Tips for Conducting a Child Sexual Abuse Exam

ACEP News
June 2010

By Robert Finn
Elsevier Global Medical News



LAS VEGAS -- In cases of suspected child sexual abuse, parents, police, and attorneys tend to assume that any physician should be able to determine whether abuse has occurred.

But Dr. Neha H. Mehta of the University of Nevada Medical Center, Las Vegas, says that even experts can find definitive evidence of sexual abuse in only a small minority of cases.

In fact, a relatively recent survey of primary care physicians showed surprising ignorance of prepubescent genital anatomy. Of the 166 physicians surveyed, 38% did not accurately identify the hymen, 28% did not accurately identify the urethra, and 21% did not accurately identify the labia majora (Child Maltreat. 2000;5:72-8).

The American Board of Pediatrics administered the first certification exams for the subspecialty "child abuse pediatrics" in November 2009, and Dr. Mehta said that she's currently the only certified child abuse specialist in the state of Nevada.

With so few physicians certified in the subspecialty, it's certain that, for the time being at least, most child abuse exams will be conducted by relatively inexperienced physicians.

At a workshop organized for the annual meeting of the North American Society for Pediatric and Adolescent Gynecology, Dr. Mehta listed some of the mistakes that inexperienced examiners make (see first sidebar).

She also pointed out that normal findings on an exam do not prove no abuse has occurred. Conversely, abnormal or seemingly abnormal findings do not necessarily indicate that a child has been abused (see second sidebar).

Top Mistakes of Inexperienced Examiners

  1. Thinking that if the exam is normal, then abuse has not occurred.
  2. Dismissing cases based on the presence of custody disputes.
  3. Claiming to determine that a child has been a victim of sexual abuse based on her behavior during the exam.
  4. Saying that they can tell if an adolescent has or has not had sex.
  5. Trying to measure the size of the hymenal opening.
  6. Insisting that a registered nurse who is trained in adult assaults evaluate prepubertal children for sexual abuse.
  7. Forcing exams on children.
  8. When uncertain about findings, feeling pressured into guessing.
  9. Saying that erythema indicates sexual abuse.
  10. Saying that frequent yeast infections or urinary tract infections are caused by sexual abuse.
  11. Using the term "virginal" to describe the genital anatomy.
Source: Dr. Mehta

Dr. Mehta offered the following hints, tips, and clinical pearls when examining children for sexual abuse.

  • It's critical to identify yourself to the child as a physician at the beginning of the exam. "This has legal implications," Dr. Mehta said. "I always document that I introduced myself as a doctor. If the child says something to me, there's a potential that [those statements] can get into court under the medical-legal exception to hearsay."
  • Conducting the exam in a matter-of-fact way normalizes the experience for the child. In particular, it's important not to react emotionally. Talking with the child can help her relax, but it's best to avoid sensitive topics. For example, if abuse at school is suspected, don't ask her to tell you about her favorite subject.
  • "We really don't encourage using endearments," like "Honey" or "Sweetie," Dr. Mehta said. She also recommended that physicians avoid complimenting the child on her appearance. "It's kind of like they're a sexual commodity in some way. You are re-validating some of the things that people have been telling them. I like to stay with neutral things like, 'I like your shoes,' or, 'Who braided your hair today?' "
  • The tone of your questioning is important, too. "Children respond really really well to Colombo and not to Sherlock Holmes," Dr. Mehta said. Strongly interrogative questioning may cause them to shut down.
    Instead, use nonthreatening openings such as, "There's something I don't understand," or "I'm not so bright. Can you help me out?"
  • While the typical physical exam presents many teachable moments, it's best to avoid teaching during an abuse exam. "I had a case one time where the girl talked about how the boy put his 'thingy' in her 'poo-poo,' " Dr. Mehta recalled. "The nurse stopped and said, 'Oh, Honey, we don't call that a "thingy." We call that a "penis." ' She introduced a term to the child that the child didn't naturally have."
  • As for the exam's technical details, it's become routine to document the physical findings with photos from a colposcope focused on the external genitalia. Young children may become frightened at the sight of the colposcope, so it's best to explain that it's not hot and that it won't touch them.

    Obtain clear images of the name plate, and then take photos of the external appearance, labial traction views of the hymen, and anal views. For boys, get images of the glans and urethral meatus. For adolescent girls, get an image in which you use a Q-tip to separate the folds of the labia and hymen.

    Prepubertal girls hate having their very sensitive hymen touched with a Q-tip, so Dr. Mehta prefers using a squirt of normal saline to separate the folds. Drip a little saline on her hand first; "Otherwise, they see the saline bullet heading to them, and they think you're going to stab them with it," she said.

    Some Red Herrings

    • Bumps or mounds.
    • Intravaginal ridges.
    • Skin tags or perianal protru- sions.
    • Haemophilus influenzae vaginitis.
    • Labial adhesions.
    • Anal fissures, redness, or excoriation.
    • Pooling of vascular blood near anus.
    • Gaping anus.
    • Diastasis ani (smoothing or flattening of anal folds).
    Source: Dr. Mehta
  • Dr. Mehta prefers placing the child in the frog position.

    "The investigator grasps the labia majora between thumb and forefinger," she explained. "Instead of trying to pull [the lips] apart, pull forward and downwards. It causes a lot less discomfort for the child, and it also opens structures much more nicely."

    In some children, however, the frog position makes it difficult for the examiner to visualize the section of the hymen closest to the anus. In such cases, Dr. Mehta likes to use the knee-chest position, where the knees and chest are down on the table and the buttocks are up in the air.

    "We usually tell children it's kind of the way babies sleep, the way kitty cats sleep," she said. "Unfortunately, sometimes we have to crawl on the floor and show them, because they're not quite picturing it.

    "What's easier about it is that instead of having to grasp the labia, you can just lift up on the buttocks," continued Dr. Mehta.

    "This makes the hymen fall downward because of gravity. It's a lot easier for the examiner in terms of ability to visualize. It's a little bit awkward and difficult for [children] to follow along with, but once they get it, they're usually pretty okay with it."

Dr. Mehta said that she had no conflicts of interest to declare.

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