Medical Evaluation for Child Sexual Abuse: What the PNP Needs to Know

Appropriate triage of a child or adolescent presenting with a concern of sexual abuse or assault is essential. Crucial information to gather prior to beginning a sexual abuse physical examination includes what happened to the child’s body (i.e., what body part of the perpetrator touched where on the child, such as the perpetrator’s penis in child’s vagina), when the sexual abuse last happened, who perpetrated the sexual abuse, and any past or current physical concerns (e.g., genital/anal bleeding, discharge, or pain) (). The timing of the latest incident of sexual abuse is important in determining the need for the collection of trace forensic evidence and prophylaxis for STIs and/or pregnancy. The American Academy of Pediatrics recommends that when the alleged sexual abuse has occurred within 72 hours or there is an acute ano-genital injury, the physical examination should be conducted immediately (). Adolescents experiencing acute sexual abuse/assault may require prophylaxis for pregnancy and/or STIs. Typically, prepubertal children are not given prophylaxis for gonorrhea or chlamydia because of the low incidence of these STIs in sexually abused children (). Human immunodeficiency virus prophylaxis may be warranted for both children and adolescents experiencing acute sexual abuse/assault, especially coupled with ano-genital injury and perpetrator risk factors. In acute situations, the collection of trace forensic evidence to be analyzed for the perpetrator’s semen, saliva, or blood may be warranted. Collection of forensic evidence from the victim includes body swabs, hair samples, and blood samples, as well as clothing and linens. Forensic evidence should be collected by a medical provider with training and expertise and therefore may necessitate the transfer of the patient to a more appropriate provider, such as an emergency department or child advocacy center.

Children presenting with a non-acute concern of sexual abuse require a thorough medical evaluation consisting of a physical examination, medical history including a minimal facts history of the sexual abuse concern, and a familial psychosocial history. PNPs must be aware of local resources available for sexual abuse evaluations. Communities may possess multidisciplinary teams with expertise in assessing children with sexual abuse concerns such as those found at a child advocacy center or a children’s hospital; children presenting with a non-acute concern of sexual abuse may be best served by referral. However, may communities do not possess such services; therefore, a basic understanding of the medical evaluation for child sexual abuse is crucial for every PNP.

The diagnosis of sexual abuse is typically made based on the history of abuse given by the child, because less than 5% of children who are sexually abused will have a physical finding upon examination (). This lack of ano-genital physical findings can be explained by several factors: a history of sexual abuse involving noninvasive forms of abuse; elasticity of the hymen and other ano-genital structures; and healing of ano-genital injuries without residual injury (). Therefore when a child presents with a concern of sexual abuse, obtaining a comprehensive medical history from the patient and family is crucial. As with providing any clinical care, the medical history will serve to guide the physical examination. The PNP is not conducting a comprehensive forensic interview but rather obtaining a medical history for purposes of medical treatment and diagnosis and to ensure the safety of the child.

Obtaining a medical history in cases of suspected sexual abuse is a multi-step process consisting of the parental/caregiver concern of sexual abuse; a familial psychosocial history; a detailed medical history of the child with a review of systems focusing on any ano-genital complaints such as bleeding, discharge, pain, or past genital injury; the child’s history of sexual abuse, ideally obtained without the parent/caregiver present; and preparation of the child for the physical examination (). An adolescent medical history should include age of menarche and date of last menstrual period. Box 2 indicates pertinent psychosocial information to obtain from the parent or caregiver. Additional information to obtain includes any witnesses to the alleged sexual abuse, changes in the child’s behavior, specifically sexualized behaviors, and—especially in young children—the names the child uses for body parts (e.g., breasts, vagina, penis, and anus). The parent/caretaker interview should take place without the child present whenever possible. Once this information has been obtained the PNP is better prepared to talk with the child about the sexual abuse concern.

