There are various elements to the evaluation of a child or adolescent who presents with potential sexual abuse. These include:
Medical Interview – The medical provider gathers pertinent medical information from the child or caretaker (medications, hospitalizations, allergies, review of systems, etc.). Further, the medical interview often provides an opportunity to clarify some intake information directly from the caregiver.
Medical History with Child – The medical provider explains the examination to the child or adolescent and directly and objectively, and may gather from the child the information relevant to medical diagnosis and treatment. This is distinct from the forensic interview, and should solely focus on medical symptoms and sexual activity aside from the abuse issues at hand and answering questions the child or adolescent may have.
General Physical Examination – A head-to-toe inspection of the child’s body is conducted with a second medical professional chaperone (nurse, medical assistant) and the patient appropriately covered with a gown. Close inspection of all skin and mucosal surfaces (e.g., behind the ears and inside the mouth) should be part of any child abuse assessment. The provider must keep in mind that the examination is of a child – not just the genitals – and be comprehensive in the approach.
Genitourinary and Anal Examination –In order to adequately assess potential genital findings, there are various procedures and/or techniques that maximize accuracy. For example, the way a child is positioned for an exam may influence the appearance of the genital structures. The child or adolescent is placed in the supine frog-leg or supine stirrup position depending on age. A technique called labial separation (gentle separation of the labia majora) and another called labial traction (gentle downward pulling of the labia) allow the genital structures to be visualized and documented using photo or video colposcopy. A speculum examination is not appropriate in the evaluation of a child or adolescent in the context of sexual abuse. In boys, the penis, testes, and scrotum are evaluated also utilizing colposcopic documentation. The anus should be evaluated in the lateral decubitus (side) position, with gentle traction to allow natural relaxation of the external sphincter. If an examiner interprets the examination as evidentiary, there are additional techniques and positions that confirm the finding including prone knee–chest position, and the use of normal saline, and a Q-tip swab to outline the hymenal edge.
Collection of Forensic Evidence – Most general evidence collection protocols recommend the collection of forensic evidence within 96 hours of a sexual assault. In prepubertal children, it is rare to find forensic evidence beyond 24 hours. Collection of clothing and linens for analysis is more likely to result in positive findings.
Testing for Sexually Transmitted Disease – When a prepubertal child with a history of or suspicion of sexual contact is seen within 96 hours, there is debate as to whether baseline testing for a sexually transmitted disease (STD) is necessary. Such tests include:
- cultures for Neisseria gonorrhea (oral, vaginal/ urethral, and rectal);
- cultures for Chlamydia trachomatis (vaginal/ urethral and rectal);
- vaginal secretions for Trichomonas vagi- nalis and Candida species with any history of discharge;
- test for syphilis [rapid plasma reagin (RPR)] and blood borne hepatitis B virus (HBV), and hepatitis C virus (HCV);
- test for human immunodeficiency virus (HIV) [enzyme-linked immuno sorbent assay (ELISA)];
- follow-up cultures one to 2 weeks after the initial exposure are recommended. Follow-up testing for syphilis, HIV, and HBV is recommended 4 – 6 weeks after the initial exposure. Testing for syphilis, HIV, HBV, and HBC is recommended at 3 months after the exposure. Testing for HIV and HCV is recommended at 6 months after the exposure.
Prophylactic Medication for Sexually Transmitted Disease and Pregnancy – It is strongly recommended to discuss risks and benefits with caretakers and factor in the age and risk of reported perpetrator, presence of findings on exam (bleeding/bruising present higher risk), and familial and/or child/adolescent wishes when considering preventive medication.
Interpretation of Medical Evidence – A wide range of normal variants (findings that are not related to sexual abuse) exist in the genitourinary assessment of children. Further, medical conditions, such as urethral prolapse or a non-sexually transmitted infection, may be interpreted erroneously to be evidentiary for abuse. The medical provider should interpret any perceived medical findings with the utmost caution, using evidence-based practice and peer review and/or supervision, depending on the level of expertise.