AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

Child sexual abuse affects more than 100,000 children a year. Many of these children present to the emergency department (ED). The following article outlines triage determinants for examinations, examination techniques, and interpretations of genital findings of sexual abuse.

Pathophysiology

Child sexual abuse has been defined by the American Academy of Pediatrics as the engaging of a child in sexual activities that the child cannot comprehend, for which the child is developmentally unprepared and cannot give informed consent, and violate the social taboos of society.¹ In general, children cannot consent to any sexual activity, but the legal age of consent may vary by state.

Sexual activities involving a child may include activities intended for sexual stimulation, such as those involved in contact sexual abuse (eg, touching the child's genitalia or the child touching an adult's genitalia), penetrating injury (eg, penile, digital, and object insertion into the vagina, mouth, or anus), and nonpenetrating injury (eg, fondling, sexual kissing).

Noncontact sexual abuse, which may include exhibitionism, voyeurism, and the involvement of a child in verbal sexual propositions or the making of pornography, often occurs.

Physical findings of sexual abuse are often not present. The most important determinant for abuse is the child's (or a witness's) account of the incident. Physical indicators may be present, such as bruises to the skin (eg, on the arms and legs from pinch marks or force), abrasions to wrists and ankles (eg, from tethering), bruises to the genital area and mucosa, oral palatal bruises and/or petechiae, and rectal abnormalities. Hymenal abnormalities may be present from chronic abuse or acute injury. Sexually transmitted diseases (STDs) may be present in sexually abused children and teenagers.

Frequency

United States

In 2005, 83,850 children in the United States  reported to Child Protective Services, were determined to be suspected victims of child sexual abuse. The actual number is likely to be higher because these numbers reflect only children whose cases are investigated by Child Protective Services.²

Mortality/Morbidity

Although perforation of the vagina or viscera could result in injury and death, death resulting from sexual abuse is unusual.

• Most of the morbidity associated with sexual abuse is a result of emotional and psychological trauma.
• Reactions to sexual abuse can include posttraumatic stress disorder, depression, anxiety, anger, impaired sense of self, dissociative phenomena, suicidal behavior, sexually reactive behaviors that are beyond the scope of normative child sexual development, and indiscriminate sexual behavior.
• STDs may result in further morbidity. However, the prevalence of STDs in sexually abused children varies with geographic location and with the child's age. Most STD prevalence rates in prepubertal children tend to be below 4%; in adolescents, the prevalence rate is approximately 14%.

Sex

It is estimated that 1 in 4 girls and 1 in 6 boys will have experienced an episode of sexual abuse while younger than 18 years. The numbers of boys affected may be falsely low because of reporting techniques.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

Children suspected of being sexually abused require a behavioral, social, gynecologic, and general medical history. Sufficient information about the current incident of sexual abuse is needed to ensure that all needed evidence is properly collected.

• In addition to information obtained from the child, details about the abuse should be obtained from other reliable sources, if possible.
• Obtain a history from the parent or caregiver alone. Social workers and physicians should build rapport with the child in order to establish trust.
• Possible warning signs regarding the social environment include the following:
• • Parents who share intimate feelings and emotions in front of their children
  • Parents who know little about the child's health or have vague recollections of past medical history
  • Parents who are overly concerned with custody issues
  • Social isolation
  • Alcohol and/or drug abuse
  • Intimate partner violence or other violence in the home environment of the child
• The history should also include questions regarding possible behavioral indicators of abuse.
• • Abrupt behavioral changes - Aggression, depression, suicidal behaviors, withdrawal, low self esteem, nightmares, phobias, regression, school problems
  • Self-destructive behaviors - Substance abuse, sleep disorders, prostitution, cutting or other self-mutilation
  • Sexualized behavior inappropriate for developmental level (eg, excessive masturbation, forcing sexual acts on other children)
  • Runaway behavior in teens, loss of memory for events following a social gathering, intimate partner violence
• Physical complaints
• • Foreign bodies in the vagina or rectum, genitourinary complaints, painful defection or urination, vaginal discharge, bleeding or itching, grasp or rope marks, oral complaints, STDs, or possible pregnancy
  • General somatic complaints including headaches, abdominal pain, constipation, diarrhea, encopresis, and general fatigue
• In adolescents, the gynecologic history should always include the following:
• • Date of last menstrual period, number of pregnancies, possible gynecologic surgery or traumatic injury to the genital area
  • Date of the last consensual intercourse and use of contraceptives
  • Prior STDs
• Depending on local protocols, the forensic (investigative) interview may best be performed with the assistance of trained law enforcement officials or social workers from Child Protective Services. The forensic interview differs from a good medical history.
• • This interview is essential to prosecution of a case and is often a critical aspect of the evaluation.
  • The forensic interview is mostly concerned with detailed answers to who, what, where, and when the abuse occurred.
  • The forensic interview should not replace the medical history obtained by the health care provider from the child.
  • If possible, professionals in the field of child sexual abuse should interview children alone.
  • Children may spontaneously disclose abuse to the physicians during the physical examination.
  • The medical record should clearly document who was present when the child disclosed the information, what question or activity prompted the disclosure, and, if possible, the exact words spoken recorded in quotation marks.
  • Questions regarding the incident should be focused but not leading. For example: "What were you touched with?" is an appropriately focused question. "Did he touch you with his fingers?" is a leading question.
  • Children with special communication needs, such as children with developmental disabilities, may require sign language, use of assistive devices, or illustrations.
• Family and social histories are vital to understanding the environment in which the abuse occurred.
• A brief developmental history may be critical in legal aspects of a child's case and should be documented.
• Screening tools for the behavioral and medical history for sexual abuse have been developed and may be utilized.³

