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Guidelines for medical care of children evaluated for suspected

sexual abuse: an update for 2008


Joyce A. Adams
Department of Pediatrics, University of California-San Purpose of review
Diego, San Diego, California, USA
Child sexual abuse is a common problem in our society and medical professionals who
Correspondence to Joyce A. Adams, MD, Professor of provide evaluations of children who may have been abused need to be updated as to
Clinical Pediatrics, UCSD Pediatric Associates, 7910
Frost Street, Suite 350, San Diego, CA 92123, USA recent research findings and recommendations for conducting examinations and
Tel: +1 858 496 4823; fax: +1 858 496 4851; interpreting results.
e-mail: jadams@ucsd.edu
Recent findings
Research studies have provided important new information regarding the qualifications
Current Opinion in Obstetrics and Gynecology of examiners, the recovery of forensic evidence in children, the frequency of
2008, 20:435–441
abnormal findings in children and adolescents, the healing of genital injuries, and
the interpretation of medical findings and sexually transmissible infections with respect
to abuse.
Summary
The recommendations for the timing and type of examinations for prepubertal children,
in contrast to adolescent sexual assault victims, may need to be changed. Studies
showing that partial tears of the hymen, as well as abrasions and contusions, may heal to
leave very little or no sign of previous injury emphasize the importance of urgent
evaluations. There is a need for standardization of the training of medical professionals
who perform child sexual abuse evaluations to ensure continuing competence.

Keywords
child sexual abuse, genital injuries, interpretation of medical findings

Curr Opin Obstet Gynecol 20:435–441


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no signs of residual injury such as scars, unless the injuries


Introduction were severe.
Physicians with an interest and expertise in the field of
child sexual abuse medical evaluation met at conferences McCann et al. [21] published the first of three articles
and collaborated through the Internet, between 2003 and reporting the results of a multicenter retrospective study
2007, to develop and revise recommended guidelines for of acute and healing genital trauma in children and
medical care for children with suspected sexual abuse. adolescents in 2007. The cases for this study were soli-
These guidelines were published in 2007 [1] and cited from colleagues by an electronic listserv. The final
included a table listing an approach to the interpretation sample included photographs and case information for
of medical and laboratory findings in children, which was 113 prepubertal girls and 126 pubertal girls who had
based on research studies published before 2006 [2–20]. sustained a genital injury and had at least one follow-
The interpretation table is included here as Table 1. up examination.

The present article will review research studies and Because of the study design, it was not possible to have
commentaries published in the past 2 years and discuss photographs taken at defined time periods after the first
recommendations for changing the guidelines to reflect acute examination. The timing of the follow-up examin-
new knowledge. ations, number and type of photographs, and examination
techniques were variable. The photographs collected
were reviewed by three team members together, and
Healing of genital trauma the authors report that agreement was reached before
Before 2007, there were a limited number of studies the findings were classified. There was no external review
looking at the healing of genital and anal injuries in of the photographs, however, and the method of describing
children. These studies [11–13] showed that injuries five levels of hymen lacerations (superficial, intermediate,
heal very rapidly, within days or weeks, and usually leave deep, complete, transection, transection with extension)

1040-872X ß 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins DOI:10.1097/GCO.0b013e32830866f4

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436 Adolescent and pediatric gynecology

Table 1 Approach to interpretation of medical findings in suspected child sexual abuse


