Diagnosis of Sexual Abuse in Children

Sexual abuse is often connected with other types of abuse. Addressing such abuse requires collaboration and early consultation with an experienced specialist. Sexual abuse in children may be revealed during interviews or medical exams. The abuser typically has a specific relationship with the child, which may involve affection mixed with threats. Due to this complex dynamic, disclosure by the child is rare, especially in the early stages of the abusive relationship. Identifying sexual abuse requires linking history, behavior, and physical signs.

Signs and Symptoms

(a) Vaginal Bleeding – Possible causes:
• Trauma (e.g., sexual abuse or accidental injury—detailed examination of circumstances is essential)
• Premature puberty
• Skin conditions (e.g., lichen sclerosus, which doesn’t rule out abuse)
• Rare anatomical anomalies (e.g., hemangioma)

(b) Rectal Bleeding – Possible causes:
• Fissures (due to severe constipation, inflammatory bowel disease, or abuse)
• Constipation or inflammatory bowel disease
• Infectious diarrhea
• Polyps (rare)

(c) Vulvovaginitis (with or without dysuria) – Possible causes:
• Poor hygiene
• Trauma (intercrural sex)
• Skin conditions (e.g., lichen sclerosus, eczema)
• Allergies (to soap, shampoo, etc.)
• Infection/invasion (persistent cases require additional investigation)
• Masturbation (excessive or public)
• Foreign objects in anus/vagina (rare but could be abuse-related)

(d) Encopresis/Enuresis – Often due to psychological or behavioral factors, but sexual abuse should be considered in differential diagnosis.

(e) Behavioral Manifestations:
• Self-harm, aggression, sexualized behavior, or motor disruptions
• Manifestations like nightmares, academic decline, anxiety, and clinginess should prompt further investigation if no obvious cause is found.

(f) Diagnostic Indicators:
• Pregnancy
• Sexually transmitted infections (e.g., chlamydia, gonorrhea)
• Sperm evidence

History

As with any diagnosis, taking a thorough history is critical. Important factors to consider include urinary and bowel issues, history of genital or anal symptoms, behavioral changes, and in adolescents, menstrual and sexual history. If there’s a strong suspicion of sexual abuse, law enforcement and child protection services must be involved for child interviews and investigation. Avoid direct or leading questions, and record both questions and responses verbatim, as they may be used as evidence in court.

When to Examine the Child’s Genitals and Anus

(a) Examination may be part of routine care or necessary in certain conditions (e.g., urinary tract infection, encopresis, abdominal pain, or physical injury).
(b) Obtain consent from both the child and parent before examination. Statements like “I usually examine the whole body, including the lower parts” may be helpful.
(c) If abuse is suspected, the examination should be conducted by a certified specialist with experience in sexual abuse, ideally including colposcopy and photodocumentation. Testing for sexually transmitted infections (STI) is essential.

Examination Methodology

• For suspected abuse:
o Female Genital Examination: Typically done in the frog-leg position, or knees-to-chest for better visualization.
o Anal Examination: Typically performed in a left-side lying position; observe for any delayed dilation, which may suggest abuse (though not diagnostic alone).
o Collect samples for STI testing and forensic examination.

Evidence Collection

• Evidence collection must be meticulous and recorded accurately, noting each individual who handles the evidence. In acute cases, evidence should be collected within 24 hours, though it may be viable up to 72 hours or even a week post-incident.

Management

• After sample collection, consider age-appropriate contraception and prescribe prophylactic antibiotics if STIs are detected.
• Address all of the child's needs, including educational, social, and developmental considerations, and assess for possible HIV exposure.
• Discuss testing options with a virologist if HIV infection is suspected.