Child sexual abuse - Suspected Child Abuse
It is important to either provide the child the care they need as soon as possible or transfer them to someone who can. There is a very short window of opportunity to collect forensic evidence and/or provide prophylaxis.
Although often difficult to obtain, a child's disclosure of maltreatment is one of the most important pieces of information in determining the likelihood of abuse as well as the evaluation and treatment. Young children should be interviewed by someone trained in interviewing children about possible abuse whenever possible.
Per the Children's Bureau of the US Department of Health and Human Services, child sexual abuse is a type of maltreatment that refers to the involvement of the child in sexual activity to provide sexual gratification or financial benefit to the perpetrator, including contacts for sexual purposes, molestation, statutory rape, prostitution, pornography, exposure, incest, or other sexually exploitative activities. There were an estimated 3 016 000 cases of child abuse investigated in 2021 in the United States. Of these, US states reported 558 229 victims of abuse or neglect. Of reported cases, 10.1% were sexual abuse cases and 0.2% were sex trafficking cases.
In the majority of children with legal confirmation of sexual abuse, the genital examination of the abused child is normal. In one study, only 4% of all children referred for medical evaluation of sexual abuse had abnormal examinations at the time of evaluation. This study also showed that in those children who reported vaginal or anal penetration, the rate of abnormal examination findings was only about 5%. Physical findings are often absent even when the perpetrator admits to penetration of the child's genitalia. Thus, it is not appropriate to interpret a normal genital examination as evidence that sexually abusive contact did not take place.
History is oftentimes the most useful element in making a diagnosis of child sexual abuse, given that anogenital examinations can be, and frequently are, normal even in the setting of a disclosure or confession. A normal examination neither supports nor refutes concern for sexual abuse.
Taking an appropriate history includes the caregiver's description of the alleged abuse (depending on the age of victim*); the child's medical history with a thorough review of systems, including recent changes in behavior; and the child's account obtained independently to avoid any impediment to disclosure from caregiver presence.
*In adolescent patients, the patient's history is primary. In a younger patient, ask the caregiver – outside the presence of the child to avoid contaminating the history – what the child has said.
While a normal examination or nonspecific findings are not, on their own, supportive of a diagnosis of sexual abuse, there are abnormal findings that are highly specific for sexual contact.
The following knowledge is crucial for appropriate diagnosis: physical signs of sexual abuse, when present; diagnostic tests for sexually transmitted infections (STIs); and medical conditions commonly misdiagnosed as sexual abuse.
Related topics: male Tanner normals, female Tanner normals, normal hymen variants
T76.22XA – Child sexual abuse, suspected, initial encounter
95922009 – Child sexual abuse
Differential Diagnosis & Pitfalls
- Erythema – candidiasis, pinworm infection, irritant dermatitis, contact dermatitis, atopic dermatitis, inverse psoriasis, acrodermatitis enteropathica, perianal streptococcal dermatitis, cellulitis, Kawasaki syndrome (perianal erythema commonly precedes the development of the diagnostic criteria for the disease), straddle injury
- Ecchymoses – lichen sclerosus (hemorrhagic blisters / submucosal hemorrhages), venous pooling (commonly misdiagnosed as perianal bruising), congenital dermal melanocytosis, other trauma, eg, straddle injury
- Erosions / ulcers – Jacquet erosive diaper dermatitis, complex aphthosis, Behçet disease, acrodermatitis enteropathica, Langerhans cell histiocytosis, pemphigus vulgaris, bullous pemphigoid, sexually transmitted infections (primary syphilis, herpes simplex virus, chancroid, lymphogranuloma venereum), PFAPA syndrome (periodic fever, aphthae, pharyngitis, cervical adenitis), MAGIC syndrome (mouth and genital ulcers with inflamed cartilage)
- Anal fissures – constipation, inflammatory bowel disease (eg, Crohn disease), irritant dermatitis
- Scarring – perianal Crohn disease, medical procedures. Note: midline findings, such as failure of midline fusion, are less suspicious for abuse.
- Anogenital warts – condyloma acuminata, molluscum contagiosum, verruca vulgaris, acrochordon (skin tag)
- Rectal bleeding – hemorrhoids, Crohn disease, polyps, rectal prolapse, rectal tumors, ingested food dyes (eg, overconsumption of food infused with red dye no. 40 such as red Jell-O, red cereals, red frosting, Flamin' Hot Cheetos) or overconsumption of red food (eg, beets)
- Flattened anal folds – relaxation of anal sphincter (ie, normal finding), perianal edema from infection or trauma, failure of midline fusion
- Lichen sclerosus
- Lichen simplex chronicus
- Atopic dermatitis
- Infantile hemangioma
- Cutaneous candidiasis
- Irritant dermatitis
- Jacquet erosive diaper dermatitis
- Langerhans cell histiocytosis
- Straddle injury
- Scarring – linea vestibularis (10% of newborns), female genital mutilation
- Labial adhesion – from chronic irritation or rubbing
- Vaginal and urethral findings – sarcoma botryoides (form of embryonal rhabdomyosarcoma resembling a bunch of grapes protruding from the vagina), caruncle (erythematous, vascular, papillary growth in urinary meatus of females), ureterocele, urethral prolapse
- Vaginal discharge – retained vaginal foreign object