The most crucial step when talking to a child about alleged sexual abuse is to create an environment that is safe, private, free of distractions, and child-friendly. Whenever possible, children 3 years or older should be interviewed without a parent present (). One can begin the conversation by talking about less threatening subjects, such as colors, school, or likes and dislikes. When talking with the child the PNP should utilize open-ended, non-leading questions asked in a developmentally and culturally appropriate manner. Younger children should be asked to identify body parts, including private parts, using the words that the child uses to identify private parts. The child should be asked if anyone touched, tickled, hurt, or put anything inside each private part. Interviewing tools such as anatomic drawings with private parts the child or adolescent can point to and name may assist in obtaining a medical history.

With older children and adolescents, the PNP can focus the discussion by talking about private parts, have the child identify private parts, and then ask about touching. Adolescents need to be asked about prior consensual sexual activity using terms the adolescent understands, and the adolescent’s definition of sex, the age of the partner(s), and the timing of the sexual activity should be clarified. Past consensual sexual intercourse (vaginal or anal) may affect the interpretation of a physical finding on ano-genital examination, making it impossible to state that the finding is the result of sexual abuse versus consensual sexual activity. Also, the age of the adolescent’s sexual partner(s) may necessitate a referral to CPS (i.e., a 14-year-old having vaginal intercourse with a 25-year-old); the PNP must be aware of state laws defining the age of sexual consent. When interviewing a child or adolescent regarding their sexual abuse, the PNP needs to gather enough information to ensure the child’s safety by reporting to CPS and to guide the physical examination regarding the need for STI and pregnancy testing. However, the PNP also should keep in mind that the child most likely will be required to undergo a forensic interview at a child advocacy center or by CPS/law enforcement, and it is not in the best interest of the child for the PNP to attempt a detailed forensic interview. Thorough and accurate documentation of the entire medical evaluation is crucial, particularly the statements made by the child describing his or her sexual abuse.

Children and adolescents should have the choice to have a parent/caretaker in the room with them for the physical examination to provide support. The physical examination, including the ano-genital examination, should be explained to the child/adolescent and parent in detail. The history of sexual abuse given by the child typically dictates the type of STI testing necessary. For instance, if a child gives a history of a penis penetrating his or her mouth, a throat culture for GC should be obtained. Box 3 provides STI testing indications according to the history given by the child. Every child should have a complete head-to-toe physical examination, with a special inspection for any additional signs of trauma such as bruising, abrasions, or lacerations to the body beyond the ano-genital region. Careful written and photographic (if possible) documentation should be noted.

The ano-genital examination for both prepubertal and pubertal boys involves a thorough visualization and inspection of the anus and genitalia utilizing an adequate light source. Sexual maturity should be noted. Testes should be palpated to ensure descension and lack of masses or tenderness. Any trauma, lesions, or rashes should be noted. Traumatic findings that raise a concern for sexual abuse in the absence of a plausible history of accidental trauma include lacerations, abrasions, bruises, and perianal scarring (). Ano-genital lesions that are of concern but not diagnostic for sexual abuse include warts (human papilloma virus [HSV]) and herpes (herpes simplex virus) (). Ano-genital warts are diagnosed clinically. Ano-genital lesions of concern for HSV should be confirmed by viral culture with typing or rapid polymerase chain reaction (). Anal dilatation should be noted. Marked anal dilatation greater than 2 cm without the presence of stool in the vault may support a child’s history of anal penetration; if noted on examination, the child should be referred to a sexual abuse examination expert for confirmation and interpretation of the finding (). If acute traumatic findings such as bruising, swelling, abrasions, or lacerations are noted on ano-genital examination, consideration should be given to referring the child to an emergency department or child advocacy center for an immediate examination and collection of trace forensic evidence.

