In TrainingMedical evaluation of suspected child sexual abuse
Section snippets
What is sexual abuse?
Definitions vary, but any sexual contact between an adult and a child is considered abuse. Children under the age of 12 years cannot “consent” to any sexual activity with an adult. The age at which sexual contact between adolescents must be reported varies from state to state; however, any sexual contact in which force or coercion is used, or which is prohibited because of the relationship of the victim to the suspect (i.e., incest), is always abusive, and is reportable.
Role of the medical evaluation in suspected sexual abuse
The medical evaluation is only one part of a comprehensive, multi-disciplinary evaluation when child sexual abuse is suspected. The role of the medical examiner is to:
- 1.
Identify treatable injuries or infections.
- 2.
Collect forensic specimens, if the abuse was recent.
- 3.
Screen for sexually transmitted conditions.
- 4.
Reassure the child that she/he is still “OK” and hasn't been damaged or injured in a way that won't heal quickly.
- 5.
Assess the patient and parent's mental and emotional state and make referrals for
History from the parent
What does the parent say? How did the abuse come to light? If the child has not made a disclosure, why is the parent suspicious? If the child has made a statement, what exactly did he/she say, and in what context? How did the parent react to the child's statement?
History from the child
“Do you know why you are here for a checkup today?” “I'm a doctor (nurse, etc.) who checks boys and girls, including their boy and girl parts, or privates. Has someone touched you or hurt you in your privates?” Who, with what, where,
When is a medical examination necessary?
- 1.
If the child is complaining of pain with urination, pain with bowel movements, bleeding from vaginal area, bleeding from anus, or vaginal discharge, a screening exam, involving careful inspection of the genital area and anus should be done.
- 2.
If the child describes being sexually molested, and the last episode was within the past 72 h, or an adult has observed a child being sexually abused within the past 72 h, an “evidential” examination should be done by someone who is skilled in performing
Position
- 1.
Supine, frog-leg, on mother's lap or exam table, using labial separation and labial traction.
- 2.
Supine, knee-chest: Lying on back, with knees flexed, hands on legs.
- 3.
Lithotomy position, in stirrups: may be helpful in older girls.
- 4.
Prone, knee-chest: Usually well accepted by child. Best position for seeing in the vagina and for visualizing the anal area.
Instruments
The only instrument required for a careful examination of a child's genital and anal area is a good light source. Some type of magnification, however,
Interpreting the findings on physical examination
Normal vs. abnormal, suspicious vs. suggestive, definitive evidence of injury, “consistent with” abuse—How do we interpret what we see?
Studies of newborn infants, and of prepubertal children screened for non-abuse have provided essential information as to the wide variation in normal genital findings and peri-anal findings. (See attached Classification System).
Acknowledgements
Terminology used is taken from: American Professional Society on the Abuse of Children. Practice Guidelines: Descriptive Terminology in Child Sexual Abuse Medical Evaluations. Published by the American Professional Society on the Abuse of Children, 1995.
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