Evaluation of sexual abuse in children and adolescents

INTRODUCTION — Health professionals who care for children in a variety of settings, from clinics and office practices to emergency departments, encounter those who may have been sexually abused. As an example, a clinician may become concerned that a child has been sexually abused because of an unusual injury pattern or behavior identified at the time of a scheduled visit. Alternatively, an evaluation in the emergency department may be initiated when a child is injured or discloses an incident to a caregiver. Specific interviewing skills, evidence-collection procedures, and/or specialized examination techniques may be required to perform a thorough evaluation.

The epidemiology, evaluation, and differential diagnosis of sexual abuse in children and adolescents will be reviewed here. The management and sequelae of childhood sexual abuse and human trafficking, including sex trafficking, are discussed separately. (See "Management and sequelae of sexual abuse in children and adolescents" and "Human trafficking: Identification and evaluation in the health care setting".)

DEFINITIONS — Sexual assault is defined as attempted sexual touching of another person without their consent and includes sexual intercourse (rape), sodomy (oral-genital or anal-genital contact), and fondling [1].

A generally accepted definition of sexual abuse is when a child engages in sexual activity for which they cannot give consent, is unprepared for developmentally, cannot comprehend; and/or an activity that violates the law or social taboos of society [2]. This includes fondling and all forms of oral-genital, genital, or anal contact with the child (whether the victim is clothed or unclothed), as well as non-touching abuses such as exhibitionism, voyeurism, or involving the child in pornography [2-4]. Thus, child sexual abuse can include acts that would be considered sexual assault. For the purpose of this chapter, the term "sexual abuse" will be used to indicate that the perpetrator has a role as a caregiver.

It is important to distinguish between sexual abuse and "sexual play" [4]. Sexual abuse occurs when there is asymmetry in age or development among the participants, with a coercive quality to the event. Sexual play occurs in the absence of coercion and involves children of the same age (separated by no more than four years [5]) or developmental level who engage in viewing or touching each other's genitalia because of mutual interest or curiosity. Sexual play is considered normal behavior and does not have the psychological, developmental, or physical consequences of sexual abuse [3]. In addition to sexual play, many preschool-aged children mimic behaviors of older family members such as flirting, batting eyelids, and "walking sexy." This behavior is also considered part of normal development [6].

EPIDEMIOLOGY — The United States Department of Health and Human Services reports that >60,000 children are sexually abused annually [7]. Each year, approximately 1 percent of children experience some form of sexual abuse [3]. Worldwide, an estimated 25 percent of girls and 9 percent of boys are exposed to any form of sexual abuse during childhood [8].

The number of reported sexual abuse grossly underestimates the true prevalence. Comparison of the prevalence of substantiated sexual abuse in developed countries (United Kingdom, United States, Canada, Australia) as determined by agency reports with self-reported sexual abuse by parents or victims who reside in these countries suggests that only 1 in 10 instances of sexual abuse comes to official attention [8]. One United States survey found that 20 percent of high school students experienced sexual assault, but only 50 percent of these students revealed the incident to someone else [9,10]. Reasons that these events go unreported include fear of the medical evaluation, social stigma, and desire for privacy [10-12].

Sexual abuse of children occurs primarily in the preadolescent years [13,14]. Girls are more likely than boys to be sexually abused; however, boys are less likely to report sexual abuse [14].

Perpetrators of sexual abuse are usually male and often trusted adult acquaintances [5,13,15]. Statistics from reported cases in the United States indicate that "father" and "other relatives" were responsible for 21 and 19 percent of sexual abuse victims, respectively; mothers acting alone or with another person accounted for 4 and 8 percent of perpetrators, respectively [16]. In one German study, 10.5 percent of all participants reported child sexual abuse, female perpetrators were involved in 10 percent of the abuse cases, and victims of female perpetrators were significantly more often male. A quarter of the adult female perpetrators were the mother figure of the child [17]. In adolescence, peers may constitute the largest group of perpetrators [18]. Perpetrators report that they gained access to children through caretaking (eg, babysitting); that they targeted children using bribes, gifts, and games; and they systematically desensitized children through touch, talk about sex, and persuasion [19].

Victims of sexual abuse include children from all social, cultural, and economic backgrounds. However, some features related to family structure and parenting have been associated with an increased risk of childhood sexual abuse; the increased risk associated with these features is small, and their absence in no way precludes sexual abuse as a possibility [14]. These features include poor parent-child relationships, poor relationships between parents/primary caregivers, the absence of a protective parent/primary caregiver, and the presence of a nonbiologically related male in the home [13,14].

PRESENTATION — Victims of sexual abuse may present with a variety of medical complaints. They may be brought to medical attention specifically for evaluation of possible sexual abuse, or they may present for routine care or acute evaluation of medical or behavioral concerns that are not obviously related to the abuse. In the latter scenarios, the diagnosis of sexual abuse depends, to some extent, upon the willingness of the evaluating physician to consider it as a possibility [3].

Most of the complaints that are possible indicators of sexual abuse are nonspecific (table 1). Those that are more specific for inappropriate sexual contact or exposure include rectal or genital bleeding and/or sexually transmitted infections (STIs) that were not acquired perinatally.

Behaviors that may indicate that a child has been sexually abused include perpetration of sexual abuse and/or sexually explicit acting out, developmentally inappropriate knowledge of sexual activities, or developmentally inappropriate play (such as repeatedly touching an adult's genitals or asking an adult to touch the child's genitals). Such behaviors are learned and are not a normal part of childhood fantasy [13,20-22].

EVALUATION — The medical evaluation of childhood sexual abuse has several immediate goals [23,24]:

●To identify injuries or other conditions that require treatment

●To screen for or diagnose sexually transmitted infections (STIs)

●To evaluate for and, if possible, reduce the risk of pregnancy

●To document findings of potential forensic value

The evaluation for possible sexual abuse includes a history and physical examination and may include forensic evidence collection and/or screening for STIs. Whenever possible, the evaluation should be performed by an experienced child abuse team, including a child abuse specialist or clinician with similar experience. Consultation with a regional child abuse specialist or assessment center may also be helpful in difficult cases or in cases that occur in the context of other family problems such as family violence or substance abuse [3]. (See 'Resources' below.)

Sexual abuse evaluations are best performed in a nonemergency setting, such as a child abuse advocacy center, where the history and physical examination can be performed in a calm, quiet environment and proceed at a pace tailored to the victim's needs.

Urgent evaluation is necessary under the following circumstances and typically occurs in an emergency setting [3,13,25]:

●The alleged abuse occurred within 72 to 96 hours, depending upon jurisdiction.

●There are genital or anal injuries that require treatment.

●There is obvious forensic evidence on the patient's clothes or body that must be collected.

●There is danger of continued abuse or reprisal by the alleged perpetrator.

