The medical evaluation of the sexually abused child

The diagnosis of suspected sexual abuse is nearly always based on a description of abuse provided by the child. The physician should invite a child to describe his or her sexual victimization in detail if such a "disclosure" interview has not already occurred, if the child seems ready to describe the abuse, and if a child protective services worker has not yet been notified of the suspected abuse. If an allegedly abused child has already been carefully interviewed, however, the physician should instead obtain information from the child's parents or other appropriate adults to determine how best to address the questions being raised. Nonspecific behavioral or somatic complaints unaccompanied by a specific description of sexual abuse should generate a differential diagnosis for further investigation. The goals of the physical examination of the sexually abused child are to identify abnormalities that warrant further diagnostic efforts or treatment, to obtain specimens to screen the patient for sexually transmitted infections, and to make observations and take specimens that may corroborate the patient's history of victimization. These goals should be met in the context of a standard, complete physical examination. The advisability of postcoital contraception should be discussed with every postmenarcheal victim seen within 72 hours after a rape. Because gonorrhea and chlamydial infections are the most prevalent STDs seen after sexual abuse and are often asymptomatic, universal screening for these infections is recommended. Parents of all abused children should be given an opportunity to make an informed choice about HIV screening. Because the risk of acquiring STDs is low, routine antibiotic prophylaxis is not recommended for sexually abused children. Physicians must report all cases of suspected sexual abuse to states' child protective services agencies. Failure to do so can incur legal penalties. Reporting sexual assaults of children to local law enforcement officials is strongly advised. The long-term impact of sexual abuse on children's psychological adjustment is unpredictable. In the short term, children's circumstances vary widely. Some show no evidence of psychological distress. Others have severe, pervasive difficulty. Office counseling by the empathetic and knowledgeable primary care physician, short-term crisis counseling, a more formal psychological evaluation, and longer-term psychotherapy may be recommended for individual children, depending on the nature and severity of each child's symptoms, his or her parents' preference, and the availability of services in the child's community.