Physical

Complete physical examinations in prepubertal children should include an examination of the external genitalia. Children who are suspected of being sexually abused may need an examination emergently, urgently, or electively scheduled for a later time with their own physician. If the child and family are adequately prepared for this examination, it will improve the diagnostic capability of the examiner.

• Following an initial phone call from a parent or from a person from Child Protective Services, pediatric patients may be triaged for a medical examination to find evidence of sexual abuse.
• • Emergent examinations: Any child with acute bleeding or injury should be examined immediately. Children with a history of sexual contact within 96 hours of presentation should be examined for evidence of sexual abuse. Children in severe emotional or psychological crisis also deserve an emergent examination. Children exposed to HIV-positive alleged perpetrators need to begin HIV postexposure prophylaxis within 36 hours of exposure. Adolescents who wish to obtain pregnancy prevention need to be evaluated within 120 hours.
  • Urgent examinations may take place within 2-3 days of an incident of sexual abuse. Indications for an urgent examination include vaginal discharge, the possibility of STDs, and pregnancy in the pubertal child.
  • Delayed presentations are most common because children generally do not disclose abuse until they feel safe. This may occur months or years after the incident of abuse.
  • Other children may not disclose the abuse at all, and only behavioral indicators will be present.
  • If persons from Child Protective Services or law enforcement agencies request examinations of children with nonemergent cases, the examination can be deferred to a scheduled office visit or be referred to a child sexual abuse team.
  • The examination of a child who is involved in a custody situation is challenging. Whether the allegations of abuse are true or not, children involved in sexual abuse allegations must be considered to be victimized. An examination is almost always indicated.
• Preparation of the child and family should be a part of every examination for sexual abuse.⁴
• • The discussion should include the following:
  • • Information regarding the need for an external examination of the genitalia
    • The fact that almost all prepubertal children do not need a speculum or internal examination
    • Information on the use of cotton-tipped swabs to check for infections (if determined that these will be needed)
  • If a colposcope will be used for the examination, children should be allowed to look at the equipment and look through the eyepieces or at the video screen.⁵ Parents and older children should be informed of the use of the equipment and given opportunities to consent to the use of photographs for legal documentation. Note: Consent for photographs may not be necessary if the case is under investigation by Child Protective Services, but it is recommended.
• The examination of the external genitalia should occur as part of the natural progression of the complete head-to-toe pediatric examination.
• • Proper positioning of the child for the genitalia examination enables better visualization. Common positions for female prepubertal children include the supine-frog-leg position, the knee chest position, and use of the labial traction technique.
  • Some physicians utilize a technique with a Foley catheter to get a better view of the hymen or utilize water to "float" the hymen for better visualization.⁶
  • The male genitalia can be examined with the child supine or standing.
• Abnormal findings that are suspicious for sexual abuse are rare.
• • Findings of sexual abuse in boys may include injuries to the glans, shaft of the penis, or scrotum. Anal findings are unusual but may include scars (most apparent if located off the midline), distorted or irregular folds, flattening of the anal folds, and poor anal tone.
  • Most cases of suspected or substantiated sexual abuse of prepubertal girls have normal examination findings. This may be due to elasticity of the hymenal tissue and genital mucosa and rapid healing of any injuries.^{7, 8}
  • • In most cases, children who are sexually abused are not physically injured (as in fondling), and the abuse does not leave physical evidence.
    • The normal crescent-shaped hymen is most common in prepubertal girls.
    • Other normal findings may include midline avascular areas, periurethral bands, longitudinal intravaginal ridges, superior and lateral notches, and some bumps and hymenal tags.
    • Other anatomical configurations of the hymen, which may normally be observed in prepubertal girls, include an annular hymen, fimbriated hymen, septate hymen, and microperforate hymen.
• Physical findings in sexually abused prepubertal girls may include lacerations and bleeding of the genital area or more subtle chronic findings. Findings on the hymen should be documented by noting the location with the analogy of the hands of a clock. Findings may be significant for abuse.⁹
• • A hymenal tear may result in a healed transection of the hymen. However, over time, a hymenal tear may heal completely, leaving no signs of trauma or scarring.
  • Absence of all or part of the hymen, particularly in the posterior portion of the hymenal ring should be confirmed using different examination positions or techniques. For example, hymenal tissue may be adherent to part of the vaginal wall. Using a moist swab or drops of water to loosen the edge should clarify the finding.
  • Measuring the vaginal introital diameter is not necessary. When the examiner notices a subjectively large diameter, the hymenal rim should be observed for signs of narrowing and attenuation or absence of tissue. However, superficial notches in the hymen may be a normal finding.
  • Fresh lacerations or tears located in the genital area without a history of accidental trauma should be noted.
• Other areas of the body should be inspected for signs of injury, including the oral pharynx for bruises to the hard or soft palate and grasp, rope, or tie marks on the extremities.