●The victim has reported homicidal or suicidal ideation or other emergency complaints.

In all other cases, an evaluation by an experienced child abuse team, if available, and in a nonemergency setting should be scheduled as soon as possible after the alleged incident or disclosure [3,26]. In addition to an evaluation for sexual abuse, it is essential that each child receives a thorough general medical assessment that may identify unmet medical and psychological needs [24].

History — Obtaining an unbiased history from a child who may have been sexually abused may be the most important part of the evaluation, particularly since diagnostic physical findings are frequently absent [5,13,22,27]. A history of sexual abuse that is obtained in the course of medical diagnosis and treatment may be admissible in court as an exception to the laws restricting hearsay testimony. Thus, complete (verbatim, if possible) documentation in the medical record of questions and answers using quotation marks when appropriate is critical [15,28,29]. (See "Child abuse: Social and medicolegal issues".)

On the other hand, in the evaluation of nonspecific complaints that are possibly related to sexual abuse, the history should focus on differentiating among possible explanations for the child's symptoms: sexual abuse, physical abuse to the genital area, unintentional injury to the genital area, or other medical conditions [3,30]. (See 'Differential diagnosis' below.)

Caregiver history — The history regarding concerns about sexual abuse and any accompanying symptoms should be obtained from the parent or caregiver separately from the child in a calm, unhurried manner. Many parents/primary caregivers are understandably worried and appreciate an opportunity to share their concerns privately.

The history should be comprehensive and include the child's current and past medical problems as well as social and family histories [13]. The review of systems should identify changes in bowel or bladder habits (such as enuresis or encopresis), sleep disturbances, and behavioral changes. It is important to note when the changes were first noticed, as sexual abuse often triggers these symptoms.

Parents/primary caregivers should be asked how the abuse came to light or, if the child has not disclosed abuse, why the parents/primary caregivers suspect it [31]. For children who have made a disclosure, the content of statements to parents or other caregivers should be documented.

Patient interview — Since the history from the child is such an important part of the evaluation, it should be performed by an experienced professional. For patients who have disclosed sexual abuse, the history obtained by the evaluating physician may be abbreviated [13]. Investigative interviews should be performed by the appropriate agencies, and if possible, by forensic interviewers [5,15]. This minimizes the need for a child to relate painful and distressing information on multiple occasions and also reduces bias that may be introduced by repeated, suggestive, or leading questions.

In cases where sexual abuse is suspected but not yet disclosed, the evaluating physician must obtain additional information from the caregiver. Child Protective Services (CPS) should intervene to determine the need for a trained forensic interviewer when there is reasonable concern that abuse has occurred.

During the evaluation of child sexual abuse cases, the role of each clinician should be clearly defined and based on clinical expertise. As an example, a clinical assistant who is handling laboratory specimens should not ask the child or family about the details of the abuse. In the situation where the clinician must obtain a history of abuse from the child, they must remember that this should be an opportunity for the patient to tell the story without guidance or prompting from the parent/primary caregiver or examiner.

The following section outlines a common approach taken by trained interviewers when questioning a child or adolescent who has been sexually abused.

●Children – Children should be interviewed without the parents or primary caregivers present, if possible. However, when the child is uncomfortable alone with the examiner, it may be more effective to permit the parent/primary caregiver to stay. The clinician should explain to the parent/primary caregiver the importance of obtaining the history in the child's own words. The presence of a parent/primary caregiver can be an opportunity to observe parent-child interaction. Although there is no consensus regarding the necessity of a chaperone for the interview, we suggest that it be conducted with either the parent/primary caregiver or a Child Life specialist in the room. A translator should be used if necessary.

In addition to obtaining the patient history, the clinician should explain the reason for the visit and describe the examination that may follow. As rapport is established, it is important to observe the words the child uses to describe his or her body parts.

The accuracy of the history may be improved by asking open-ended questions, such as "Has someone ever touched you in a way you didn't like or that made you feel uncomfortable?" [13,15]. To encourage a spontaneous narrative, the examiner should avoid any display of shock or disbelief, and maintain a "Tell me more" or "And then what happened?" approach [3,4].

When an incident is disclosed, the following information must be obtained with a gentle and nonthreatening manner, using developmentally appropriate language [31]:

•Who was the person who did this?

•With what part of his/her body?

•What part(s) of the patient's body was (were) touched?

•How many times was the child touched?

•When was the last time that it happened?

•At what location did the abuse occur?

•Was there any exposure to blood or body fluids?

•Did the child experience pain to the affected body part?

•For male assailants, was there ejaculation?

•Did the child tell anyone about the incident?

Leading and suggestive questions (such as, "Mr. X touched your bottom, didn't he?" or "Did Mr. X touch your bottom?") should be avoided. Allowing the child to use a doll or drawing to describe what happened may be helpful in obtaining and clarifying information. The patient may disclose more details during the course of the physical examination.

At the end of the history, it is important that the child understands that they did the right thing in telling what happened, that they did nothing wrong, and that they are not in trouble [13]. (See "Management and sequelae of sexual abuse in children and adolescents", section on 'Anticipatory guidance'.)

●Adolescents – The adolescent history should occur without the presence of family members. It is helpful to inform the adolescent that this is an opportunity for him/her to ask questions as well as share details about the event(s).

The patient should be told that information disclosed in this setting is, to an extent, confidential. Adolescents may receive confidentiality around some issues (as an example, their sexual activity), but health care providers are mandated to report disclosures about sexual abuse to a CPS agency. Many adolescents are more willing to share information once they realize that the law grants them some protection of confidentiality. (See "Confidentiality in adolescent health care".)

At the conclusion of the interview, the examiner should support the adolescent's decision to report the abuse and reassure the adolescent that they have done nothing wrong [13].

Physical examination — As with the history, the nature and timing of the examination depend to some extent upon the presenting complaint. The examination should be performed by trained and experienced examiners as soon as possible after the alleged incident [3,26].

The physical examination of the possibly sexually abused child may be more difficult for the examiner than the child. It is helpful to approach this evaluation as one would any other type of physical complaint. The tone in the room is often set by the examiner; the more comfortable they are, the more comfortable the patient and their parent/primary caregiver(s) will be.

The physical examination should not result in additional emotional or physical trauma [3]. The purpose and noninvasive nature of the examination should be explained to the child and parents/primary caregivers before it is performed [3,26]. Many children and adolescents are comforted by knowing that "adults need to have these examinations too" and that such examinations can help the child or adolescent know that his or her body is "okay."

Parents/primary caregivers may expect that the physical examination will yield evidence that confirms or excludes abuse. It is important to explain that physical evidence is rarely present in pediatric patients who are evaluated for sexual abuse [22]. Even among children who report vaginal or anal penetration, the rate of abnormal physical examination findings is only 5 to 15 percent [22,31,32]. The examination is important for assessing medical problems that require attention, but other aspects of the evaluation (eg, history, laboratory analysis) may be more helpful in determining whether the child has been abused. (See 'Diagnosis' below.)

