Increasing numbers of women will be asking their gynecologists to examine their daughters for signs of suspected sexual abuse. With number of victims now reaching catastrophic proportions, even physicians accustomed to examining only adult patients need to familiarize themselves with the approach to this complex problem.

The National Center on Child Abuse and Neglect (NCCAN) defines child sexual abuse as “contact or interaction between a child and an adult, when the child is being used for the sexual stimulation of that adult or another person. Sexual abuse may be committed by a person under the age of 18 years, when that person is either significantly older than the victim, or when the abuser is in a position of power. or control over that child.”¹ Hence, vaginal penetration is a not a prerequisite. Abuse can represent any type of behavior such as disrobing, genital exposure. photographing, oral-genital contact, instrumentation with foreign objects, or vaginal or rectal intercourse. Molestation is a nonspecific term, sometimes used in a more polite setting, generally referring to nongenital or less violent contact.

Incest is the term applied to a special subclass of sexual abuse that includes any sexual behavior inappropriate to a normal pre-existing family relationship. Relatives may be of various types and degrees. of either sex, and may include stepchildren and stepparents. (Abuse does not include infantile sex games, such as “playing doctor,” acted out between youngsters of the same age.²)

Various statistics are quoted, of which only the more recent implicate the monstrous extent of this crisis. The NCCAN estimates the number of abuse cases to be more than 200,000 per year. A typical child sex offender has abused an average of 68 victims.³ A 1985 nationwide poll by the Los Angeles Times revealed that 22% of adults surveyed had been sexually victimized before the age of 18 years. Other more recent studies imply that the actual incidence is closer to 40%. In other words, we are now seeing only the tip of the iceberg.⁴

Reports indicate that abuse occurs at all ages. from infancy to early adulthood. Although average reported age is 8 to 11 years at the time of the first incident, it is now believed that younger children are at higher risk because of their physical vulnerability, trusting attitude, and moral ignorance regarding right and wrong behavior. Younger victims are more likely to know the assailant (especially incestuously), to be victims of recurrent abuse, to report crimes not involving intercourse, and to present with abused siblings.⁵ Boys now represent 20% to 30% of victims, but this figure may be falsely low as a result of underreporting and misdiagnosis.

The child knows the abuser in more than three fourths of the cases in which the victim is able to give a history. The perpetrator is a member of the family in greater than 50%, with the parent implicated in more than half of these incidents (and in over three fourths when stepparents are included). A family friend or neighbor is involved in 20% of the time.⁶

Almost invariably, the abuser is in a position of being the child's caretaker, thus being someone known and trusted in a position of authority over the child. Abusers ordinarily have easy access to the child and have numerous opportunities to be left alone at home. The home situation frequently is such that the child lacks sufficient attention and affection; the abuser cultivates a warm, friendly relationship that the child values and wants to sustain. This sympathetic rapport progressively evolves from hugs, caresses, and nonerogenous kisses into seemingly innocent nudity and fondling; overt sexual acts follow.

The perpetrator simultaneously persuades the victim that such “games” must be kept secret. He or she convinces the child that if any of these clandestine frolics come to light, it is the youngster (and not the abuser) who will be punished, removed from the home and prevented from seeing his or her family ever again. They may also threaten harm will come to the child's parents or siblings.

Victimizers frequently believe that they are actually creating a positive situation for the child, by exposing them to a sexual relationship in a “loving” or “caring” way and thus preparing them for the mature sexuality of adulthood. An elderly or widowed perpetrator may have no other carnal outlet; younger relatives may be the preferred prey precisely because of their virginal innocence and cleanliness, compared with a paid prostitute.

Approximately 95% of abusers are male: this may be an overestimate, because females may be coabusers or inflict more subtle injuries than are easily recognizable. When the father or a father figure is the perpetrator, the mother may actually be aware of the wrongdoing but be in a state of denial or be a victim of abuse herself. This is especially true in households in which alcohol or drug abuse is commonplace. In addition to making use of a child for his own debauchery, a father figure may subjugate the victim into engaging in sex acts for other family members or even prostitution. Youths who run away from home to escape this environment are at higher risk for continuation of prostitutional behavior or substance abuse in the future.