Causes

• Risk factors
• • Parent abused as a child: Most perpetrators are not strangers but are known to the child (eg, stepfathers, uncles, mother's paramour). Female perpetrators are reported less often. Parents who have been abused do not always abuse their own children, but the risk for continued familial abuse is present.
  • Multiple caretakers for the child
  • Caretaker or parent who has multiple sexual partners
  • Drug and/or alcohol abuse
  • Stress associated with poverty
  • Social isolation and family secrecy
  • Child with poor self-esteem or other vulnerable state
  • Other family members (eg, siblings, cousins) abused
  • Gang member associations

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Other Problems to be Considered

Vaginal foreign body
Urethral prolapse
Shigella infection

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

• Chlamydia trachomatis culture: Chlamydia vaginitis or proctitis may be present without obvious signs of discharge, erythema, or inflammation. Oral chlamydia is rare. DNA tests using polymerase chain reaction (PCR) may offer more sensitivity in detection of C trachomatis and N gonorrhoeae. Since they are often less expensive and may be simpler to obtain, these tests may be useful for initial screening of urine or vaginal/urethral swabs. Follow-up must be ensured because the gold standard for courtroom acceptance of results remains culture-proven infection. PCR positive tests need to be followed up with culture testing.¹⁰
• • Cultures should be obtained if any of the following are present: symptoms of vaginitis (discharge) in the prepubertal girl, the perpetrator is known to be infected with C trachomatis, the child has physical findings of sexual abuse, or there is patient or parental concern regarding possible infection.
  • Not all children in whom sexual abuse is suspected require cultures for STDs. Clinical judgment should be based on the presence of the above factors, as well as the local epidemiology of STDs.
  • In boys, a urethral swab (premoistened) should be obtained only if urethral discharge, dysuria, erythema, or positive urine leukocyte esterase is present.
  • Cultures for Chlamydia species should be obtained after rape kit swabs using a Dacron, rayon, or cotton tipped swab on plastic or aluminum (may use batch tested calcium alginate). Indirect testing methods for chlamydia (eg, ELISA testing) should not be performed in the prepubertal child. PCR of urine or vaginal swabs may be helpful in screening, but the gold standard in children is still culture results.
• Neisseria gonorrhoeae culture: Gonorrhoeae vaginitis infection usually results in a purulent discharge. However, infection, particularly rectal and oral infections, may be subclinical.
• • Cultures of all 3 areas (oral, rectal, and vaginal/urethral should be obtained if any of the following are present: symptoms of vaginitis (discharge) in the prepubertal girl, the perpetrator is known to be infected with N gonorrhoeae, the child has physical findings of sexual abuse, or there is patient or parental anxiety regarding possible infection.
  • Not all children suspected of being abused need cultures for STDs, and clinical judgment should be based on the presence or absence of the above factors as well as the local epidemiology of STDs.
  • In boys, a urethral swab (premoistened) should be obtained if urethral discharge, dysuria, erythema, or positive urine leukocyte esterase is present.
  • Cultures should be performed using cotton-tipped swabs inoculated onto Thayer Martin plates and incubated in a carbon dioxide enriched environment.
  • • Attention should be given to isolating the appropriate Neisseria species.
    • First-catch urine cultures in male adolescents may be used instead of swabs.
    • Biochemical and enzyme substrate or serologic techniques should confirm isolates.