During the examination, a supportive adult who is not suspected of involvement in the abuse should be present [3]. Recognizing that the physical examination may be emotionally difficult for the child, permitting the child to decide who they would prefer to have in the examination room is one way to empower him or her. Distraction techniques may help the child tolerate the uncomfortable nature of the evaluation. Respect for the child's modesty whenever possible (such as by using drapes) is important [13]. For children who are extremely anxious or uncooperative, use of a mild sedative, with careful monitoring, may be considered [3,23]. (See "Procedural sedation in children: Approach".)

The examination should include the mouth, breasts, genitals, inner thighs, perineal region, buttocks, and anus [3]. Good illumination is essential [15,33]. An otoscope light source often provides sufficient illumination for direct visualization of genital structures. Colposcopy offers the advantages of magnification and photographic documentation [13]. It may be helpful in identifying subtle lacerations or tears, but is not considered essential [23,34]. Signs of trauma should be documented by photographs or detailed drawings [3]. (See "Child abuse: Social and medicolegal issues".)

An ultraviolet (UV) or Wood's lamp may be used for detecting semen within several hours after the abuse. However, urine and oily fluids also fluoresce under the Wood's lamp [11,35,36]. In addition, semen may not reliably fluoresce using a Wood's lamp (360 nm wavelength) [35]. Consequently, the Wood's lamp examination is most helpful for identifying suspicious areas for more definitive forensic testing [23]. An alternate UV light source, such as one with a 420 to 450 nm wavelength, may be more useful for identifying semen on the skin. (See 'Forensic evidence collection' below.)

Oral cavity — Examination of the oral cavity should include evaluation for evidence of forced oral penetration such as bruising or petechiae of the hard or soft palate and/or tears of the frenulum [15].

Female genitalia — The anatomy of the female genitalia is depicted in the figure (figure 1). In all girls, the labia majora, labia minora, introitus, and hymen should be inspected for erythema, lesions, abrasions, or tears. The presence of a vaginal discharge in a prepubertal girl should prompt evaluation for STIs [37,38]. (See 'Sexually transmitted infection testing' below.)

The female genitalia are best viewed with the child lying supine (either on the examination table or in the lap of an adult, depending upon the child's comfort) with her hips externally rotated and knees flexed (frog-leg position). This allows examination of the external genitalia, vaginal vestibule, and hymenal structures. The prone knee-chest position (figure 2) is helpful in evaluating the anogenital region. In girls, it permits better visualization of the posterior hymen, vagina, and sometimes cervix [13,26]. The lithotomy position may be helpful in older girls [22].

Prepubertal girls (Tanner stage 1 or 2 for pubic hair) do not require a speculum examination unless there is active bleeding of unknown etiology [13,22]. When a speculum examination is required, the child should be adequately sedated, and the hymenal findings (eg, hymen configuration, presence of tears, erythema, abrasions) should be clearly documented before insertion of the speculum. (See "Procedural sedation in children: Approach".)

A speculum examination may be necessary for pubertal adolescent females. Saline or water should be used instead of petroleum-based lubricants, since petroleum-based lubricants may affect sperm motility and culture results [9,39]. The vaginal walls as well as the cervix should be visualized to detect any evidence of trauma and to obtain samples from fluid collections. After the speculum examination is completed, a bimanual examination should be performed to assess adnexal and cervical tenderness. A rectal examination may be included as indicated.

●Hymen – One of the most challenging aspects of the female genitalia examination is evaluation of the hymen. Visualization of the hymen is best achieved by gently grasping the labia minora bilaterally and pulling downward and outward when the patient is lying supine. The redundant folds of the estrogenized adolescent hymen may be more easily visualized using a moistened cotton swap or saline drops to fold out the edges [13].

The appearance of the hymen changes with age and in response to hormonal influences [40]. The prepubertal hymen is characterized as thin, translucent, and sensitive to touch (figure 3). It becomes thickened, elastic, redundant, and accommodating in puberty, as the result of a physiologic increase in estrogen exposure. Common normal variations in the appearance of the hymen include imperforate, microperforate, cribriform, and septate forms (figure 4) [6].

The significance of notches or clefts in the hymen depends upon the location and extent of the defect [41]. Superficial notches can occur in the absence of abuse [6,13,40], whereas deep notches (ie, >50 percent of hymenal diameter) are more concerning for abuse [6,41,42], although this finding is controversial [31]. (See 'Diagnosis' below.)

Acute lacerations, transections (clefts that extend to the junction of the hymen and the vestibule), and bruising of the hymen are more specific for penetrating sexual trauma, as is the absence of hymenal tissue [6,31,41,42]. However, the absence of these findings is common in girls who have suffered perceived genital penetration [43-45]. For example, an observational study of 506 girls, age 5 to 17 years who disclosed penile-genital penetrative abuse, found that most girls did not have definitive physical findings of abuse regardless of the number of reported penetrations [45]. Specifically, no findings were seen on expert review of photocolposcopy in all of the girls less than 10 years of age (n = 74), 87 percent of girls ≥10 years of age with no history of consensual sex (358 of 410 patients), and 82 percent of girls ≥10 years of age with a history of consensual sex (18 of 22 patients).

Attachments or fusions between the labia minora and hymen may represent prior hymenal injury and are suggestive of abuse [34]. In contrast, labial adhesions (agglutination or fusion of the labia minora in the midline) normally occur in children and are not indicators of abuse.

Measurements of the hymenal orifice vary widely among abused and normal children [22,40,46,47]. Consequently, the transverse diameter of the hymenal orifice is not a marker for whether or not vaginal penetration occurred. (See 'Diagnosis' below.)

Male genitalia — Male genitalia may be examined with the patient standing or supine. The anatomy of the male genitalia is depicted in the picture (picture 1). A younger child may be more comfortable being examined in his parent/primary caregiver's lap. He should be supine in the frog-legged position, so that the penis, scrotum, perineal area, and anus can be visualized. (See "The pediatric physical examination: The perineum", section on 'Male genitourinary system'.)

The scrotum and penis should be examined for signs of acute or chronic trauma, including erythema, bruises, bite marks, or abrasions.

The urethral meatus should be examined for erythema and lacerations. Genital injuries that have been described in retrospective series include lacerations, bruises, and burns [48,49]. Penile and anal injuries are much more common than injuries to the scrotum.

Discharge at the urethral meatus may indicate infection. Penile or anal secretions should be obtained via swabs and cultured when discharge is noted. Anal secretions should be examined for evidence of semen if anal penetration within the previous 24 hours is suspected or reported (see 'Sexually transmitted infection testing' below and 'Forensic evidence collection' below). Lesions suggestive of STIs should be noted (eg, ulcerations, condyloma lata). (See appropriate topic reviews).