Findings documented in newborns or commonly seen in nonabused children (the presence of these findings generally neither confirms nor
discounts a child’s clear disclosure of sexual abuse)
Normal variants
1. Periurethral or vestibular bands
2. Intravaginal ridges or columns
3. Hymenal bumps or mounds
4. Hymenal tags or septal remnants
5. Linea vestibularis (midline avascular area)
6. Hymenal notch/cleft in the anterior (superior) half of the hymenal rim (prepubertal girls), on or above the 3 o’clock to 9 o’clock line,
patient supine
7. Shallow/superficial notch or cleft in inferior rim of hymen (below 3 o’clock to 9 o’clock line)
8. External hymenal ridge
9. Congenital variants in appearance of hymen, including: crescentic, annular, redundant, septate cribiform, microperforate, imperforate
10. Diastasis ani (smooth area)
11. Perianal skin tag
12. Hyperpigmentation of the skin of labia minora or perianal tissues in children of color, such as Mexican–American and
African–American children
13. Dilation of the urethral opening with application of labial traction
14. ‘Thickened hymen’ (may be due to estrogen effect, folded edge of hymen, swelling from infection, or swelling from trauma.
The latter is difficult to assess unless follow-up examination is done)
Findings commonly caused by other medical conditions
15. Erythema (redness) of the vestibule, penis, scrotum or perianal tissues (may be due to irritants, infection or traumaa)
16. Increased vascularity (‘dilatation of existing blood vessels’) of vestibule and hymen (may be due to local irritants, or normal pattern in the
non estrogenized state)
17. Labial adhesion (may be due to irritation or rubbing)
18. Vaginal discharge (many infectious and noninfectious causes; cultures must be taken to confirm if it is caused by sexually transmitted
organisms or other infections)
19. Friability of the posterior fourchette or commisure (may be due to irritation, infection, or may be caused by examiner’s traction
on the labia majora)
20. Excoriations/bleeding/vascular lesions (these findings can be due to conditions such as lichen sclerosus, eczema or seborrhea,
vaginal/perianal Group A Streptococcus, urethral prolapse, hemangiomas)
21. Failure of midline fusion (also called perineal groove)
22. Anal fissures (usually due to constipation, perianal irritation)
23. Venous congestion, or venous pooling in the perianal area (usually due to positioning of child, also seen with constipation)
24. Flattened anal folds (may be due to relaxation of the external sphincter or to swelling of the perianal tissues due to infection or traumaa)
25. Partial or complete anal dilatation to less than 2 cm (anterior–posterior dimension), with or without stool visible.

Indeterminate findings: insufficient or conflicting data from research studies (may require additional studies/evaluation to determine significance)
(these physical/laboratory findings may support a child’s clear disclosure of sexual abuse, if one is given, but should be interpreted with
caution if the child gives no disclosure; report to Child Protective Services may be indicated in some cases)
Physical examination findings
26. Deep notches or clefts in the posterior/inferior rim of hymen, between 4 and 8 o’clock, in contrast to transections (see [41]).
27. Deep notches or complete clefts in the hymen at 3 or 9 o’clock in adolescent girls
28. Smooth, noninterrupted rim of hymen between 4 and 8 o’clock, which appears to be less than 1 mm wide, when examined in the
prone knee–chest position, or using water to ‘float’ the edge of the hymen when the child is in the supine position.
29. Wart-like lesions in the genital or anal area (biopsy and viral typing may be indicated in some cases)
30. Vesicular lesions or ulcers in the genital or anal area (infectious and noninfectious causes; cultures, serology, and/or nucleic acid
amplification tests should be done)
31. Marked, immediate anal dilation to an AP diameter of 2 cm or more, in the absence of other predisposing factors such as chronic
constipation, sedation, anesthesia, neuromuscular conditions.
Lesions with etiology confirmed: Indeterminate specificity for sexual transmission
32. Genital or anal Condyloma accuminata in a child, in the absence of other indicators of abuseb
33. Herpes type 1 or 2 in the genital or anal area in a child with no other indicators of sexual abuseb
Findings diagnostic of trauma and/or sexual contact (the following findings support a disclosure of sexual abuse, if one is given, and are highly
suggestive of abuse even in the absence of a disclosure, unless a clear, timely, plausible description of accidental injury is provided by the
child and/or caretaker)
Acute trauma to external genital/anal tissues
34. Acute lacerations or extensive bruising of labia, penis, scrotum, perianal tissues, or perineum (may be from unwitnessed accidental
trauma, or from physical or sexual abuse)
35. Fresh laceration of the posterior fourchette, not involving the hymen (must be differentiated from dehisced labial adhesion or failure
of midline fusion (see [21]); posterior fourchette lacerations may also be caused by accidental injury or consensual sexual
intercourse in adolescents)
Residual (healing) injuries (these findings are difficult to assess unless an acute injury was previously documented at the same location)
36. Perianal scar (rare, may be due to other medical conditions such as Crohn’s disease, accidental injuries, or previous
medical procedures)
37. Scar of posterior fourchette or fossa (pale areas in the midline may also be due to linea vestibularis or labial adhesions)
Injuries indicative of blunt force penetrating trauma (or from abdominal/pelvic compression injury if such history is given)
38. Laceration (tear, partial or complete) of the hymen, acute
39. Ecchymosis (bruising) on the hymen (in the absence of a known infectious process or coagulopathy)
40. Perianal lacerations extending deep to the external anal sphincter (not to be confused with partial failure of midline fusion)

