Bernhard Herrmanna, Francesca Navratil b
aChild Protection Center, Kinderklinik des Klinikums (Pediatric Department,
Klinikum Kassel), Kassel, Germany, and bPediatric and Adolescent Gynecology
Outpatient Department, Child Protection Center, University of Zürich Children’s
Hospital, Zürich, Switzerland
Child sexual abuse (CSA) has been and continues to be a diagnostic challenge. Only for little more than two decades has medicine been involved in the diagnosis, treatment and management of sexually abused children and adolescents.
CSA is no longer ‘another hidden pediatric problem’ as Kempe  stated more than 20 years ago. In the USA and – to a lesser extent – in Great Britain, many physicians have integrated knowledge about the recognition of CSA into their medical education and practice. A great number of specialized referral centers evolved and developed a significant expertise in evaluating abused children in a qualified and non-traumatizing manner.
A number of recent reports have summarized the results of numerous studies and research and of the accumulating clinical experience. They have also described the shortcomings and limitations of our current knowledge and outlined the emphasis of further research [Bays and Chadwick, 1993; Navratil, 1995, 1997; Herrmann et al., 1997, 2002; Kerns, 1998; Atabaki and Paradise, 1999].
The American Academy of Pediatrics has published guidelines to facilitate the management of CSA for healthcare providers [AAP, 1999, 2001a]. A couple of recently revised handbooks and a very instructive CD-ROM atlas give an excellent overview of all aspects of medical involvement in CSA evaluation [Finkel and De Jong, 2001; Finkel and Giardino, 2002; Heger et al., 2000; McCann and Kerns, 1999; Hobbs et al., 1999a; Monteleone and Brodeur, 1998; Reece and Ludwig, 2001].
The situation in most countries in Europe seems to be far less satisfying, concerning pediatrics as well as gynecology, not speaking of general practice (for Germany: Herrmann ). We feel an urgent need for all physicians caring for children to develop a basic understanding of behavioral and physical indicators of CSA. Furthermore, the need for specialized referral centers is evident. Child abuse examinations should preferentially be performed by specialists in pediatric and adolescent gynecology. Nevertheless, even those specialists will need supplementary qualification and training in the evaluation of sexually abused children and adolescents. The same goes even more for general pediatricians and gynecologists who engage in this specialty. Given the inherent risk of both under- and overdiagnosis of CSA, both with devastating consequences for children and their families, a thorough understanding of the medical approach is crucial. Performing medical examinations requires sound knowledge about the specifics of anogenital findings in abused and non-abused children as well as knowing the potentials and limitations of medical diagnosis in CSA [Adams, 1999].
This knowledge needs to be contributed and blended into a multiprofessional approach. Especially in Europe, physicians frequently still need to find and define their role within the child protection system. In contrast to the emotional and often unqualified public debate on CSA, medical professionals have a significant responsibility to contribute a rational and objective approach to the multidisciplinary assessment, diagnosis, management and treatment of sexually abused children and adolescents [‘Cool science for a hot topic’ – Kerns, 1989]. Nevertheless, CSA is an emotionally disturbing and troubling event even for medical professionals and requires emotional balance and commitment. The first step to the diagnosis of CSA and of utmost importance is being aware and acknowledging that the problem exists. Recognition of sexual abuse requires a high index of suspicion and familiarity with the historical, physical and behavioral indicators of abuse.
Revision date: June 22, 2011
Last revised: by Jorge P. Ribeiro, MD