Perianal area — Examination of the anus in both males and females may be accomplished with the patient lying in the lateral recumbent position and grasping his or her knees. The examiner separates the buttocks for approximately 30 seconds, allowing sphincter relaxation and visualization of the anal canal. If penetration is suspected, a stool guaiac test should be performed [12].

Laxity of the anus may represent abuse [50,51]. It also can be seen with chronic constipation, neurologic disorders, or sedation. Dilation greater than 20 mm is suggestive of abuse if there is no stool in the ampulla [31]. However, consensus regarding the significance of this finding is lacking (see 'Diagnosis' below). Irregularity of anal folds after complete dilation is suggestive of abuse as well [51].

Evidence of acute anal trauma may be seen if the child is evaluated soon after the abuse; however, anorectal changes are rarely definitive indicators of abuse. Swelling of the anus with blue discoloration is suggestive of trauma [50] and may be present up to 48 hours after the event. It is important not to confuse this finding with hemorrhoids (picture 2A-B). Perianal erythema is suspicious for trauma [50]. It may also be seen in children with encopresis, poor hygiene, pinworms, or Group A streptococcal or staphylococcal infection. (See 'Differential diagnosis' below.)

Penetrating injuries causing lacerations of the rectum may heal with scarring but over time are difficult to detect. Midline anal tags are not indicative of abuse, whereas deformities outside of the midline may indicate chronic trauma [12,13].

Forensic evidence collection — Material evidence, when it is identified, is invaluable in the investigation of allegations of sexual abuse [52]. Every institution that provides care to victims of alleged sexual abuse must have an organized approach to the collection of forensic evidence. Many states have developed the Sexual Assault Nurse Evaluator (SANE) system, which utilizes specially trained nurse examiners for evidence collection from adults and children. (See "Evaluation and management of adult and adolescent sexual assault victims in the emergency department", section on 'Trained providers'.)

The use of SANEs in the pediatric emergency department setting may improve the medical care of children and adolescents who have been sexually abused; it has been demonstrated that such patients are more likely to have documentation of anogenital injury, more appropriate testing for STIs and pregnancy when indicated, and more referrals for mental health services when SANEs are involved [53,54]. However, the impact of SANEs in the judicial outcomes in such cases is not clear [54].

Utilization of specific guidelines for adolescents with sexual assault is associated with more frequent provision of prophylactic therapy and may aid in the timely evaluation and treatment of patients in the emergency department setting when SANEs are not available [55].

Timing — Current guidelines on evidence collection reflect data and conclusions from adult studies that may not be directly applicable to children [56]. Several retrospective series have demonstrated that the yield for forensic examinations in children is low and that the majority of forensic evidence is found on clothing and linens [57-59]. However, more recent evidence suggests that DNA can be recovered from body swabs of prepubertal children even after 24 hours have elapsed since the assault and that recovery of evidence was not correlated with physical findings or laboratory evidence [60,61]. Thus, the risks and benefits of forensic evidence collection should be weighed carefully in each case, especially in prepubertal children. Arrangements should be made such that the most experienced examiner collects forensic evidence in a manner and setting that is emotionally supportive for the child or adolescent and family.

The decision to collect forensic evidence from children who may have been sexually abused should take into consideration state protocols, the probability that the examination will yield evidence, and the potential emotional impact of the collection procedure on the child. Whenever possible, the decision to perform a forensic examination should be made by individuals with training and experience in child sexual abuse.

Careful documentation of the decision-making process regarding evidence collection is essential. Reasons for not collecting evidence or modifying the type of evidence that is collected must be documented. Information should be included regarding the emotional needs of the child and details of the abuse that are likely to decrease the yield of evidence (such as the use of condoms, lubricant, or showering or bathing prior to the examination).

For prepubertal children and adolescents who are evaluated within 24 hours of the alleged abuse, forensic evidence should generally be collected in any of the following situations:

●There is reasonable concern that sexual abuse has occurred.

●The child has a genital injury as the result of alleged sexual abuse.

●Clothing or linen associated with the abuse is available.

●There are other concerning clinical features.

For children who are evaluated more than 24 hours after the incident, protocols of the local jurisdiction should be followed, recognizing that the yield in evidence collection often decreases after 24 hours. The clinician must also consider that evidence may be identified that was unanticipated by the child's history or general physical examination and that there are reported instances of collection of identifiable DNA samples beyond 24 hours in young children under 10 years of age [57,60,61].

Although limited data suggest that the yield of evidentiary exams after 24 hours is also low for adolescents, patients in this age group are usually managed according to adult protocols [52,56]. (See "Evaluation and management of adult and adolescent sexual assault victims in the emergency department", section on 'Forensic evaluation'.)

Evidence collection may be modified (as allowed by local protocols) to eliminate procedures that are unlikely to yield evidence based on details of the alleged abuse. Clothing and linen, very important sources for semen and DNA should be collected when available. Aspects of the examination itself that should be considered include:

●DNA evidence may be identified from sources other than semen. Consequently, the clinician should consider the details of the alleged abuse when deciding which parts of the rape kit to complete. As an example, fingernail scrapings should be obtained when a victim describes grabbing the assailant or pulling the assailant's hair.

●Swabs to confirm the presence of semen should be collected from areas of fluorescence identified with an UV light source. (See "Evaluation and management of adult and adolescent sexual assault victims in the emergency department", section on 'Forensic evaluation' and 'Physical examination' above.)

●A speculum examination is not indicated to obtain evidence from prepubertal girls. For those who are postpubertal, collection of semen from vaginal fluid or cervical mucus can be done using swabs or a pipette facilitated by a speculum examination (see 'Female genitalia' above). Motile sperm may be found in the vagina for eight hours and in the cervical mucus for two to three days after intercourse. Nonmotile sperm may persist in the vagina and rectum for 24 hours and in the cervical mucus for 17 days [11,62].

●Photo-documentation is recommended and is especially valuable in cases that have positive genital findings. Photographs or video permit peer review and should be obtained whenever possible. A detailed description of examination findings should always be included in the medical record, even when photo-documentation has been utilized [63,64].

Every effort must be made to collect forensic evidence without traumatizing the child. Some children may require sedation for the procedure, particularly in the unlikely event that a speculum examination is necessary. Evidence can be collected in the operating room for those patients with injuries who require evaluation and/or treatment under general anesthesia.

Sexually transmitted infection testing — The identification of an STI in a prepubertal child or an adolescent who has not become sexually active may be evidence that the child has been sexually abused [65,66]. The prevalence of STIs in pediatric victims of sexual abuse is approximately 5 to 8 percent. However, the prevalence varies according to physical findings, geographic location, and infectious agent [67-71].

