Clinical findings in sexual abuse are rare. A "negative" or normal examination does not exclude the possibility of sexual abuse. The most important aspect of the child sexual abuse evaluation is the child’s history. Children who have non-specific findings may actually have findings that are consistent with the history, such as perineal erythema after fondling. Having no physical findings after sexual abuse is an expected finding. Therefore, the fact that there are no findings or signs of injury may be consistent with a history of sexual abuse, even though it does not provide further evidence to support the history.
There are several reasons for lack of physical findings and forensic evidence in sexually abused children and adolescents. They include the following:
Many types of sexual abuse do not include acts that would be expected to cause trauma to skin or body tissues.
Delays in seeking medical care decrease the likelihood of positive findings.
Evidence of ejaculate is unlikely to be found if many hours have elapsed since the assault (particularly if more than 96 hours).
Semen and evidence of ejaculate are unlikely to be found in sexually abused children if the child has washed, urinated, or defecated.
Rape can occur without ejaculation or damage to tissues.
Hymenal tissue is elastic and penetration by a finger or penis may cause invisible trauma or simply stretch the hymenal opening.
The anal sphincter is highly elastic and may not be damaged by penetration.
Injuries, when they do occur, heal rapidly and often completely.
A child may interpret a painful sexual act as intercourse, when it may have been vulvar coitus.
With onset of puberty, evidence of injury can be obscured by changes in hymen tissue due to estrogen effect.
For recommendations related to how to document the diagnosis, see DOCUMENTATION: Documenting the Diagnosis.
Genital Bleeding
Genital bleeding in a prepubertal girl may be a presenting complaint that leads to the suspicion of child sexual abuse. There are many medical possibilities for a history or finding of genital bleeding. The table Prepubertal Genital Bleeding: Diagnostic Possibilities, below, provides information regarding the differential diagnosis of genital bleeding.
The diagnosis of trauma is generally based on clinical assessments and exhaustive evaluations for other diagnoses are usually not medically relevant.
Endometrial shedding caused by
estrogen withdrawal
Endogenous
Exogenous
Tumors
Clear cell adenoma
Rhabdomyosarcoma
Endodermal carcinoma
Mesonephric carcinoma
Ovarian
Adrenal
Hemangioma
Vaginitis
Non-sexually transmitted disease
(Shigella, Candida, Group A Strep)
Sexually transmitted disease
Foreign body
Poor hygiene
Urinary tract
Urethral prolapse
Hemorrhagic cystitis
Urate crystals
Hematuria
Urinary tract infection
Trauma
Accidental (straddle injury)
Abuse (inflicted trauma)
GI tract
Hematochezia
Anal fissure
Crohn’s disease
Metabolic
Hypothyroidism
Liver cirrhosis
Coagulopathy
Precocious puberty
McCune-Albright syndrome
Ovarian cyst
Dermatosis
Lichen sclerosus et atrophicus
Adapted from: Frasier, LF. Child abuse or mimic: Vaginal bleeding in an infant. Consultant for Pediatricians, Cliggot Publications, January 2003; 2(1):30-33.
Spermatozoa and Seminal Plasma
A lack of spermatozoa is not conclusive evidence that an assault did not occur. Historically, medical and law enforcement personnel have placed significant emphasis on the presence of spermatozoa in or on the body or clothing of a sexual assault victim as the most positive indicator of sexual offense. Conversely, when no spermatozoa are found, a shadow of doubt may be cast upon the victim's allegation of sexual assault. This contributes to the misconception that the absence of spermatozoa means no sexual offense occurred.
Some sexual assault offenders are sexually dysfunctional and do not ejaculate during the offense. In addition, offenders may have had a vasectomy, use a prophylactic, have a low sperm count (common with heavy drug use or alcohol use), ejaculate somewhere other than in an orifice or on the victim's clothes or body, or fail to ejaculate if the assault is interrupted. Therefore, a lack of spermatozoa is not conclusive evidence that an assault did not occur. It only means that spermatozoa may have been destroyed after being deposited or that spermatozoa may never have been present.
However, if spermatozoa are identified on the body or clothes of a child, the information can be critical to the legal prosecution of the case. The finding of spermatozoa is useful for these reasons:
It is positive indication that ejaculation occurred and semen is present.
When spermatozoa are motile, it can be an indicator of the length of time since ejaculation. The survival time of the spermatozoa in the vaginal, oral, and rectal orifices following ejaculation varies in scientific studies. However, there is fairly wide consensus that they may remain for up to 96 hours or longer in the vagina and persist even longer in the cervical mucosa. They can survive up to several hours or more in the rectal cavity, particularly if the victim has not defecated since the offense.
DNA isolated from sperm can be used to identify the source, and several DNA tests are now available. These tests vary in the level of precision with which an offender can be identified.
Most of the serological markers, enzymes, and other proteins used to identify the possible source are found in seminal plasma, which is in the ejaculate of all males, vasectomized or not. In contrast to the requirement for the presence of spermatozoa for forensic DNA identification techniques, it is primarily the seminal plasma, not the sperm, which gives evidence of the ABO type of the secretor and the other protein serological markers of the donor of the specimen. The finding of seminal plasma is useful for two reasons:
In the absence of spermatozoa, seminal plasma components (p30 and acid phosphatase) can be used to identify semen.
