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Make the Diagnosis: Sexual Abuse, Child

Prior Probability

The reported prevalence of sexual abuse during childhood is approximately 1.1%.1 However, this estimate is from population surveys.1 The probability is likely higher when a caregiver expresses his or her concern about maltreatment. Some surveys of adult women show that they recall abuse at rates as high as 25%.2 These values also do not apply to the child who is brought to the clinician for care after alleged recent abuse (≤72 hours).

Population in Whom Sexual Abuse Should be Considered

Sexual abuse is not typically considered in the prepubertal child in the absence of caregivers’ concerns or changes in the child's behavior. This can be particularly vexing in the preverbal child. In the verbal child, nonspecific behavioral changes can include headaches, unexplained stomach aches, sleep disorders, changes in appetite, changes in school performance, anger, sexualized behaviors, unusual fears, depressive symptoms, or changes in bowel or bladder habits.

Assessing the Likelihood That a Prepubertal Girl has been Sexually Abused

A child who has been recently abused should be referred immediately for examination by experts, typica8">For nonacute concerns of abuse, the verbal girl and her caregivers should be interviewed separately. The discussion with young children should include a limited set of open-ended questions, avoiding multiple interviews by different medical personnel. Physicians with limited experience might choose to refer the child to professionals with expertise in the evaluation of child sexual examination of vaginagynecological examinationmanual pelvic examinationsexual assault examinationphysical examinationA complete physical examination should be performed, including an anogenital examination. The anogenital examination may be performed in the supine, frog-leg or butterfly positions (Figure 54-1). A complete description of the positioning of the child and method of the examination must be recorded. Documentation should include the sexual maturity rating and the presence and location of any anogenital erythema, lesions, abrasions, bruising, lacerations, scarring, or discharge (Figure 54-2). For both the vagina and anus, these are typically recorded using a clock-face analogy to show location (Figure 54-3). The presence of a vaginal discharge requires testing for sexually transmitted illnesses. A vulvar discharge has a 95% likelihood ratio (LR) confidence interval (CI) that excludes 1.0 for both the LR+ and LR− (Table 54-1). The presence of a widened horizontal hymenal diameter > 6.5mm also has CIs excluding 1.0 [for the examination with the child in the knee-chest position, LR+ 2.0 (95% CI 1.3-3.2); LR- 0.83 (95% CI 0.74-0.93)], but the lack of high diagnostic accuracy in combination with limited information about precision limits the usefulness of the finding.

Figure 54-1
Positions and Techniques for Examination of Genitalia in Prepubertal Girls

Two examination positions commonly used are the supine frog leg or butterfly position and the knee chest position. When findings are abnormal or concerning in the supine position, the examination ...

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