Among children undergoing evaluation for sexual abuse, positive test results for an STI are found in up to 25 percent of girls with vaginal discharge and 6.5 percent of girls with normal or nonspecific physical findings [71]. Thus, most sexually abused girls with STIs have normal or nonspecific findings on physical examination. The prevalence of STIs in boys with normal examination findings appears to be extremely low [67,71,72]. All positive test results should be considered presumptive evidence of infection and, if used, should be interpreted with caution. Positive results should be confirmed using additional tests in populations with a low prevalence of the infection or when a false-positive test could have an adverse outcome [29].

The decision to test for STIs (which is often made on a case-by-case basis) is discussed below. Prophylaxis for STIs, including HIV, is reviewed elsewhere. (See "Management and sequelae of sexual abuse in children and adolescents", section on 'Sexually transmitted infection prophylaxis'.)

Prepubertal victims — Experts recommend STI testing in the prepubertal child in any one of the following circumstances [64]:

●High likelihood of sexual abuse based on interview [71].

●Suspected perpetrator is a stranger.

●The presence of signs or symptoms consistent with STIs (eg, genital discharge) or child already diagnosed with at least one STI [37,73,74].

●An STI in the patient's sibling or another child in the patient's intimate environment [75,76].

●The suspected perpetrator has an STI or is at high risk for having an STI (eg, multiple sexual partners, intravenous drug abuser, or man who has sex with men).

●There is evidence of anal or genital penetration (eg, acute tears) [22].

●Evidence of ejaculation is present.

●The child lives in a community with a high rate of STIs [29].

●The child or parent/primary caregiver requests STI testing [29].

As a general rule, screening for HIV should be performed for the same indications and in conjunction with other STI screening [65]. However, before HIV screening is performed, the possibility of vertical transmission (if the child is found to be positive) and its implications must be discussed with the child's mother or primary caregiver.

It is important to consider the incubation period of potential pathogens when testing for STIs after an acute event. Testing for gonorrhea, chlamydia, trichomonas, and bacterial vaginosis should be performed two weeks after the incident for patients who did not receive prophylactic therapy at the initial evaluation [15]. Serologic testing for HIV should be performed at baseline and 6, 12, and 24 weeks after the incident [15,65].

The appropriate culture method must be used if and when STI testing is performed. In the United States, culture in addition to nonculture methods (eg, nucleic acid amplification tests [NAAT]) are preferred [71,77,78]. In one study of 485 children undergoing evaluation of sexual abuse, the use of urine NAAT significantly increased the detection of chlamydia and gonorrhea infection in prepubertal children undergoing evaluation for sexual abuse (4.5 percent positive by NAAT versus 3.3 percent positive by culture) [79]. Nonculture methods are still not accepted as forensic evidence in some United States jurisdictions.

However, in Canada, nonculture methods are being used in the evaluation of sexually abused children and are accepted as forensic evidence [80]. Given that urine NAAT may be more accurate than culture and is less invasive, it may be the preferred method of detection in children with normal or nonspecific findings who live in legal jurisdictions that accept such methods as a forensic standard. Confirmation tests of positive NAATs should be done with a second US Food and Drug Administration (FDA)-approved NAAT that targets a different DNA sequence from the initial test [65].

Depending upon the suspected pathogen, the following specimens may be obtained as guided by the description of the events and the child's symptoms and physical findings [81]:

●Neisseria gonorrhoeae: Rectal, throat, and urethral or vaginal cultures and NAAT (cervical specimens should not be collected from prepubertal girls).

●Chlamydia trachomatis: Rectal or vaginal cultures (cervical specimens should not be collected from prepubertal girls) and urine NAAT.

●Syphilis: Darkfield microscopy from chancre fluid, if possible; blood for serologic tests at time of abuse, 4 to 6 weeks later, and 12 weeks later.

●HIV: Serologic testing of abuser (if possible); serologic testing of child at time of abuse and 6, 12, and 24 weeks later.

●Hepatitis B virus: Serum hepatitis B surface antigen testing of alleged abuser (if possible) or hepatitis B surface antibody testing of the child only if they have not received three doses of the hepatitis B vaccine.

●Herpes simplex virus (HSV): Culture of suspicious lesion and, for crusted lesions, polymerase chain reaction assay; all specimens should be typed (HSV1 versus HSV2). Routine serology for HSV infections is not warranted [82].

●Bacterial vaginosis: Wet mount, pH, and potassium hydroxide testing of vaginal discharge or Gram stain.

●Human papillomavirus (HPV): Biopsy of lesion.

●Trichomonas vaginalis: Wet mount and culture of vaginal discharge (although not always accepted as forensic evidence, NAAT may be used as an alternative to culture for treatment purposes).

●Pediculosis pubis: Identification of eggs, nymphs, and lice with naked eye or using a hand lens.

The significance of the identification of a sexually transmitted agent in a child as evidence of possible child sexual abuse varies by pathogen. (See 'Diagnosis' below.)

Postpubertal victims — For adolescents who have been sexually active, testing for STIs is controversial. Evidence of infection is generally not necessary for prosecution, and positive tests may be used by the defense as discrediting evidence of promiscuity. In addition, prophylactic treatment is typically prescribed regardless of culture results [65,81]. (See "Evaluation and management of adult and adolescent sexual assault victims in the emergency department", section on 'Laboratory testing and diagnostic imaging'.)

Some experts recommend that all postpubertal patients be screened for STIs, including HIV, because the prevalence of preexisting asymptomatic infection is high [81]. Others suggest that the decision to test a victim of sexual abuse for STIs be made on an individual basis [65].

DIAGNOSIS

Clinical suspicion — As with other forms of child abuse, the interpretation of findings in children with suspected sexual abuse depends upon the constellation of historical, physical, and laboratory findings. Isolated examination or laboratory findings are rarely diagnostic but become more concerning when combined with a disclosure of sexual abuse, specific behavioral changes, and/or the lack of another plausible explanation.

History — The history is often the most important part of the evaluation. The provision by the child of a spontaneous, clear, consistent, and detailed description of sexual molestation is specific for sexual abuse and should be reported to Child Protective Services (CPS) [37,83]. CPS should also be consulted to evaluate situations where there is reasonable concern that abuse has occurred, but the initial history is inconclusive.

Normal physical examination — A normal physical examination does not preclude the possibility that a child has been sexually abused [38]. The lack of physical findings may be inherent in the nature of the abuse (eg, fondling of the breast or genitals, oral-genital contact, exposure to pornographic material) or may be the result of the intrinsic elasticity and rapid healing of the anogenital tissues [84-88]. Furthermore, in retrospective series, there were no differences in the rates of healing of hymenal and other genital injuries between children with inflicted injuries and those with accidental mechanisms [86,87].