(continued overleaf )

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Guidelines for medical care of sexually abused children Adams 437

Table 1 (continued )
41. Hymenal transection (healed). An area between 4 and 8 o’clock on the rim of the hymen where it appears to have been torn through,
to or nearly to the base, so there appears to be virtually no hymenal tissue remaining at that location. This finding has also been referred
to as a ‘complete cleft’ in sexually active adolescents and young adult women.
42. Missing segment of hymenal tissue. Area in the posterior (inferior) half of the hymen, wider than a transection, with an absence
of hymenal tissue extending to the base of the hymen, which is confirmed using additional positions/methods
Presence of infection confirms mucosal contact with infected and infective bodily secretions, contact most likely to have been sexual in nature
43. Positive confirmed culture for gonorrhea, from genital area, anus, and throat, in a child outside the neonatal period
44. Confirmed diagnosis of syphilis, if perinatal transmission is ruled out
45. Trichomonas vaginalis infection in a child older than 1 year of age, with organisms identified by culture or in vaginal secretions by
wet-mount examination
46. Positive culture from genital or anal tissues for Chlamydia, if child is older than 3 years at time of diagnosis, and specimen was tested
using cell culture or comparable method approved by the Centers for Disease Control.
47. Positive serology for HIV, if perinatal transmission, transmission from blood products, and needle contamination has been ruled out
Diagnostic of sexual contact
48. Pregnancy
49. Sperm identified in specimens taken directly from a child’s body
AP, anterior-posterior.
a
Follow-up examination is necessary before attributing these findings to trauma.
b
Changes made since the publication of the table in 2007.
Adapted from Adams et al. [1].

had not been previously described or validated. In spite of severity. Deep lacerations of the posterior fourchette
these limitations, the study is important because it was the or perineum took 2–3 weeks to heal in prepubertal girls.
first to review such a large number of cases and document
how rapidly acute injuries can heal.
Examination techniques
In prepubertal girls, findings of hymenal abrasions, pete- The study including a subset of the cases reviewed for
chiae, ‘mild’ submucosal hemorrhages, and hematomas at the healing of injuries was analyzed by Boyle et al. [23] to
the first acute examination appeared to have healed compare the effectiveness of three examination methods
completely by 2–3 days in most of the cases reviewed. used by the participating centers to detect the acute and
When the submucosal hemorrhages were rated by the healing genital injuries. The authors found that the prone
reviewers as being ‘moderate’ or ‘marked’, some were knee–chest position was the most successful method for
still identified at follow-up visits up to 15 days later. detecting hymen lacerations in both prepubertal and
pubertal girls. Of 10 hymen lacerations identified in nine
The authors identified and classified 40 lacerations of the prepubertal girls, 6/10 were identified when labial trac-
hymen among the prepubertal girls. Of the 19 hymen tion was used and 10/10 with the use of the prone knee–
lacerations that were classified as less than complete, four chest position. In pubertal girls, 35/49 hymen lacerations
healed with no evidence of injury. Among pubertal girls, were identified using labial traction and 44/49 with the
there were more cases in which the hymen defect at the prone knee–chest position.
site of the initial laceration appeared to be deeper at the
follow-up examination; for example, a deep laceration This is useful information for medical providers who
initially would be revealed as a transection at follow-up, examine children and adolescents following genital injury
due to the decrease in swelling of the tissues. or acute sexual assault, though techniques other than the
prone knee–chest position can be used with adolescent
An interesting difference was found between the location girls. Cotton swabs and Foley catheters can also be used to
of the hymen lacerations between prepubertal and pub- stretch out the edge of the redundant hymen in order to
ertal girls. In the prepubertal girls, 35/40 lacerations look for acute or healing injuries in pubertal girls.
(88%) were in the posterior location, below the 3
o’clock–9 o’clock line, whereas in adolescents, 50/80
(60%) were posterior and 18/80 (23%) were lateral, at Cross-sectional studies of injuries and
either the 3 o’clock or 9 o’clock location. forensic evidence
Table 2 summarizes the results of nine studies
In another article, the authors describe nonhymenal [24,25,26–31,32] conducted at various centers with
findings in the same group of prepubertal and pubertal a large number of child or adolescent sexual assault cases,
girls whose photographs they reviewed [22]. Similar to analyzing the prevalence of abnormal physical findings,
the findings on the hymen, abrasions resolved within 3 positive test results for sexually transmitted diseases,
days, petechiae within 24 h, and submucosal hemorrhage and/or rates of recovery of forensic material. In general,
and hematomas within 7–14 days, depending on the these studies showed that abnormal physical examination