Behaviorial indicators may be the first or only sign that sexual abuse has taken place. A change from a normal pattern of behavior, especially if regressive, is most significant. A previously toilet-trained child may revert to enuresis; a formerly well-adjusted one may demonstrate sleep disturbances such as nightmares or demand to sleep with a night-light. Older children may evince a deterioration of school performance or manifest sexualized behavior inappropriate for their developmental level.⁴

History taking in abuse cases is a true art and continues to be the most important part of any evaluation. Ideally it is conducted by a trained professional such as a therapist or social worker. Careful documentation of all details in the child's own words is vital and constitutes legal evidence. Privacy and ample time are prerequisites: the best history may be obtained without the parents present. A child should not be made to repeat the story of the incident over and over. Unnecessary personnel in the room will only add to the child's embarrassment and so may hinder adequate information gathering.

The original history obtained is usually the best one. Tape recording the initial interview has been recommended.⁷ The conversation should be conducted in a slow, unhurried fashion and must not resemble an interrogation. With younger children, use of anatomically correct dolls or picture drawings not only enhances rapport but also establishes the child's terminology for body parts.

It is important that children's sense of guilt and fear be addressed in a way that will not make them feel responsible for any wrongdoing. Reassurance that they will not be punished by either the system or the perpetrator will also engender a more supportive atmosphere.⁴

The disclosure sometimes is accidental, and the relationship may not yet have progressed to the point of any painful physical contact or emotional conflict. A child might recall pleasurable sensations from the encounters and now feel ambiguous or confused about the new aspect of immorality brought to awareness. Therefore, a neutral approach is crucial so that a child does not hold back any information.

A child's eventual disclosure almost never takes place after only one incident. The interviewer may attempt to date back to a singular experience suggesting seasonal clues such as occurrence around the time of a birthday, holiday, or school vacation. Other helpful particulars include hour of the day, exact locations, and the absence or proximity of other family members. Historical factors that help validate the account include the occurrence of multiple episodes over time, a progression from fondling to penetration, an element of secrecy fostered by coercion, and explicit details of the abuse. Remember that children are often unfamiliar with exact genital anatomy and may report penetration when only “vulvar” or “dry” intercourse has occurred (rubbing of the erect penis on the child's vulva between her thighs). For these reasons, a child's own terminology should be recorded and simple “yes” or “no” questions are best avoided.

Children rarely anticipate the sequelae of the allegation. They confess in an effort to gain protection or an end to victimization and hardly ever expect the consequent police involvement or complex medical examination. Ambivalence may taint their feelings toward their abuser; in some cases, this may have been the only source of affection for an emotionally starved child.⁸ On the other hand, children may remember the abuser's threats or retribution or feel sorry for their mother if the father figure was their assailant. On realization of these consequences, patients may retract their story in order to pressure family harmony, or they may suddenly claim that they just “don't remember.” This situation is best circumvented by sensitive reassurance throughout the interview, for it is nearly impossible to press criminal charges or prevent further misfortune without: the testimony of the victim.

An understanding, unhurried approach obviously is critical. A parental figure or guardian of the patient's choice should be present. The entire examination procedure is explained to the patient and parent. In addition to the history already taken, a physician must inquire about pain, bleeding, ejaculation, and the use of force or instrumentation. If the most recent assault has occurred within the past 72 hours, the examination is conducted immediately. Otherwise, choose a time agreeable to the child, her or his caretaker, and the trained interviewer. The first visit sometimes is used to take the history and establish familiarity; the physical examination follows in 1 to 2 weeks.

A general physical examination reveals important information in terms of demeanor, affect, and general hygiene; overall neglect may be clear. Maintain modesty and decrease embarrassment by draping any part of the body not under immediate inspection. Note evidence of extragenital as well as genital trama: bruising, hair loss, bite marks, lacerations, or indications of forceful restraint. Documentation using diagrams^{9, 10} or sensitively taken photographs is essential.⁴

In the absence of penetration, trauma is limited to the vulva and perineum and varies with the degree of force exerted by the abuser. Note the presence of all physical findings, regardless of how innocuous or nonspecific they may seem initially. These encompass erythema, edema, excoriations, petechiae, bruises, and urethral inflammation. Because many milder injuries heal within a few days,² a careful search for old wounds must be carried out, and a magnifying lens or colposcope is especially helpful here. Long-standing abuse can manifest itself by seemingly innocent conditions such as nonspecific vaginal discharge or labial agglutination.¹¹ Sexually transmitted disease cultures are always performed, and a Wood's lamp can demonstrate the presence of semen in cases of recent ejaculation. In cases of recent attack, any dried secretions, threads of clothing, or pubic hairs are collected as criminal evidence.

