Physical Examination - Child sexual abuse

Physical Examination - Child sexual abuse

The preparation and conduct of the physical examination of sexually abused children requires 'time, patience and a gentle manner...' [Horowitz, 1987].

Appropriate timing of the examination is the first step. Most examiners agree to perform immediate examinations due to forensic reasons if the alleged contact took place less than 72h ago. The same goes for acute bleeding anogenital injuries. Due to typically delayed disclosure, most examinations are nonemergency.

The issue of sedation or anesthesia for the examination remains controversial. Although some argue in favor because of a reduction of immediate stress, it is not routinely warranted. General anesthesia is usually required in cases of acute bleeding anogenital injuries [Harari and Netzer, 1994; Rogers and Murdoch, 1994; Sury, 1994; Hogan, 1996; Leventhal, 1998].

Anticipating and addressing children's fears concerning the medical examination are crucial for a successful exam. Younger children rarely have problems with issues of shame. They rather are fearful of painful and unknown procedures. Any form of force or coercion is strictly contraindicated. The child should be given as much choice as possible in the procedure to ensure a sense of control. It is important to explain all steps of the examination in an age appropriate terminology. The child should be reassured that the purpose of the examination is to check if everything is 'alright', that it is healthy and 'okay'.

Clinical experience indicates that at least for prepubertal children the style and gentleness of the exam are far more important factors for the emotional impact than the gender of the examiner [Horowitz, 1987; Lazebnik et al., 1994; Leventhal, 1998].

The sense of control may be enhanced by examining a 'fearful' doll which expresses all the potential fears which children might have in this situation.

Asking the child to help the doctor examine the doll lets them anticipate their own examination, gain a sense of control and power and actively cope with their own fears by comforting the doll [B. Herrmann, personal observations].

Even for non-pediatricians, a complete head-to-toe examination is mandatory.

It should always precede the anogenital examination in order not to focus on the anogenital area (like the abuser has done). The implicit message is that the whole child is important. It also allows estimating the developmental stage and avoids missing extragenital signs of sexual or physical abuse.

The anogenital examination in cases of suspected sexual abuse of the prepubertal child is principally an external visualization by varying techniques of separation, traction and positioning. It does not require anal or vaginal palpation or the use of specula. In adolescents the use of specula is appropriate but not mandatory. Stirrups may be used in older consenting children, while often increasing unfamiliarity and fear in younger children [Emans, 2000; Horowitz, 1987; Finkel and De Jong, 2001].