Guidelines Summary

American Academy of Pedatrics

The 2013 update of the AAP guideline for the evaluation of sexual abuse in children states that the medical assessment of suspected child sexual abuse should include obtaining a history, performing a physical examination, and obtaining appropriate laboratory tests. The role of the physician includes determining the need to report suspected sexual abuse; assessing the physical, emotional, and behavioral consequences of sexual abuse; providing information to parents about how to support their child; and coordinating with other professionals to provide comprehensive treatment and follow-up of children exposed to child sexual abuse.^[20]

Whenever the issue of possible child sexual abuse arises in the office setting, 5 important issues should be addressed.

The child's safety - The health care provider must determine whether the child is at any risk for additional harm if he or she returns home.
Reporting to authorities - In the absence of imminent risk, the physician needs to determine if there is evidence of suspected abuse that would require him or her to contact law enforcement or child protection.
The child's mental health - The child should be assessed for possible mental health problems (e.g., PTSD, depression). If any are identified, appropriate emergency mental health care should be sought.
Need for physical examination - The physician should perform a thorough physical examination to determine whether the child has been injured, particularly if a child is reporting genital or anal pain or bleeding.
Need for forensic evidence collection - If the abuse was recent and involved exchange of bodily fluids, the child should be immediately referred to those capable of gathering forensic evidence.

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Media Gallery

Possible factors influencing the decline in substantiated cases of child sexual abuse. Courtesy of David Finkelhor, PhD.
Adverse Childhood Experience (ACE) Pyramid. Courtesy of the Centers for Disease Control and Prevention (CDC) [https://www.cdc.gov/violenceprevention/aces/about.html].
Infant girl in frog-leg supine position. Genital examination reveals translucent hymenal membrane with significant redundant tissue making hymenal orifice difficult to appreciate in this photo. With further traction applied to both labia majora, the hymenal orifice could be observed. Courtesy of Carol D. Berkowitz, MD.
Infant girl in frog-leg supine position. Hymenal orifice is crescentic (little tissue is present at 12-o'clock posterior). Hymen is thin and translucent with vessels visible. Hymenal edge is regular and without interruption. Courtesy of Carol D. Berkowitz, MD.
Girl in knee-chest position. Hymenal orifice is crescentic, thin, translucent, and without interruption or scarring. Courtesy of Carol D. Berkowitz, MD.
Infant girl in frog-leg supine position. Hymenal orifice is annular, with tissue present around entire opening. Some redundancy is present. Courtesy of Carol D. Berkowitz, MD.
Infant girl in frog-leg supine position. Hymenal orifice is annular with a "bump" at 1-o'clock position and a small "notch" at 10-o'clock position. Hymenal membrane is thin and translucent, with no interruption or scarring. Courtesy of Carol D. Berkowitz, MD.
Girl in frog-leg supine position, exhibiting annular hymenal orifice. Tissue is thin and translucent without disruption or scarring. Courtesy of Carol D. Berkowitz, MD.
Girl in frog-leg supine position exhibiting hymenal orifice, which is crescentic and has symmetric attenuation at lateral margins. No scarring is present. Courtesy of Carol D. Berkowitz, MD.
Girl in frog-leg supine position exhibiting hymen. Hymen is septate; a band of tissue crosses the hymenal orifice. Tissue is thin with no scarring present. Courtesy of Carol D. Berkowitz, MD.
Adolescent girl in supine position demonstrating estrogenized tissue. Hymen is thicker, pink, and fairly opaque with no vessels visible. Tissue is redundant. Courtesy of Carol D. Berkowitz, MD.
Genital examination of adolescent girl revealing estrogenized hymenal tissue that is pink, thick, and opaque. Orifice appears irregular, secondary to significant redundancy of tissue. Courtesy of Carol D. Berkowitz, MD.
Genital examination of adolescent girl demonstrating estrogenized hymenal tissue that is pink, thick, and opaque. Orifice is irregular due to areas of redundancy, especially at the 9-o'clock position. Courtesy of Carol D. Berkowitz, MD.
Prepubertal girl with foul-smelling bloody discharge. On examination, a foreign body in the vagina was found just past the hymenal orifice. The foreign body is lodged in vagina and appears to be toilet tissue that is colonized with bacteria, causing a vulvovaginitis. The foreign body was dislodged with gentle water flushing during examination. Courtesy of Carol D. Berkowitz, MD.
Genital examination of prepubertal girl with foul-smelling bloody discharge. On examination, a foreign body in the vagina was found lodged just past the hymenal orifice and appears to be toilet tissue that is colonized with bacteria, causing a vulvovaginitis. The foreign body was dislodged with gentle water flushing during examination. Courtesy of Carol D. Berkowitz, MD.
Infant girl with imperforate hymen and absence of a hymenal orifice. Courtesy of Carol D. Berkowitz, MD.
Genital examination of girl revealing bruising on medial aspects of labia minora, hymenal trauma with disruption of hymenal tissue, and fresh blood. Courtesy of Carol D. Berkowitz, MD.
Infant girl with significant bruising that involved labia minora and labia majora, hymenal trauma with disruption of hymen, and fresh blood. Courtesy of Carol D. Berkowitz, MD.
Genital examination 10 days after infant girl presented with significant bruising that involved labia minora and labia majora, hymenal trauma with disruption of hymen, and fresh blood. Bruising on vulvar structure is nearly resolved. Hymen is healing and no blood is observed. Courtesy of Carol D. Berkowitz, MD.
Genital examination of girl in frog-leg supine position after genital trauma. Examination reveals suture in place at 6-o'clock position to stop bleeding from injury. Hymenal edge is irregular and asymmetric. Courtesy of Carol D. Berkowitz, MD.
US Maltreatment Trends, 1990-2019. Courtesy of David Finkelhor, PhD [Finkelhor D, Saito K, Jones L. Updated Trends in Child Maltreatment, 2019. Crimes Against Children Research Center, University of New Hampshire. February 2021. Online at: http://unh.edu/ccrc/pdf/CV203%20-%20Updated%20trends%202019_ks_df.pdf.].

