Examination for sexual abuse in prepubertal children: an update

The complete physical examination of prepubertal children should always include a genital examination. Most children, even those who have been sexually abused, will have a normal genital examination. A child's acceptance and tolerance for this aspect of the examination will be enhanced by use of the techniques described. Sexually abused children may be identified through routine review of systems and history, including behavioral and psychosocial, and open-ended questions regarding sexual abuse. Regular genital examinations will also help to identify sexually abused children. Although the diagnosis of sexual abuse can never rely solely on physical findings, abnormal findings suspicious for sexual abuse are significantly more useful if there have been prior documented normal examinations. When sexually abused children initially present to their medical practitioner, the practitioner should obtain a complete medical and psychosocial history and perform a thorough examination. The practitioner need not be an expert in the interpretation of the possible legal significance of specific genital findings but should recognize normal, abnormal, and suspicious findings. Reassurance from a trusted practitioner relating to a normal body can be the most valuable treatment for a child's emotional healing. Practitioners need to be aware of the resources in their community for medical evaluations for sexual abuse, legal investigations, and mental health referrals. If there is a local center for child abuse evaluations, such as a Child Advocacy Center or Center of Excellence for child protection, practitioners should consider referrals to and consultations with these resources.