• A wet prep can be obtained from patients with a vaginal discharge to determine the presence of Trichomonas vaginalis or bacterial vaginosis.
• • A potassium hydroxide (KOH) preparation assists in ruling out a yeast infection.
  • A fishy odor when KOH is added to the discharge indicates bacterial vaginosis.
  • In addition, a Papanicolaou (Pap) smear may show false-positive results for yeast (see Vaginitis).
• Any ulcerated lesions should be cultured for herpes simplex virus and typed. In the absence of lesions, routine cultures are not recommended. Isolation of herpes in the genital area of a prepubertal child does not always result in suspicion of sexual abuse. Transmission of herpes can be from autoinoculation of oral lesions for Type I or Type II in children.
• Most prepubertal vaginas harbor bacteria as normal flora. Thus, a Gram stain of discharge in prepubertal females is usually not indicated.
• Molluscum contagiosum located in the genital area may be consistent with sexual transmission.
• Human papillomavirus (HPV) may be present in prepubertal and pubertal children as a result of congenital transmission (up to 2-3 y), hand contact, household transmission, or sexual transmission.
• • Children with HPV may require testing for other STDs, and the HPV should be typed in order to determine if an oncogenic type is present.
  • The diagnosis is usually clinical; however, some laboratories use DNA assays. Biopsy is rarely necessary.
• Other laboratory tests
• • Syphilis: If a genital lesion is present, fluid can be obtained for darkfield microscopy. Serology (eg, VDRL, RPR, ART) should be obtained at the time of abuse (if at risk) and 6-12 weeks later.
  • Hepatitis B
  • • If the victim is incompletely or previously unimmunized, a hepatitis B vaccine should be given as soon as possible.
    • The patient should also be tested for hepatitis B surface antigen and antibody.
    • If the alleged offender is known to have acute hepatitis B, passive immunoprophylaxis with hepatitis B immune globulin (HBIG) should be given.
    • If the vaccine has already been given, no further treatment for hepatitis B is necessary.
  • Human immunodeficiency virus
  • • If possible, a serologic test should be obtained on the alleged offender.
    • The child should be tested for HIV when in areas of high prevalence of HIV and if the alleged perpetrator is a known drug abuser or is HIV positive. In general, local protocols for HIV prophylaxis and testing should be followed. In New York State, the Department of Health protocol for HIV currently requires testing and prophylaxis for all victims of sexual assault who are evaluated within 36 hours of the incident.
  • The testing should occur at the time of the first evaluation (baseline), and 3 months, 6 months and 12 months.

Imaging Studies

• Pelvic sonogram: This study may be indicated in children who have a septate hymen and need an evaluation for a bifid genitourinary tract. Children with vaginal discharge without resolution despite appropriate evaluation and treatment may need a pelvic sonogram to rule out congenital genital tract abnormalities or foreign bodies.

Other Tests

• A rape kit should be utilized if the child presents for an examination within 96 hours of the sexual abuse.
• • Most rape kits are available for the adult sexual assault victim and can be adapted for pediatrics.
  • Child sexual abuse victims may not require all of the tests contained within the adult kit.
  • The rape kit is usually provided by the local law enforcement agency and has a specific protocol, including a chain of evidence procedure.
  • Isolation of areas to swab for semen or other evidence may be enhanced by use of a Woods lamp (which shows the fluorescence of alkaline phosphatase in semen). Other materials may fluoresce with the Woods lamp, including urine.