In the event that there are no physical findings consistent with abuse, the report should contain a statement such as "Normal or nonspecific findings are to be expected in a child who describes this type of molestation," or "A normal examination neither rules out nor supports an allegation of sexual abuse" [83].

Abnormal physical examination — Abnormal physical examination findings are present in the minority of children who are evaluated for possible sexual abuse [22,42].

Nonspecific findings — The physical examination in cases of possible sexual abuse may identify nonspecific findings that are associated with other medical conditions or are normal variants of anogenital structures (table 2A-B and table 3) [31,40,46,89-97]. (See 'Differential diagnosis' below and "Overview of vulvovaginal conditions in the prepubertal child" and "Vulvovaginitis in the prepubertal child: Clinical manifestations, diagnosis, and treatment".)

In the absence of a disclosure of sexual abuse, these nonspecific findings do not necessarily raise concern for sexual abuse [31]. The physician should refer the child to a child abuse specialist (usually at an academic medical center, children's hospital, or child advocacy center) for further evaluation before a report of suspected abuse is made whenever there is a question regarding the significance of physical findings.

Suspicious findings — Certain anogenital findings have been noted in children with documented sexual abuse. However, data regarding the specificity of these findings for sexual abuse are insufficient or contradictory [31,83].

Suspicious findings include [3,5,31,38,46,50,89,90,98-104]:

●Genital or anorectal injury that requires surgical care is concerning. One observational study of 44 girls found that 25 percent of such injuries were caused by sexual abuse, and the other injuries were associated with straddle or impalement mechanisms or motor vehicle collisions [105]. Sexually abused children had no plausible mechanism by history to explain the severity of findings.

●Deep notches or clefts (>50 percent of the width of the hymenal rim) in the posterior/inferior rim of the hymen (below the line drawn through 3 o'clock to 9 o'clock with the patient supine) may be caused by previous blunt force or penetrating trauma [5,38,98]. In one case control study, deep notches were described in none of the controls, but in only 2 out of 192 girls with a history of penetration [42]. However, deep notches may be an artifact of examination technique and it is difficult to distinguish between superficial and deep notches [31].

●A thin posterior hymenal rim may also be indicative of penetrating trauma, but accurate measurement of the hymenal rim is difficult [5,31]. Studies have demonstrated inconsistent results. The finding was absent in several studies of girls chosen who were not abused [46,89,90]. However, in a series of similar girls who also had not been abused, 22 percent had a posterior rim estimated to be <1 to 2 mm [97].

●A wide hymenal orifice may be a normal finding [46]. In a large cohort of girls 3 to 12 years of age being evaluated for sexual abuse, transverse diameter of the hymenal ring did not correlate with sexual abuse [99].

●Lesions that appear to be genital warts may be skin tags, nongenital warts, or genital warts (picture 3 and picture 4) acquired by perinatal or nonsexual transmission [3,100,101]. (See 'Sexually transmitted infections' below.)

●Vesicular lesions or ulcers in the anogenital area may be caused by sexually transmitted infections (STIs) (such as syphilis or herpes simplex virus [HSV]) as well as other viruses (including Epstein-Barr virus), Behçet syndrome, Crohn disease, and others (table 2A-B) [3,100,101]. (See 'Sexually transmitted infections' below.)

●Marked, immediate anal dilation to a diameter of 2 cm or more in the absence of other predisposing factors such as chronic constipation, sedation, anesthesia, or neuromuscular conditions may be indicative of sexual abuse [50,92,102]. However, there is no clear consensus among experts regarding the significance of this finding [31].

The history is critical in determining the overall significance of suspicious or indeterminate findings. In the absence of a history of abuse, children with these findings require further investigation (eg, diagnostic studies or careful questioning of the child). Consultation with a child abuse specialist may be helpful. Reporting to CPS should be considered [31,103].

Specific findings — Examination findings that are diagnostic of genital trauma, and in the absence of a clear, timely, plausible history of accidental injury should be reported to CPS, are listed in the table (table 4).

Laboratory — Laboratory findings that are diagnostic for sexual abuse include [3]:

●Pregnancy in the absence of consensual intercourse

●Identification of sperm, semen, semen-specific antigens (eg, prostate-specific protein p30), or enzymes (eg, acid phosphatase) in or on a child's body

Sexually transmitted infections — The significance of the identification of a sexually transmissible pathogen in the evaluation for childhood sexual abuse varies according to the pathogen [65]. STIs that are specific for sexual contact in prepubertal children and should be reported to CPS include [3,31,65,100,103,104]:

●Postnatally acquired gonorrhea

●Postnatally acquired syphilis

●HIV infection that is not acquired perinatally or iatrogenically

STIs that are less specific for childhood sexual abuse, either because there are other modes of acquisition or because perinatal infection may remain asymptomatic include [64]:

●HSV

●Genital warts (picture 3 and picture 4)

●Chlamydia infection

●Trichomonas vaginalis

When these infections are present, the likelihood of sexual transmission should be assessed based upon history, other physical findings, and the presence of other STIs. If sexual transmission is suspected, then a report to CPS is indicated.

Limited observational evidence suggests that children can acquire HSV through nonabusive contact (such as diaper changing or autoinoculation) or through sexual contact [106]. Sexual transmission may be more likely for children ≥5 years of age, for those with only genital lesions, and when HSV type 2 is isolated from lesions. Genital herpes caused by HSV type 1 can be acquired through sexual contact [107]. Consequently, the type of HSV isolated from a genital lesion may not be sufficient to establish whether or not the infection was transmitted through abusive contact. Nevertheless, new herpetic lesions in children who are beyond infancy and have independent toilet habits are suspicious for abuse and should be reported [81].

Genital warts (condyloma acuminata) are caused by human papillomavirus (HPV) [108]. The virus may be transmitted both sexually and nonsexually [109]. In young children, these lesions can develop as the result of sexual contact or via nonabusive contact with common warts [110]. Infants may acquire HPV perinatally from infected mothers. In a prospective study of vertical transmission of HPV, the maximum likelihood of transmission was only 2.8 percent [111]. Perinatally acquired condyloma acuminata may present any time before 20 months of age. Examination of the mother via colposcopy may be helpful in determining the etiology [110]. Sexual abuse should be considered in children who develop genital warts after the age of approximately two years [3,23,100]. A study designed to delineate the clinical characteristics of pediatric patients with anogenital warts concluded that the modes of transmission of anogenital warts in children cannot be identified either by the clinical appearance of the lesions or by HPV typing, thus highlighting the importance of the clinical history and exam along with the social context of the family [112].

Chlamydial infection of the vagina, urethra, or rectum that occurs after infancy is suggestive of abuse, although infection acquired at birth can remain asymptomatic until as late as three years of age [113]. Sexual contact is likely if chlamydia is cultured from anal or genital tissues of a child who is older than three years via cell culture or comparable method approved by the CDC [3,31,100].