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Table 2 Summary of findings from cross-sectional studies of sexually abused children and adolescent girls
Timing of Abnormal medical Positive forensic
N Age range examination examinations (% ) Positive STIs (% ) results (%) Special characteristics or findings

Drocton et al. [24] 1674 women 12–20 years <72 h 53 overall, 63 positive NA NA Adolescents, virgins, history of
anal finding if anal penetration, alcohol use had
abuse described more injuries
Hobbs and Osman [25] 86 men 1 month to 15 years, Variable All (sample selected NA NA Boys with genital injuries referred
mean 5 years for injury) for suspected abuse. Lacerations,
bruises, abrasions most common
finding
Palusci et al. [26] 190 <13 years, mean <72 h 13 5% 9 (17/93 tested) Positive forensics from body
438 Adolescent and pediatric gynecology

age 6.5 years swabs only recovered from


girls aged 10–13 who had
not bathed.
Palusci et al. [26] 586 <13 years, mean >72 h 4 NA NA Positive examinations more
age 7.0 years common in women, after
puberty, and with h/o
genital contact
Young et al. [27] 48 4 months to 11 years <72 h NA NA 6 No swabs from child’s body
were positive, only clothing,
bedding in three children
Young et al. [27] 31 12–16 years <72 h NA NA 42 All positive swabs collected
within 24 h of assault
Christian et al. [28] 273 <10 years Most cases 23 (only cases reviewed NA 25 No body swabs positive
<72 h were those with forensic after 18 h
swabs taken and analyzed)
Edinburgh et al. [29] 226 women 10–14 years <72 h Hmong: 63 other: 21 Hmong: 36 positive NA Hmong girls were significantly
(32 of Hmong Chlamydia; other: 4 more likely to be victims of
ethnicity) multiple assailants, be
runaways, depressed and
suicidal
Kelly et al. [30] 2134 1 month to 17 years Variable 6 3 NA Abnormal findings more
common in adolescents
Kelly and Koh [31] 1392 <10 years Variable NA 1 NA No STI was found in prepubertal
child without symptoms
770 10–17 years Variable NA 6
Kohlberger and 180 girls 1–16 years Variable 24 (‘hymen vaginal tear’) 0 (HIV, syphilis) to NA Gardnerella vaginalis found in
Bancher-Todesca [32] 2 (gonorrhea) 25%, no correlation with
‘hymen vaginal tear’
NA, not available; STI, sexually transmitted infection.

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Guidelines for medical care of sexually abused children Adams 439