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Author

Angelo P Giardino, MD, PhD, MPH, FAAP Wilma T Gibson Presidential Professor and Chair, Department of Pediatrics, University of Utah School of Medicine; Chief Medical Officer, Intermountain Primary Children's Hospital

Angelo P Giardino, MD, PhD, MPH, FAAP is a member of the following medical societies: Academic Pediatric Association, American Academy of Pediatrics, American Professional Society on the Abuse of Children, Harris County Medical Society, International Society for the Prevention of Child Abuse and Neglect, Ray E Helfer Society

Disclosure: Nothing to disclose.

Coauthor(s)

Reena Isaac, MD Assistant Professor of Pediatrics, Baylor College of Medicine; Forensic Pediatrician, Child Protection Section of Emergency Department, Texas Children’s Hospital, Houston; Staff Physician, Children's Assessment Center, Houston

Reena Isaac, MD is a member of the following medical societies: American Academy of Pediatrics, Texas Pediatric Society, Ray E Helfer Society

Disclosure: Nothing to disclose.

Eileen R Giardino, RN, MSN, PhD, ANP-BC, FNP-BC Associate Professor of Nursing, Department of Family Nursing, University of Texas Health Sciences Center Houston, School of Nursing

Eileen R Giardino, RN, MSN, PhD, ANP-BC, FNP-BC is a member of the following medical societies: American Association of Nurse Practitioners, American College Health Association, American Nurses Association, American Professional Society on the Abuse of Children, International Society for the Prevention of Child Abuse and Neglect

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Chief Editor

Caroly Pataki, MD Health Sciences Clinical Professor of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, David Geffen School of Medicine

Caroly Pataki, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, New York Academy of Sciences, Physicians for Social Responsibility

Disclosure: Nothing to disclose.

Additional Contributors

Chet Johnson, MD Professor of Pediatrics, Associate Director and Developmental-Behavioral Pediatrician, KU Center for Child Health and Development, Shiefelbusch Institute for Life Span Studies; Assistant Dean, Faculty Affairs and Development, University of Kansas School of Medicine

Chet Johnson, MD is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Acknowledgements

The authors acknowledge the consistent support and mentorship by Carol D Berkowitz who, despite multiple clinical, teaching, and administrative responsibilities, has found the time to share her considerable expertise and even took the time out of her busy schedule to provide the photographs used to illustrate the physical findings possible when evaluating cases of suspected child sexual abuse. Dr. Berkowitz exemplifies the characteristics of a committed medical educator who is not limited by organizational or geographic boundaries.

Child Sexual Abuse Guidelines

Guidelines Summary

American Academy of Pedatrics

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