Great controversy exists over hymenal diameter and its relevance in sexual abuse cases. Better studies of normal hymenal anatomy have established that absolute diameter varies with the type of hymen (circumferential, fimbriated, or posterior rim), the amount of tissue present, and the degree of patient relaxation, as well as with age, weight, examination position (dorsolithotomy vs. knee-chest), and labial separation technique. “Bumps” and clefts previously considered abnormal findings are now recognized as commonplace, particularly when occurring anteriorly from 9 to 3 o'clock¹² or when found as the distal terminus of a longitudinal vaginal ridge.¹³ Examination of the patient in both dorsolithotomy and knee-chest position makes for a truly thorough evaluation, particularly in the case of a fimbriated hymen that needs the influence of gravity to allow it to fall open. Still, a hymenal diameter greater than 1.2 cm is almost certainly abnormal in a prepubertal child. ¹⁴

Stronger emphasis is now placed on findings of disturbance of the normal clear lacy hymenal vasculature or loss of the velamentous delicate border, especially posteriorly from 9 to 3 o'clock. Asymmetric tears of the hymen in this area. especially deep stellate tears accompanied by the previously mentioned changes, are highly suspicious. Scarring and attenuation are unequivocal proof of penetration¹⁴ (Fig. 1). Straddle injuries or other accidental trauma (e.g., balance beam falls, horseback riding) do not injure the hymen alone and must be accompanied by additional evidence of vulvar trauma to warrant etiologic consideration. ¹⁵

In pubertal females, vaginal penetration may occur without evidence of trauma, when the hymen stretches or when rape is accomplished by means of coercion and not force.¹⁶ Because the genital structures and pelvic support tissues in prepubertal girls are relatively more rigid and inelastic, penetrating injury carries a greater risk of tearing with internal extension. Bleeding usually indicates at least attempted penetration, and vaginoscopy is required here to rule out associated vaginal lacerations or hematomas. Benzocaine spray or lidocaine-jelly may lessen the pain of the procedure. If adequate assessment is impossible for emotional reasons or excessive bleeding, examination under general anesthesia is indicated to rule out injury to the upper vagina or intrapelvic viscera. Other grounds for the use of general anesthesia include an inability to urinate, hematuria, lower abdominal tenderness, and signs of hypovolemia.

Hematomas result from trauma to the fragile perineal subcutaneous vasculature or the corpus cavernosum of the labia majora. The venous disruption produces a tense, tender, purplish swelling; if bleeding persists, it can enlarge as it dissects through the soft-tissue planes. Depending on the location and size of the hemartoma, pain can be significant and cause an inability to urinate. Vaginal hematomas may be the source of referred pain to the rectum or buttocks (at times palpable on rectal examination) and can coexist with only obtrusive external injury. Enlarging hematomas require evacuation under anesthesia and ligation of bleeding vessels with fine delayed-absorbable suture. Otherwise, management is conservative with ice packs initially, then sitz baths, perineal cleansing, and bacteriostatic ointment application. Dysuria may be relieved by application of the ointment before urination or by urinating in a tub of water.¹⁷ The hematoma should subside in a few weeks.

Examination of the anus and rectum is usually done last, with the patient in either knee-chest or left lateral position. This portion of the examination is never omitted, even if the patient denies anal penetration. More historical information may become available at a later date, at which time most injuries will have healed and will have left no residual scars or only nonspecific changes.¹⁴

The extent of damage depends on the degree of force, use of lubricant, and whether penetration was digital, penile, or with an instrument. Digital assault rarely results in tearing. Use of a large object, however, can effect swelling, abrasions, tears, and some degree of relaxation followed by spasm acutely. Skin tags form as tears heal and the sphincter regains normal function. Chronic or repeated sodomy victims may eventually lose their normal sphincter tone, resulting in a gaping anal orifice that can easily admit two to four fingers.¹² However, long-term follow-up studies reveal that up to 85% of sodomized children may have findings normal on examination.^{14, 18}

Standard cultures are performed for gonorrhea (oropharynx, vagina or cervix, and rectum) and chlamydiae (vagina or cervix), and blood is drawn to test for syphilis and human immunodeficiency virus. If the child is asymptomatic, withhold treatment for sexually transmitted diseases until culture results are available. The exception is the rare instance in which the abuser is known to be culture positive; victims should be treated without delay. Perimenarchal girls should also have a baseline pregnancy test and a repeat test in 6 weeks.