The prostate antigen p30 is known to exist in the semen of humans, and its presence is regarded as a conclusive indication of semen. Acid phosphatase is a chemical present in high levels in seminal samples but is considered only a presumptive test for the presence of semen because it also appears in other body fluids, such as vaginal fluid.
Sexually Transmitted Diseases
Some STDs are caused by microorganisms that live exclusively in or around the genitalia or rectum of an infected person. These STDs are almost always transmitted through sexual contact. Other microorganisms, in addition to living in or around the genitalia or rectum, also live in non-sexual areas of the body. Infections by these microorganisms can be transmitted by sexual or non-sexual contact. For a summary of the likelihood of sexual transmission of specific STDs, see the table, The Likelihood of Sexual Transmission of Specific STDs, below. Certain STDs are transmitted to children in the perinatal period, during or before birth. A physician can differentiate most perinatal infections from infections due to sexual abuse. Some infections, such as those from chlamydia or warts, are more difficult to differentiate.
Decisions regarding the likelihood of abuse should never be made based upon preliminary or presumptive STD diagnoses. Wait for the final diagnosis. Adolescents who are sexually active may acquire an STD through consensual sex.
The Likelihood of Sexual Transmission of Specific STDs
STD
Likelihood of Transmission
Chlamydia
Very High*
Gonorrhea (GC)
Very High*
HIV/AIDS
Very High*
Syphilis
Very High*
Trichomonas
Very High*
Condyloma acuminata (venereal warts)
Possible
Hepatitis B
Possible
Herpes
Possible
Pubic lice
Possible
Bacterial vaginosis
Low
Molluscum
Low
* The physician should consider other ways of transmissions (birth process, blood transfusion, etc.) and report suspicions to the State Central Register or local hotline.
Adapted from Shapiro R. How to interpret laboratory test results for sexually transmitted diseases. Cincinnati Children's Hospital Diagnosis and Treatment reference materials;
2003 and American Academy of Pediatrics Committee on Child Abuse and Neglect. Guidelines for the evaluation of sexual abuse of children (RE9202). Pediatrics 1991; 87(2):81-87.
Female Circumcision or Female Genital Mutilation
Female circumcision (FC) or female genital mutilation (FGM) is the name for several different traditional practices that involve the cutting of female genitals. The timing of the procedure varies among countries and cultural and ethnic groups. It can be performed as early as a few days after birth and as late as the seventh month of the first pregnancy. It is most commonly performed as a right of passage for girls between the ages of four and 12.
The World Health Organization (WHO) has grouped the types of FC/FGM into four broad categories:
Type I, clitoridectomy
The excision of the prepuce with or without excision of the clitoris.
Type II, excision The excision of the prepuce and clitoris together with partial or total excision of the labia minora.
Type III, infibulation The excision of part or all of the external genitalia and stitching or narrowing of the vaginal opening.
Type IV, all other procedures The partial or total removal of the female external genitalia for cultural or any other non-therapeutic reasons.
FC/FGM has serious health consequences. The immediate complications include severe pain, infection, bleeding that can lead to hemorrhaging, and shock. Long-term complications include keloid formation, labial adherences, clitoral cysts, chronic urinary or pelvic infection, pain during sexual intercourse, infertility, and problems during pregnancy. There have been few studies on the psychological effects of FC/FGM. Some women, however, have reported a number of problems, such as sexual dysfunction, depression, and sleep disturbances.
Currently, FC/FGM is practiced in 28 countries in the sub-Saharan and Northeastern regions of Africa and some Muslim communities in Indonesia and Asia. Prevalence varies significantly from one country to another. Women and girls who have undergone FC/FGM also live in immigrant communities around the world. The prevalence of FC/FGM in the United States is not known.
Those who practice this procedure provide various justifications including:
Custom and tradition
Communities that practice FC/FGM maintain their customs and preserve their cultural identity by continuing the practice.
Women’s sexuality
In some societies, FC/FGM is thought to control women's sexuality by reducing their sexual fulfillment and preventing masturbation, lesbianism, infidelity, and neuroses from repressed sexual arousal.
Religion
Although religious duty is commonly cited as a justification, FC/FGM is a cultural, not religious, practice. Jews, Christians, Muslims, and members of indigenous religions in Africa practice FC/FGM, yet none of these religions requires it.
Social pressure
In a community in which most women are circumcised, family and friends create an environment in which the practice becomes a requirement.
In 1997 New York State adopted the New York State Prohibition of Female Genital Mutilation Act, section 130.85 to New York's Penal Code. The Act states that a person is guilty of FC/FGM when he or she "knowingly circumcises, excises, or infibulates, the whole or any part of the labia majora, labia minora, or clitoris of another person who has not reached eighteen years of age." In addition, "a parent, guardian, or other person legally responsible and charged with the care and custody of a child less than eighteen years old, [who] knowingly consents to the circumcision, excision or infibulation of whole or part of such child’s labia minora or labia majora or clitoris" is also guilty of FC/FGM. FC/FGM is classified as a class E felony, which is punishable by up to four years imprisonment. The law exempts medical practitioners when the procedure is "necessary to the health of the person on whom it is performed." Custom or ritual is not an exemption from the law.
The National Women’s Health Information Center answers frequently asked questions about FC/FGM. See www.womenshealth.gov/ for this information.
