Advertisement

Anogenital Findings in 3569 Pediatric Examinations for Sexual Abuse/Assault

  • Tanya D. Smith
    Correspondence
    Address correspondence to: Tanya D. Smith, NP-Paediatrics, MN, The Suspected Child Abuse and Neglect Program, The Hospital for Sick Children, 555 University Ave, Toronto, Ontario M5G 1X8, Canada; Phone (416) 813-6275
    Affiliations
    The Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada

    The Suspected Child Abuse and Neglect Program, The Division of Paediatric Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
    Search for articles by this author
  • Sudha R. Raman
    Affiliations
    The Department of Population Health Sciences, Duke University, Durham, North Carolina
    Search for articles by this author
  • Sheri Madigan
    Affiliations
    The Suspected Child Abuse and Neglect Program, The Division of Paediatric Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada

    The Department of Psychology, University of Calgary, and Alberta Children's Hospital, Calgary, Alberta, Canada
    Search for articles by this author
  • Judy Waldman
    Affiliations
    The Suspected Child Abuse and Neglect Program, The Division of Paediatric Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
    Search for articles by this author
  • Michelle Shouldice
    Affiliations
    The Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada

    The Suspected Child Abuse and Neglect Program, The Division of Paediatric Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
    Search for articles by this author
Published:October 27, 2017DOI:https://doi.org/10.1016/j.jpag.2017.10.006

      Abstract

      Study Objective

      Accurate interpretation of anogenital examination findings in the context of suspected child and adolescent sexual abuse/assault is essential, because misinterpretation has significant child protection and criminal justice implications. A consensus approach to the interpretation of anogenital examination findings is widely used to support accurate diagnosis; however, a large-scale study using this standardized approach is lacking. The objectives of this study were to: (1) determine the proportion of anogenital examinations for sexual abuse concerns with findings diagnostic of trauma and/or sexual contact; (2) determine whether frequency of diagnostic findings varies according to age, gender, and timing of examination; and (3) characterize diagnostic findings.

      Design, Setting, Participants, Interventions, and Main Outcome Measures

      Retrospective records of children aged 0-18 years evaluated for sexual abuse/assault were reviewed. Case details of 3569 patients were extracted and anogenital examination findings were reinterpreted using a published consensus approach.

      Results

      Anogenital examination findings diagnostic of trauma and/or sexual contact were present in 173 of 3569 patients (4.8%). The prevalence of diagnostic findings was significantly higher in adolescents than in children younger than 12 years of age (13.9%, 114/823 vs 2.2%, 59/2657), in female vs male patients (5.7%, 164/2866 vs 1.5%, 9/614), and in examinations within 72 hours for children younger than 12 years (14.2%, 91/643 vs 4.5%, 45/997). Acute injuries were the most common type of diagnostic finding.

      Conclusion

      Diagnostic findings are present in a small proportion of children and adolescents examined for suspected sexual abuse/assault. It is essential that practitioners who interpret examination findings be adequately trained and familiar with the current consensus approach and are aware of case characteristics associated with higher likelihood of findings.

      Key Words

      To read this article in full you will need to make a payment

      Subscribe:

      Subscribe to Journal of Pediatric and Adolescent Gynecology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Adams J.A.
        • Kaplan R.A.
        • Starling S.P.
        • et al.
        Guidelines for medical care of children who may have been sexually abused.
        J Pediatr Adolesc Gynecol. 2007; 20: 163
        • Adams J.A.
        • Kellogg N.D.
        • Farst K.J.
        • et al.
        Updated guidelines for the medical assessment and care of children who may have been sexually abused.
        J Pediatr Adolesc Gynecol. 2016; 29: 81
        • Adams J.A.
        Medical evaluation of suspected child sexual abuse: 2011 update.
        J Child Sex Abuse. 2011; 20: 588
        • Adams J.A.
        Guidelines for medical care of children evaluated for suspected sexual abuse: an update for 2008.
        Curr Opin Obstet Gynecol. 2008; 20: 435
        • Adams J.A.
        Medical evaluation of suspected child sexual abuse: 2009 update.
        APSAC Advisor. 2010; 22: 2-7
        • Jenny C.
        • Crawford-Jakubiak J.E.
        • Committee on Child Abuse and Neglect
        The evaluation of children in the primary care setting when sexual abuse is suspected.
        Pediatrics. 2013; 132: e558
        • Anderst J.
        • Kellogg N.
        • Jung I.
        Reports of repetitive penile-genital penetration often have no definitive evidence of penetration.
        Pediatrics. 2009; 124: e403
        • Kelly P.
        • Koh J.
        • Thompson J.M.
        Diagnostic findings in alleged sexual abuse: symptoms have no predictive value.
        Paediatr Child Health. 2006; 42: 112
        • Berenson A.
        • Chacko M.
        • Weimann C.
        • et al.
        A case control study of anatomical changes resulting from sexual abuse.
        Am J Obstet Gynecol. 2000; 182: 820
        • Heger A.
        • Ticson L.
        • Velasquez O.
        • et al.
        Children referred for possible sexual abuse: medical findings in 2384 children.
        Child Abuse Negl. 2002; 26: 645
        • Cantwell H.
        Vaginal inspection as it relates to child sexual abuse in girls under 13.
        Child Abuse Negl. 1983; 19: 1431
        • Pugno P.A.
        Genital findings in prepubertal girls evaluated for sexual abuse: a different perspective on hymenal measurements.
        Arch Fam Med. 1999; 8: 403
        • Hobbs C.J.
        • Wynne J.M.
        Child sexual abuse–an increasing rate of diagnosis.
        Lancet. 1987; 2: 837
        • Emans S.J.
        • Woods E.R.
        • Flagg N.T.
        • et al.
        Genital findings in sexually abused, symptomatic and asymptomatic, girls.
        Pediatrics. 1987; 79: 778
        • Bowen K.
        • Aldous M.
        Medical evaluation of sexual abuse in children without disclosed or witnessed abuse.
        Arch Pediatr Adolesc Med. 1999; 153: 1160
        • Palusci V.J.
        • Cox E.O.
        • Cyrus T.A.
        • et al.
        Medical assessment and legal outcome in child sexual abuse.
        Arch Pediatr Adolesc Med. 1999; 153: 388
        • Adams J.A.
        • Harper K.
        • Knudson S.
        • et al.
        Examination findings in legally confirmed child sexual abuse: it's normal to be normal.
        Pediatrics. 1994; 94: 829
        • Kellogg N.
        • Parra J.
        • Menard S.
        Children with anogenital symptoms and signs referred for sexual abuse evaluations.
        Arch Pediatr Adolesc Med. 1998; 152: 634
        • Adams J.
        Evolution of a classification scale: medical evaluation of suspected child sexual abuse.
        Child Maltreat. 2001; 6: 31
        • Heppenstall-Heger A.
        • McConnell G.
        • Ticson L.
        • et al.
        Healing patterns in anogenital injuries: a longitudinal study of injuries associated with sexual abuse, accidental injuries, or genital surgery in the preadolescent child.
        Pediatrics. 2003; 112: 829
        • Herrmann B.
        • Crawford J.
        Genital injuries in prepubertal girls from inline skating accidents.
        Pediatrics. 2002; 110: 1
        • Boos S.
        • Rosas A.
        • Boyle C.
        • et al.
        Accidental hymenal injury mimicking sexual trauma.
        Pediatrics. 1999; 103: 1287
        • Boos S.
        • Rosas A.
        • Boyle C.
        • et al.
        Anogenital injuries in child pedestrians run over by low-speed motor vehicles: four cases with findings that mimic child sexual abuse.
        Pediatrics. 2003; 112: e77
        • McCann J.
        • Miyamoto S.
        • Boyle C.
        • et al.
        Healing of nonhymenal genital injuries in prepubertal and adolescent girls: a descriptive study.
        Pediatrics. 2007; 120: 1000
        • McCann J.
        • Miyamoto S.
        • Boyle C.
        • et al.
        Healing of hymenal injuries in prepubertal and adolescent girls: a descriptive study.
        Pediatrics. 2007; 119: e1094
        • Slaughter L.
        • Brown C.R.
        • Crowley S.
        • et al.
        Patterns of genital injury in female sexual assault victims.
        Obstetr Gynecol. 1997; 176: 609
        • Heger A.
        • Ticson L.
        • Guerra L.
        • et al.
        Appearance of the genitalia in girls selected for nonabuse: review of hymenal morphology and nonspecific findings.
        J Pediatr Adolesc Gynecol. 2002; 15: 27
        • McCann J.
        • Voris J.
        Perianal injuries resulting from sexual abuse: a longitudinal study.
        Pediatrics. 1993; 91: 390
        • McCann J.
        • Voris J.
        • Simon M.
        • et al.
        Perianal findings in prepubertal children selected for nonabuse: a descriptive study.
        Child Abuse Negl. 1989; 13: 179
        • Myhre A.K.
        • Berntzen K.
        • Bratlid D.
        Perianal anatomy in non-abused preschool children.
        Acta Paediatr. 2001; 90: 1321
        • Hobbs C.J.
        • Osman J.
        Genital injuries in boys and abuse.
        Arch Dis Child. 2007; 92: 328
        • Watkeys J.M.
        • Price L.D.
        • Maddocks A.
        The timing of the medical examination following an allegation of sexual abuse: is this an emergency?.
        Arch Dis Child. 2008; 93: 851
        • Myhre A.K.
        • Adams J.A.
        • Kaufhold M.
        • et al.
        Anal findings in children with and without probably anal penetration: a retrospective study of 1115 children referred for suspected sexual abuse.
        Child Abuse Negl. 2013; 37: 456
        • Laitinen F.A.
        • Grundmann O.
        • Ernst E.J.
        Factors that influence the variability in findings of anogenital injury in adolescent/adult sexual assault victims: a review of the forensic literature.
        Am J Forensic Med Pathol. 2013; 34: 286