findings, positive tests for sexually transmitted diseases, cology at one large medical school. The mean correct
and positive forensic specimen results were more com- response rate ranged from 42% for residents to 58% for
mon in adolescent than prepubertal children. Impor- faculty, in spite of the fact that regular seminars and
tantly, both Palusci et al. [26] in reviewing 190 cases lectures in pediatric gynecology were provided at the
and Young et al. [27] reviewing 80 cases found that no teaching hospital. The authors also report that many of
forensic evidence was recovered from a prepubertal the residents and faculty members had a tendency to
child’s body, even if they had been brought for examin- label examinations, both normal and abnormal, as indica-
ation within 6 h of the last episode of abuse. These two tive of sexual abuse.
studies support the findings of Christian et al. [28].
Botash et al. [35] found that even after participating in a
comprehensive educational intervention for generalist
Change the ‘72-hour’ rule? pediatric providers on evaluating suspected child sexual
As Palusci et al. [26] and Christian et al. [28] describe, this abuse, 59% of the participants could not correctly identify
rule evolved as a result of data from a few studies showing the medical findings on presented case photographs.
that sperm could be recovered from the adult female
genital tract up to 72 h following penile vaginal intercourse. The conclusion of the consensus group who developed
If the goal of performing an urgent examination is to collect the guidelines for child sexual abuse medical evaluation
swabs for forensic evidence, this author would argue that [1] is that medical providers should have formal medical
the ‘72-hour rule’ should be changed to the ‘24-hour rule’ education in the field, including didactic education,
for prepubertal children. Prepubertal children who are practical experience in performing medical evaluations,
brought in within 24 h of an alleged episode of abuse, have and mentoring by an established expert; be familiar and
not been bathed, and have a history or possibility of having keep up to date with published research and recommen-
been exposed to the alleged perpetrator’s semen or saliva dations from relevant professional organizations; be able
should have samples taken for forensic evidence. Those to demonstrate substantial experience and proficiency in
who have been bathed, or in whom the last contact was performing medical evaluations of children and under-
more than 24 h prior to the request for an examination, and stand the process of differential diagnosis of physical
have no symptoms or signs of injury or infection would findings that could be mistaken for abuse; and have a
most likely be better served, if the examination could be system in place to consult with established experts when
scheduled, during the day, at the facility with the most a second opinion is needed regarding the interpretation of
experienced medical providers. These examinations a medical finding.
should be expedited and performed as soon as possible
by medical providers with specific training in order to
increase the chances of finding signs of minor injury that Rethinking herpes, vulvar ulcers, and
tend to heal within a few days. gonorrhea
Ongoing education of medical providers is particularly
Commenting on the need for urgent examinations when important when considering the diagnosis of sexually
children have been sexually abused, Dubowitz ([33], p. transmissible infections. Shapiro and Makoroff [36]
998) states: ‘Too often, the perceived need for an immedi- reviewed the topic of sexually transmitted diseases in
ate evaluation leads to an emergency department, in the children and adolescents who are evaluated for suspected
middle of the night, with staff not trained to evaluate these sexual abuse, focusing on research related to human
children and in a setting that may exacerbate their stress.’ papilloma virus transmission and indications for HIV
If there is little or no likelihood of recovering forensic prophylaxis following sexual assault.
evidence from the child’s body, the examination could just
as easily be scheduled within the next day or two and still
accomplish the most important goal: reassurance of the Herpes simplex virus type 1 and 2
child and family that the child is not ‘damaged’. Studies of the prevalence of antibodies to herpes type 1
and 2 (HSV-1, HSV-2), among children and young ado-
lescents have been published in the last year. Xu et al.
Expertise in interpreting genital findings with [37] analyzed sera from 2989 children between age 6 and
respect to abuse 13 who participated in the National Health And Nutrition
Physicians in several specialties may have difficulty in Examination Surveys (NHANES) between 1999 and
interpreting genital examination findings in children. 2002. They found seroprevalence rate for HSV-1 of 31%
Muram and Simmons [34] showed color photographs for the overall sample, with significantly higher rates
of normal anatomy and common pediatric gynecologic among older compared with younger children and among
conditions to 20 faculty members and 40 residents in those living below the poverty line compared with those
pediatrics, family medicine, and obstetrics and gyne- above the poverty line.

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440 Adolescent and pediatric gynecology