The ano-genital examination for girls also requires an adequate light source. The patient should be placed in a supine frog-leg position, or stirrups can be used. Labial traction should be gently applied, pulling toward the examiner to visualize the genital structures and the hymenal opening. If a hymenal opening cannot be visualized, one can attempt to readjust labial traction or float the hymen with a small amount of water or saline solution with use of a syringe or saline bullet (). An inspection should be conducted for any acute injuries such as bruising, edema, bleeding, or lacerations of the hymen, posterior fourchette, other genial structures, or anus (Figure 2). An acute ano-genital injury coupled with a history of sexual abuse given by the child or the lack of a history of an accidental injury requires referral for trace forensic evidence collection. Sexual maturity should be noted, along with any lesions, especially warts or herpetic lesions. Findings that raise concern for non-acute sexual abuse are areas of missing hymenal tissue or healed hymenal transections extending entirely or nearly entirely through the hymen (). These findings should be confirmed by also examining the patient in the knee-chest position to allow gravity to allow hymenal tissue to fall into the visual field, thereby negating the previous finding. Other non-acute findings that raise concern for sexual abuse include perianal scarring or scarring of the posterior fourchette (). Any non-acute finding necessitates a referral to a sexual abuse examination specialist for confirmation of the finding, especially in the absence of a history of sexual abuse given by the child.

The prepubertal hymen is very sensitive to touch, and contact during examination should be avoided if possible (Figure 3). Because of the release of estrogen the pubertal hymen is not sensitive to touch, is much more elastic, and can easily be palpated with a cotton tip applicator to inspect the integrity of the hymen (Figure 4). STIs can raise a strong concern for sexual abuse. Box 4 provides the interpretation of a positive STI finding, diagnostic testing, and treatment.

Fewer than 5% of children who give a history of sexual abuse will have a physical finding of concern for sexual abuse upon an ano-genital examination (). The ability of the PNP to provide reassurance to the child and family that despite what has happened to them their body is normal, just the same as any other girl/boy, is crucial in helping children and families heal following sexual abuse. For the few patients who do have a finding on physical examination, the PNP can also provide reassurance that this finding will not affect their ability to have sex or babies when they get older and that only a doctor or nurse conducting an examination could tell that something had happened. The patient can be reassured that no one else will ever need to know unless the patients chooses to share it with someone.

The physical examination may reveal additional medical needs that may necessitate referral for ongoing medical care. Not all children who have been sexually abused need ongoing mental health therapy; however, a referral should be made to a therapist with expertise in working with children with a history of sexual abuse to determine the need for ongoing therapy.

The PNP performing a sexual abuse medical evaluation plays a crucial role in ensuring patient safety. CPS must be notified if the PNP has a concern of possible sexual abuse; certainty is not required to report. PNPs should know their state laws defining their responsibility as a mandated reporter. A report should be made to CPS if the child gives the PNP a verbal history of sexual abuse, has an ano-genital finding that raises concern for abuse, or is diagnosed with an STI that raises concern for abuse. Failure to report suspected sexual abuse not only leaves that child at risk for further abuse but also potentially places additional children at risk. PNPs who fail to report a concern of suspected sexual abuse also risk professional liability. PNPs should inform the non-offending parent/caregiver of their concerns of suspected sexual abuse and the need to report to CPS. PNPs should verbally notify CPS of their concerns while the child is still present in the office/clinic, and a safety plan should be verified with CPS before the child is discharged home.

Sexual abuse is a problem that PNPs are likely to encounter in their practice. Anticipatory guidance and screening for sexual abuse needs to occur at well-child check-ups and when children present with behavioral and/or physical symptoms that raise concerns about sexual abuse. Parents need to be educated about how to best protect their children from sexual abuse. PNPs should be familiar with local services available for the assessment, investigation, and treatment of sexual abuse. PNPs should know and utilize local or state child sexual abuse examination experts for consultation and referral as needed. The disclosure of sexual abuse often places the child and family in a state of crisis. A thorough and competent medical evaluation for child sexual abuse is a vital step in ensuring the safety of the child and helping the child and family to heal.