The diagnosis and management of child sexual abuse differs from adult sexual assault. The majority of prepubertal victims of sexual abuse will have a normal genital exam without evidence of acute or healed trauma. Young children may present due to nonspecific findings such as behavior changes or genital rash. The history and context of concerns are often most important to make the diagnosis. Knowledge of child development and behavior informs the management and diagnosis. An emergency department (ED) physician may ask questions as necessary for the medical evaluation of the patient. As a rule, the history is obtained from the caregiver out of the presence of the child. Care should be taken to avoid leading questions, and both the question and the child’s answer should be recorded verbatim when possible. 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 (pulling toward the examiner, not laterally) will allow visualization of the vulva and the hymen. Special attention should be given to the hymen and posterior fourchette, the most common sites of injury. Use the clock-face designation when documenting locations around the hymen. The prepubescent hymen is thin and has smooth edges and is extremely sensitive to touch. A speculum is never used in the examination of a prepubertal girl, except in rare examinations under anesthesia. In postpubertal females, the hymen is thickened and redundant; a cotton-tipped applicator can be used in the postpubertal female to unfold and examine the edges of the hymen.
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 with permission from Giardino AP et al. A Practical Guide to the Evaluation of Sexual Abuse in the Prepubertal Child. New York, NY: Sage Publications; 1992.)
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.
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.
Children who are seen in the ED for acute sexual assault should receive a complete physical examination ...