In another study from Sweden [38], sera from mothers gonococcal vulvovaginitis or conjunctivitis, involving
and infants was analyzed for antibodies to HSV-1 and over 2000 children in Europe and the United States.
HSV-2. The seroprevalence of HSV-1 among mothers The article also reviews research studies that demon-
was higher than HSV-2 (65 versus 19%), and at 30 months strated the viability of gonococcus organisms on various
of age, 30% of infants had seroconverted for HSV-1 after surfaces for 2–72 h.
being negative at an earlier testing. The peak time of
acquisition of antibodies to HSV-1 among infants was Although some expert clinicians disagree, the wording as
found to be within the first 13 months of life. None of the mentioned in Table 1 regarding infections with Neisseria
infants became positive for HSV-2 antibodies. gonorrhea, Chlamydia trachomatis, syphilis, and HIV is as
follows: ‘Infection confirms mucosal contact with infec-
As both types of herpes virus infections can be, and are ted and infective genital secretions: contact most likely to
usually, transmitted by individuals who do not know they have been sexual’, not ‘Definite evidence of sexual
are infected [39], it is often not possible to know how and contact’.
from whom a child might have acquired HSV lesions or
antibodies. If the child is young enough that parents or
other caretakers are still assisting with hygiene or toilet- Conclusion
ing activities (generally under the age 5 or 6 years), it is Most genital injuries in sexually abused children heal
not unreasonable to postulate that a young child with with little residua, unless the injuries are severe. More
genital ulcers found to be caused by HSV-1 or HSV-2 may information is needed on the prevalence of infections
have been exposed through nonsexual contact. with HSV-1 and HSV-2 in children with and without a
history of sexual abuse to help with the interpretation of
How likely is it that a child with genital ulcers caused by an infection in a child. Recommendations regarding the
HSV-1 or HSV-2 acquired the infection as a result of timing of urgent forensic examinations for prepubertal
sexual versus nonsexual contact? There is little data from children should be revised, based on the low yield of
research studies in this area to help answer that question. forensic evidence from the child’s body more than 24 h
Reading and Rannan-Eliya [40] found in a literature after the last sexual contact.
review that investigators reported sexual transmission
more commonly in children who were 5 years of age or References and recommended reading
older, who had genital lesions only, and in whom HSV-2 Papers of particular interest, published within the annual period of review, have
was isolated from the lesions. However, there are no large been highlighted as:
 of special interest
studies comparing the seroprevalence of HSV-1 or HSV-2  of outstanding interest
among children with and without a suspicion of sexual Additional references related to this topic can also be found in the Current
World Literature section in this issue (p. 507).
abuse. Consequently, genital herpes infections in chil-
dren should probably remain in the ‘indeterminate’ 1 Adams JA, Kaplan RA, Starling SP, et al. Guidelines for medical care of
 children who may have been sexually abused. J Pediatr Adolesc Gynecol
category with respect to sexual transmission. 2007; 20:163–172.
This article presents guidelines for how, when, and by whom children should be
examined and suggests an approach to the interpretation of physical and labora-
tory findings in children with suspected sexual abuse. Groups of experts used a
Vulvar ulcers process of consensus development to arrive at the guidelines presented.
Vulvar ulcers in children and adolescents can have many 2 Berenson A, Heger A, Andrews S. Appearance of the hymen in newborns.
Pediatrics 1991; 87:458–465.
causes other than herpes infection. Huppert et al. [41]
3 McCann J, Voris J, Simon M, Wells R. Perianal findings in prepubertal children
reviewed 20 cases of adolescent girls aged 10–19 years selected for nonabuse: a descriptive study. Child Abuse Negl 1989; 13:179–
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including testing for Epstein–Barr virus and cytomega- 5 Berenson AB, Heger AH, Hayes JM, et al. Appearance of the hymen in
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girls. Acta Paediatr 2003; 92:1453–1462.
study emphasizes the importance of testing for herpes
7 Heger AH, Ticson L, Guerra L, et al. Appearance of the genitalia in girls
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a young woman with vulvar ulcers might have been findings. J Pediatr Adolesc Gynecol 2002; 15:27–35.
sexually abused. 8 Myhre AK, Berntzen K, Bratlid D. Perianal anatomy in nonabused preschool
children. Acta Paediatr 2001; 90:1321–1328.
9 Berenson AB, Grady JJ. A longitudinal study of hymenal development from 3
to 9 years of age. J Pediatr 2002; 140:600–607.
Is gonorrhea always sexually transmitted? 10 Berenson AB, Chacko MR, Wiemann CM, et al. A case-control study of
Sexually transmissible infections are not always sexually anatomic changes resulting from sexual abuse. Am J Obstet Gynecol 2000;
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[42], dating back to 1904, describes over 40 epidemics of A longitudinal study. Pediatrics 1992; 89:307–317.