Trichomonas vaginalis can occur in newborns but is rare in the prepubertal child [114,115]. Sexual contact is likely in a child older than one year of age if trichomonal organisms are identified (by an experienced technician or clinician) in vaginal secretions by wet mount examination or culture [3,31,100].

Molluscum contagiosum, hepatitis B infection, bacterial vaginosis, scabies, and pediculosis pubis may be transmitted sexually; however, transmission occurs by other nonabusive modes. The decision to involve CPS when these organisms are detected depends upon the history from the child and/or caregiver or level of suspicion of abuse by the health care provider [81].

DIFFERENTIAL DIAGNOSIS — Misdiagnosis of sexual abuse can be traumatic for everyone involved [37]. Thus, the differential diagnosis of sexual abuse must be carefully considered in all children, particularly those who present with nonspecific genitourinary complaints or behavioral disturbances and do not volunteer a history of abuse [30].

The differential diagnosis of child sexual abuse includes other types of genital injury, infection, dermatologic conditions, congenital conditions affecting the perineum, and other conditions affecting the urethra or anus (table 2A-B) [13].

Injuries — Unintentional injuries of the perineum include straddle injuries, zipper entrapment, hair tourniquet, and seat belt or motor vehicle accident injury to the genitalia [13,30,116]. The history in these unintentional injuries is usually readily available.

Straddle injuries typically involve the anterior structures, such as the clitoris, clitoral hood, mons pubis, and labial structures, and even posterior fourchette. Penetrating sexual abuse usually results in injury to the hymen and other more posteriorly located structures such as the posterior fourchette and fossa navicularis (figure 1) [13]. However, accidental penetrating straddle injuries have been reported [117]. (See "Straddle injuries in children: Evaluation and management".)

Other nonsexual mechanisms of injury include:

●Zipper entrapment injuries and hair tourniquet injuries. (See "Management of zipper entrapment injuries" and "Hair tourniquet and other narrow constricting bands: Clinical manifestations, diagnosis, and treatment".)

●Vaginal foreign bodies. (See "Overview of vulvovaginal conditions in the prepubertal child", section on 'Vaginal foreign body'.)

●In girls of African or Middle Eastern descent, female circumcision in infancy or childhood can cause bleeding and unusual genital adhesions and scars [118]. (See "Female genital cutting".)

Infection — Infections and/or infestations that cause inflammation and erythema of the perineum include streptococcal vaginitis, candidal infections, varicella, pinworms, and perianal cellulitis [13,30,119,120]. Autoinoculation of common warts or molluscum contagiosum can mimic warts caused by human papillomavirus (HPV) (condyloma acuminatum) (picture 5 and picture 6) [83]. (See "Vulvovaginitis in the prepubertal child: Clinical manifestations, diagnosis, and treatment", section on 'Nonspecific vulvovaginitis'.)

Skin conditions — Several dermatologic conditions may cause ulcers, erythema, friability, and/or bleeding of the perineum and should be considered in the differential diagnosis of sexual abuse [13,30,83,121]:

●Nonspecific vulvovaginitis (poor hygiene, bubble bath) (see "Vulvovaginitis in the prepubertal child: Clinical manifestations, diagnosis, and treatment", section on 'Nonspecific vulvovaginitis')

●Seborrheic, atopic, or contact dermatitis (including diaper dermatitis) (see "Diaper dermatitis")

●Lichen sclerosus (picture 7) [122-124] (see "Vulvar lichen sclerosus: Clinical manifestations and diagnosis")

●Lichen simplex chronicus (picture 8)

●Lichen planus (picture 9A-B) (see "Lichen planus")

●Psoriasis (picture 10) (see "Psoriasis in children: Epidemiology, clinical manifestations, and diagnosis")

●Bullous pemphigoid (see "Clinical features and diagnosis of bullous pemphigoid and mucous membrane pemphigoid")

●Behçet syndrome (picture 11) (see "Clinical manifestations and diagnosis of Behçet syndrome")

●Perineal hemangiomas (of the labia, hymen, perihymenal area, or urethra) (see "Infantile hemangiomas: Epidemiology, pathogenesis, clinical features, and complications")

●Mongolian spots can look like bruises (picture 12) (see "Benign pigmented skin lesions other than melanocytic nevi (moles)", section on 'Congenital dermal melanocytosis (Mongolian spots)')

Characteristic appearance or presentation helps to differentiate these conditions from sexual abuse.

Anal conditions — Anal conditions that may be associated with perianal bleeding or bruising and should be considered in the differential diagnosis of sexual abuse include hemorrhoids (picture 2A-B), Crohn disease [125], rectal prolapse (which can be caused by medical conditions as well as sexual abuse) (picture 13), hemolytic uremic syndrome [126], and rectal tumors [13,30]. (See "Clinical manifestations and complications of inflammatory bowel disease in children and adolescents" and "Rectal prolapse in children".)

Perianal erythema may also be seen as a result of encopresis, poor hygiene, pinworm infection, and Group A streptococcal or staphylococcal infection. (See "Functional fecal incontinence in infants and children: Definition, clinical manifestations, and evaluation".)

Laxity of the anus may represent abuse but also can be seen with chronic constipation [50,102], neurologic disorders [30], and sedation, diastasis ani (a normal variant in which there is a slight opening of the visible portion of the anus when the buttocks are spread) [83].

Urethral conditions — Urethral conditions to be considered in the differential diagnosis of sexual abuse include urethral prolapse, caruncle, sarcoma botryoides, and ureterocele.

●Partial or complete prolapse of the distal urethra may occur in preadolescent girls. Urethral prolapse appears as an edematous, violaceous, nontender, doughnut-shaped mass surrounding the urethral meatus; bleeding may be the presenting complaint. (See "Overview of vulvovaginal conditions in the prepubertal child", section on 'Urethral prolapse'.)

●Sarcoma botryoides is a unique form of embryonal rhabdomyosarcoma that arises within the wall of the bladder or vagina and is seen almost exclusively in infants. It presents as soft nodules that fill and sometimes protrude from the vagina, resembling a bunch of grapes. (See "Rhabdomyosarcoma in childhood and adolescence: Epidemiology, pathology, and molecular pathogenesis".)

●An ureterocele is a cystic dilatation of the terminal ureter within the bladder and/or the urethra; a prolapsed ectopic ureterocele may protrude through the urethral meatus. (See "Ureterocele".)

●A caruncle is a small, red, papillary growth; highly vascular; sometimes found in the urinary meatus in females; it is sensitive to friction and characterized by pain on urination.

