide to the Evaluation of Sexual Abuse in the Prepubertal Child. Sage Publications; 1992.)
Proper Labial Traction Allows Visualization of the Prepubertal Hymen. (A) Lateral labial traction only. The hymenal margins cannot be visualized. (B) Lateral, posterior, and caudal labial traction provides complete visualization of the hymenal rim. (Photo contributor: Cincinnati Children’s Hospital Medical Center.)
Proper Labial Traction Allows Visualization of the Prepubertal Hymen. The hymen is partially visible in the first photo (A). When traction is applied, a hymenal septum is found which creates the appearance of two vaginal openings (B). A septum is a normal hymenal variant. (Photo contributor: Cincinnati Children’s Hospital Medical Center.)
Normal Estrogenized Newborn Hymen. Infants often have thickened annular hymens. Maternal estrogens cause this effect. Do not confuse with traumatic swelling. (Photo contributor: Cincinnati Children’s Hospital Medical Center.)
Normal Annular Hymen. The hymen is doughnut shaped without any defects. (Photo contributor: Cincinnati Children’s Hospital Medical Center.)
Normal Crescentic Hymen. The hymen is crescentic shaped without any hymen present from the 11- to 1-o’clock position. This is a normal hymen and the most common configuration in prepubertal girls. (Photo contributor: Cincinnati Children’s Hospital Medical Center.)
Normal Hymenal Mound—Crescentic Hymen. The hymen is crescent shaped, tissue is absent near the urethra between 11- and 1-o’clock position. A nonspecific mound of hymenal tissue is noted at 3-o’clock position. (Photo contributor: Cincinnati Children’s Hospital Medical Center.)
Foley Catheter Technique to Better Visualize the Adolescent Hymen. In addition to using a cotton-tipped applicator (A). A Foley catheter can be inserted into the adolescent vagina, filled a mixture of air and water and gently retracted (B). Side-to-side displacement of the catheter exposes different hymenal sections for inspection (C). (Photo contributor: Cincinnati Children’s Hospital Medical Center.)
Cotton Swab Technique. These images (A, B, C) show how a cotton-tipped applicator is used to ensure that all parts of the hymen are visualized during the examination of a pubertal patient. (Photo contributor: Kathi L. Makoroff, MD.)
Hymenal Septum. This picture shows a common hymenal variant—hymenal septum. A septum that extends into the vagina must be excluded either by examination (demonstrating that a cotton-tipped applicator can pass behind the septum) or with an ultrasound. (Photo contributor: Kathi L. Makoroff, MD.)
Normal Anal Dilation. A relaxed external sphincter causes anal dilation in all children. Stool in the rectal vault contributes to dilation. This is not a finding of sexual abuse. Other conditions that can cause anal dilatation include chemical sedation, death, or a prolonged period of hypoxia. (Photo contributor: Cincinnati Children’s Hospital Medical Center.)