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Guidelines for medical care of sexually abused children Adams 441

12 McCann J, Voris J. Perianal injuries resulting from sexual abuse: a longitudinal 29 Edinburgh L, Saewyc E, Thao T, Levitt C. Sexual exploitation of very young
study. Pediatrics 1993; 91:390–397. Hmong girls. J Adolesc Health 2006; 39:111–118.
13 Heppenstall-Heger A, McConnell G, Ticson L, et al. Healing patterns in 30 Kelly P, Koh J, Thompson JM. Diagnostic findings in alleged sexual abuse:
anogenital injuries: a longitudinal study of injuries associated with sexual symptoms have no predictive value. J Paediatr Child Health 2006; 42:112–
abuse, accidental injuries, or genital surgery in the preadolescent child. 117.
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31 Kelly P, Koh J. Sexually transmitted infections in alleged sexual abuse of
14 Boos SC. Accidental hymenal injury mimicking sexual trauma. Pediatrics children and adolescents. J Paediatr Child Health 2006; 42:434–440.
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32 Kohlberger P, Bancher-Todesca D. Bacterial colonization in suspected
15 Herrmann B, Crawford J. Genital injuries in prepubertal girls from inline skating  sexually abused children. J Pediatr Adolesc Gynecol 2007; 20:289–
accidents. Pediatrics 2002; 110:e16; http://www.pediatrics.org/cgi/content/ 292.
full/110/2/e16. This study from Vienna, Austria, reports on findings in 180 girls examined between
1996 and 2006 for suspected sexual abuse. Routine vaginal cultures were taken
16 Boos SC, Rosas AJ, Boyle C, McCann J. Anogenital injuries in child pedes-
from all girls and both Gardnerella vaginalis and Ureaplasma were recovered
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significantly more often in adolescent compared with prepubertal girls.
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org/cgi/content/full/112/1/e77. 33 Dubowitz H. Healing of hymenal injuries: implications for child healthcare
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17 Heger A, Ticson L, Velasquez O, Bernier R. Children referred for possible
This commentary to the article by McCann et al. [21] reviews the findings
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reported in the article and also discusses larger issues related to the evaluation of
26:645–659.
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18 Adams JA, Botash AS, Kellogg N. Differences in hymenal morphology
34 Muram D, Simmons KJ. Pattern recognition in pediatric and adolescent
between adolescent girls with and without a history of consensual sexual
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21:103–108.
19 Kellogg ND, Menard SW, Santos A. Genital anatomy in pregnant adoles- This is a report of a small but sobering study in which physicians reviewed color
cents: ‘normal’ doesn’t mean ‘nothing happened’. Pediatr 2004; 223:e67– photographs of common pediatric gynecologic conditions. The overall percentage
e69; http://www.pediatrics.org/cgi/content/full/113/1/e67. of correct interpretations ranged from 42% for residents to 58% for faculty. The
20 Jones JS, Rossman L, Hartman M, Alexander CC. Anogenital injuries in authors propose that there is a need for an easily accessible library of images to
adolescents after consensual sexual intercourse. Acad Emerg Med 2003; assist physicians with accurate diagnosis of normal and abnormal gynecologic
10:1378–1383. conditions in children.