With all patients examined within 72 hours of sexual assault, criminal evidence must be collected in the usual manner for legal purposes. This evidence includes foreign materials (dirt, sand), scrapings from underneath fingernails, pubic hair, and dried secretions. Semen fluoresces under a Wood's lamp and can then be lifted off with moistened cotton swabs. The customary cultures are taken from the pharynx, vagina, and rectum; most hospital emergency rooms are equipped with a “rape kit” designed specifically for these purposes.

The written examination record must chronicle all historical details of the assault(s) and the presence or absence of physical findings. Any positive evidence of trauma is documented at the very least by a diagram, but optimally with photographs. Photographic documentation of subtle or minor injuries is enhanced by magnification, such as that provided by a colposcope (with built-in camera) or a traditional camera with a macro lens and ring flash. A child who has been subjected to pornographic film sessions may be less discomfitted emotionally by the colposcope apparatus. All pictures must be accurately labeled with the patient's name, identification number, time, date, place of examination, and examination position.

Because these records constitute a legal document, the final diagnosis must be carefully worded. If the findings on the history and physical examination concur, acceptable terminology would be “the clinical evaluation is consistent with sexual abuse.”

Under no circumstances should the phrase normal exam be used, even if both the child and guardian deny the assault. A confession of abuse at a later date may then be impossible to prove. Statements such as “the physical examination neither confirms nor denies the history of sexual abuse” or “unable to rule out sexual abuse” are preferred.

Victimized children must be secured from future abuse. Children who have been victimized in the home are referred to state custodial agencies such as the Department of Children and Family Services. If the child cannot be safely discharged, temporary admission to the hospital is in order.

Similarly, the emotional needs of children must not be neglected. Recovery from this type of situational derangement may be a lengthy process. Many victims suffer from feelings of depression, guilt, and low self-esteem; these emotions can persist into adulthood and be manifested as frigidity, anorgasmia, or abusive behavior toward their own offspring. Children may express ambiguous sentiments toward their abuser, who at one time may have been a positive influence in their lives. Children may actually be more upset with the nonabusive parent for not protecting them. A skilled therapist will need to engage victim and family in extensive counseling, both in private and in group sessions, and continue this support as long as is necessary.²

In conclusion, remember that sexual abuse can only be diagnosed when physicians remember to include that possibility in their differential. Even the most innocent symptoms may mask the true predicament, most tragically in preverbal children. It is often the abuser who brings the youngster in for medical treatment of a problem occurring secondary to abuse. An astute clinician may be the only person who can rescue these, the smallest victims, from a disastrous and potentially fatal plight.

1. National Center on Child Abuse and Neglect (NCCAN): Child sexual abuse: Incest. assault and exploitation. Special Report, FLEW, Children's Bureau, August, 1978

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3. Bennett R: Child sex abuse, prostitution and pornography. Proceedings of the North American Society for Pediatric and Adolescent Gynecology. Costa Mesa. California, January 1990

4. Heger A: Child Sexual Abuse: A Medical Review (video). United Way and Children's Institute International, Los Angeles, 1985

5. Tilelli J: Sexual abuse of children. N Engl J Med 302:319. 1980

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8. Sandfort TGS: Sex in pedophiliac relationships: An empirical investigation among a nonrepresentative group of boys. J Sex Research 20:/23, 1984

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11. Pokorny SF, Kozinetz CA: Configuration and other anatomic detail of the prepubertal hymen. Adol Ped Gynecol 1: 97, 1988

12. Berensen A: Normal newborn hymen. Proceedings of the North American Society for Pediatric and Adolescent Gynecology, Costa Mesa, California, January, 1990

13. Heger A: Personal communication, 1990

14. Stewart D, Heger A: Sexual abuse: An update. Proceedings of the North American Society for Pediatric and Adolescent Gynecology, Costa Mesa, California, 1990

15. Enos WF: Forensic evaluation of the sexually abused child. Pediatrics 78: 385, 1986

16. Paul DM: The medical examination in sexual offenses. Med Sci Law 15: 154, 1975

17. Davis HW, Hamp M: Pediatric and Adolescent Gynecology. Slide Atlas of Physical Diagnosis, Vol. 16, New York, Gower Medical Publishing, 1987

18. Hobbs C J, Wayne JM: Sexual abuse of English boys and girls: The importance of anal examination. Child Abuse Negl 13: 2, 1989