PSYCHOLOGICAL ASSESSMENT — Child and adolescent victims of sexual abuse are at risk for short- and long-term psychological disturbances such as posttraumatic stress disorder (PTSD), depression and suicidality, social phobias, anxiety disorders, attention problems, and poor self-esteem [127-131]. Factors that are associated with more adverse psychological sequelae include longer duration of the abuse, use or threats of force and violence, fathers as perpetrators or multiple perpetrators, adolescent age at the onset of the abuse, multiple incidents of abuse, and genital penetration [132-134]. Children and adolescents who have supportive parental figures have been shown to have less short-term and long-term psychological sequelae [135,136]. Parental support may be more important than abuse-related factors in predicting psychological recovery [135,137]. Sexual behavior problems may also be seen after child sexual abuse; however, the existence of sexual behavior problems alone may be more often seen after child physical abuse than sexual abuse [138].

After disclosure, the patient should have a behavioral health evaluation for new and current psychiatric conditions. If indicated (eg, imminent risk of harm to self or others), the clinician should request an emergency psychiatric evaluation. Otherwise, given the high risk for psychiatric illness, all sexual abuse victims warrant referral for outpatient psychological or behavioral assessment and age-appropriate counseling, preferably by a trauma-informed mental health provider, if available. (See "Management and sequelae of sexual abuse in children and adolescents", section on 'Psychosocial support'.)

RESOURCES — Some communities have a child advocacy center that provides expertise in the evaluation and treatment of sexual abuse victims and the prosecution of sexual abuse perpetrators. These centers may provide social services, law enforcement agencies, legal services, and medical evaluation; and may be a resource for consultation. Local advocacy centers can be identified on the National Children's Alliance website (www.nca-online.org).

Additional resources that may be helpful in the evaluation and management of suspected child abuse are listed in the tables (table 5A-B).

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Sexual abuse in children and adolescents" and "Society guideline links: Sexually transmitted infections".)

SUMMARY AND RECOMMENDATIONS

●Definition – Sexual abuse occurs when a child engages in sexual activity for which they cannot give consent, is unprepared for developmentally, cannot comprehend; and/or an activity that violates the law or social taboos of society. (See 'Definitions' above.)

●Epidemiology – Sexual abuse occurs primarily in preadolescent children, more often in girls. Perpetrators are usually males who are known to the victims. (See 'Epidemiology' above.)

●Presentation – Victims of sexual abuse may present for evaluation of possible sexual abuse, or they may present for routine care or acute evaluation of unrelated medical concerns. In these patients, most of the complaints that are possible indicators of sexual abuse are nonspecific (table 1). (See 'Presentation' above.)

Abnormal behaviors that should raise suspicion for abuse include:

•Perpetration of sexual abuse

•Sexually explicit acting out

•Developmentally inappropriate knowledge of sexual activities or inappropriate sexual play

●Evaluation – Evaluation of children with suspected sexual abuse is best performed in a nonemergency setting, such as a child abuse assessment center by an experienced multidisciplinary child abuse team whenever possible. (See 'Evaluation' above.)

Urgent evaluation for sexual abuse is warranted for victims with any one of the following indications:

•Present within 72 hours of the incident

•Have obvious forensic evidence on their clothes or bodies

•Have continued risk of harm from the suspected perpetrator

•Have genital or anal injuries, or report other emergency complaints (eg, suicidal ideation)

●History – Obtaining an unbiased history from a child is usually the most important part of the evaluation and should be performed by an experienced professional. The optimal approach to obtaining a history of sexual abuse from a child is provided above. (See 'History' above.)

●Physical examination – Physical examination should be performed by trained and experienced examiners as soon as possible after the alleged incident. Most children who are sexually abused have a normal physical examination. Examination findings that are diagnostic of genital trauma, and in the absence of a clear, timely, plausible history of accidental injury are specific for sexual abuse are provided in the table (table 4). These are uncommon. (See 'Physical examination' above.)

In the absence of the child’s disclosure of sexual abuse, nonspecific findings that are associated with other medical conditions or are normal variants of anogenital structures (table 2A-B and table 3) do not necessarily raise concern.

●Forensic evidence collection – Forensic evidence should generally be collected from children who are evaluated within 24 hours of the incident in any one of the following situations (see 'Forensic evidence collection' above):

•Evaluation suggests sexual abuse.

•The child has a genital injury as the result of alleged sexual abuse.

•Clothing or linen associated with the abuse is available.

•There are other concerning clinical features suggesting recent sexual abuse.

Evidence collection may be modified (as allowed by local protocols) to eliminate procedures that are unlikely to yield evidence based on details of the alleged abuse. A speculum examination is not indicated to obtain evidence from prepubertal girls.

For prepubertal children who are evaluated >24 hours after the incident, protocols of the local jurisdiction should be followed although the yield in evidence collection is often decreased. The management of adolescents should generally be according to adult protocols. (See "Evaluation and management of adult and adolescent sexual assault victims in the emergency department".)

●STI testing – Prepubertal girls who are likely to have been sexually abused based on history or physical examination should be tested for sexually transmitted infections (STIs). Specific indications and recommended tests are described above. (See 'Prepubertal victims' above.)

STIs that are specific for sexual contact in prepubertal children and warrant reporting to Child Protective Services (CPS) include (see 'Sexually transmitted infections' above):

•Postnatally acquired gonorrhea

•Postnatally acquired syphilis

•HIV infection that is not acquired perinatally or iatrogenically

Other infections such as HSV, genital warts, Chlamydia infection, or Trichomonas vaginalis are less specific and should be interpreted within the context of the child’s history, physical examination, and whether other STIs are present.

For adolescent girls who have been sexually abused, the decision to test for STIs should be made on a case-by-case basis, but all of these patients should receive antibiotic prophylaxis regardless of whether testing is performed. (See 'Postpubertal victims' above.)

●Laboratory features – Laboratory findings that are diagnostic for sexual abuse and warrant CPS reporting include:

•Pregnancy without consensual intercourse  

•Identification of sperm, semen, semen-specific antigens (eg, prostate-specific protein p30), or enzymes (eg, acid phosphatase) in or on the body

●Diagnosis – The diagnosis of sexual abuse depends upon the constellation of historical, physical, and laboratory findings. A report to Child Protective Services should be made when the evaluation supports a reasonable suspicion of sexual abuse. (See 'Diagnosis' above and "Child abuse: Social and medicolegal issues", section on 'Reporting suspected abuse'.)

●Differential diagnosis – The differential diagnosis of child sexual abuse includes other types of genital injury, infection, dermatologic conditions, congenital conditions affecting the perineum, and other conditions affecting the urethra or anus (table 2A-B). (See 'Differential diagnosis' above.)

●Psychological support – Child and adolescent victims of sexual abuse are at risk for short- and long-term psychological disturbances, such as posttraumatic stress disorder (PTSD), depression and suicidality, and warrant timely assessment of risk and referral for mental health services. (See 'Psychological assessment' above.)