21 McCann J, Miyamoto S, Boyle C, Rogers K. Healing of hymenal injuries in 35 Botash AS, Galloway AE, Booth T, et al. Continuing medical education in child
 prepubertal and adolescent girls: a descriptive study. Pediatrics 2007; 119: sexual abuse: cognitive gain but not expertise. Arch Pediatr Adolesc Med
e1094–e1106; http://www.pediatrics.org/cgi/content/full/119/5/e1094. 2005; 159:561–566.
Downloaded May 16, 2007. 36 Shapiro RA, Makoroff KL. Sexually transmitted diseases in sexually
The authors report the findings of a retrospective study reviewing photographs and abused girls and adolescents. Curr Opin Obstet Gynecol 2006; 18:
cases of genital trauma and healing in 113 prepubertal girls and 126 adolescent 492–497.
girls. The presentation of the findings is somewhat difficult to understand, but the
37 Xu F, Lee FK, Morrow RA, et al. Seroprevalence of herpes simplex virus type 1
study is important because of the large number of cases reviewed and the finding
 in children in the United States. J Pediatr 2007; 151:374–377.
that most minor injuries healed completely.
This important article reports the increasing rates of antibodies to HSV-1 among
22 McCann J, Miyamoto S, Boyle C, Rogers K. Healing of nonhymenal genital children from 6 to 12 years of age and the high rates of positive antibodies among
 injuries in prepubertal and adolescent girls: a descriptive study. J Pediatr children living below the poverty line (52%). The implication is that HSV-1 is
2007; 120:1000–1011. commonly spread by household contact rather than sexual contact, though this is
This is the second article from the retrospective study reviewing photographs of not specifically stated.
injuries. The main findings were that petechiae resolved within 24 h, ‘blood blisters’
38 Tunback P, Bergstrom T, Claesson BA, et al. Early acquisition of herpes
persisted up to 24 days, and deep perineal lacerations took up to 20 days to heal,
 simplex virus type 1 antibodies in children: a longitudinal serological study.
following the initial injury.
J Clin Virol 2007; 40:26–30.
23 Boyle C, McCann J, Miyamoto S, Rogers K. Comparison of examination In this article from Sweden, the authors show that antibodies to HSV-1 and HSV-2
 methods used in the evaluation of prepubertal and pubertal female genitalia: a are common in mothers and decrease in the children up to the age of 1 year. None
descriptive study. Child Abuse Negl 2008; 32:229–243. of the infants had antibodies to HSV-2 after maternal antibodies disappeared, but
The authors reviewed a subset of cases in which photographs were taken using 30% acquired antibodies to HSV-1, most between 12 and 30 months of age. This
labial separation, labial traction, and the prone knee–chest position. The latter study implies that HSV-2 infections in children may be more concerning for sexual
position was found to be the most effective in showing hymen lacerations. transmission and HSV-1 infections less concerning.
24 Drocton P, Sachs C, Chu L, Wheeler M. Validation set correlates of anogenital 39 Gupta R, Warren T, Wald A. Genital herpes. Lancet 2007; 370:2127–
 injury after sexual assault. Acad Emerg Med 2008; 15:1–8.  2137.
The authors of this article used an electronic database to summarize demographic The authors present a comprehensive and scholarly review of the epidemiology,
data and medical findings in 2879 cases of acute sexual assault. Half of the cases diagnosis, and treatment of genital herpes in adults.
were of girls/women between age 12 and 20 years, and this group had the highest
40 Reading R, Rannan-Eilya Y. Evidence for sexual transmission of genital herpes
rates of injury. Although limited in not being able to separate out the youngest
 in children. Arch Dis Child 2007; 92:608–618.
victims, this study is important because of the ability to correlate findings with
An attempt was made by the authors to systematically review published research
specific factors related to the assault.
concerning the transmission of HSV in children. None of the studies had sufficient
25 Hobbs CJ, Osman J. Genital injuries in boys and abuse. Arch Dis Child 2007; details regarding the cases of genital herpes and the possible modes of transmis-
 92:328–331. sion, so the authors concluded that the evidence concerning the likelihood of
This article reports on the types of genital injuries in a population of boys in Leeds, sexual transmission of HSV in children is weak.
UK, who were referred for sexual abuse evaluations because of genital injuries. The
author’s listing of anal findings such as venous pooling and anal gaping as signs of 41 Huppert JS, Gerber MA, Deitch HR, et al. Vulvar ulcers in young females:
injury does not reflect current opinion in the United States regarding the non- a manifestation of apthosis. J Pediatr Adolesc Gynecol 2006; 19:195–
specific nature of these findings. 204.

26 Palusci VJ, Cox EO, Shatz EM, Schultze JM. Urgent medical assessment after 42 Goodyear-Smith F. What is the evidence for nonsexual transmission of
child sexual abuse. Child Abuse Negl 2006; 30:367–380.  gonorrhea in children after the neonatal period? A systematic review.
J Forensic Legal Med 2007; 14:489–502.
27 Young KL, Jones JG, Worthington T, et al. Forensic laboratory evidence in The author asks a legitimate question and this review with 116 references makes
sexually abused children and adolescents. Arch Pediatr Adolesc Med 2006; very interesting reading. Although a vast majority of cases of genital gonorrhea in
160:585–588. children are due to sexual abuse, a careful reading of this article may convince
28 Christian CW, Lavelle JM, De Jong AR, et al. Forensic findings in prepubertal medical providers that transmission by mucosal contact with infected and infective
victims of sexual assault. Pediatrics 2000; 106:100–104. secretions can also spread gonorrhea.

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