Procedures

• Colposcopic photo documentation of genital findings is useful for both clinical and legal purposes.^{11, 4}
• • The colposcope is used to document normality and for comparison to cases in which children later return with abnormal findings.
  • The colposcope can also be used to address altered body image, identify discrepancies in examinations, provide information to the nonoffending parent, and assist the examiner by magnifying the image onto a video screen or using optics.
  • These images can provide legal evidence, possibly reduce the child's anxiety, and can be used as a teaching and research tool.
  • The colposcope is not necessary for examination of child sexual abuse but is generally considered state of the art for most expert child sexual abuse evaluations.
  • Using an otoscope can enhance magnification and photographs can be taken with a 35-mm or digital camera.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Prehospital Care

• If a child presents within 96 hours of an acute assault or in the case of chronic incidents of abuse, the family should not bathe the child or allow the child to have anything to eat or drink.
• Avoid questioning the child about the incident until appropriate interviewing can be arranged.
• However, if the child spontaneously discloses, then who is in the room, what prompted the disclosure, and what time the disclosure occurred should be documented.

Emergency Department Care

• The most important treatment is the staff's gentle reassurance that the child is now safe and that efforts and steps will be made to ensure further safety.
• Reassurance that there is no permanent genital damage (as is true in most cases) is an important aspect of the child's emotional healing.
• Care should be taken to avoid promises that cannot be kept.
• Treatment for identified STDs should be initiated.
• Prophylaxis is not usually indicated for STDs in prepubertal children but may be considered in adolescents. STD testing should be considered in accordance with local protocols and epidemiology of these diseases.
• Possible pregnancy should be discussed with the pubertal child (see Sexual Assault).
• Referral or consultation for mental health or other counseling should be made in almost every case of child sexual abuse.
• Prophylaxis for HIV should be considered if the sexual contact was within 36 hours. Treatment depends on local protocols, and in most cases consultation with infectious disease experts is needed.

Consultations

• Consult a medical team on call for sexual abuse evaluations if available.
• Child Protective Services or hotline
• Law enforcement agencies
• Rape crisis counselor, victim advocate, and/or other mental health professional
• Infectious disease division regarding HIV prophylaxis protocols

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Antibiotics to prevent sexually transmitted diseases may be considered depending on the circumstances of abuse. For more information, see CDC Treatment Guidelines for Sexually Transmitted Diseases.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Further Inpatient Care

• Inpatient care is recommended if the child's safety is in jeopardy or if the child has an acute traumatic injury requiring inpatient treatment.
• Occasionally, treatment for a STD requires hospital admission and inpatient treatment.
• Severe mental or emotional trauma may necessitate inpatient admission and care.

Further Outpatient Care

• Most sexually abused children should be referred for mental health counseling.
• Follow up for medical problems (eg, genitourinary complaints) should be arranged with the child's primary care physician.
• If the community has a child abuse referral center, the children should be referred there for follow-up care according to local protocol.

In/Out Patient Meds

• Prophylactic antibiotics in prepubertal sexually abused children are indicated in rare cases.
• Prophylactic antibiotics may be given to pubertal sexually abused children after an acute assault.
• Use of postassault pregnancy prevention options should be discussed with the pubertal sexual assault victim.

Complications

• Infection
• Psychological/social problems

Prognosis

• Sexually abused children have significantly higher occurrences of the following:
• • Eating disorders
  • Suicidal behaviors
  • Self-injury
• Children who are sexually abused may be at increased risk of reabuse.
• Ongoing emotional/psychological problems may be indicative of abused children's false beliefs about themselves and the sexual abuse experience.

Patient Education

• Families are usually concerned about injury in the child. Reassurance may involve an explanation that children can be sexually abused and have no physical findings to support their allegations.
• For excellent patient education resources, visit eMedicine's Children's Health Center and Public Health Center. Also, see eMedicine's patient education articles Child Abuse and Sexual Assault.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• Proper history and physical documentation using a sexual abuse protocol decrease the need for future testifying.
• The following are tips for testifying:
• • Prepare the case. Review the entire medical record, review literature pertinent to the case, and plan your explanation of medical findings and case development to the jury. Call the court and arrange to be "on call" for testimony.
  • Meet with the prosecutor and review the case. Practice sample questions; discuss significant findings; assist the attorney with a logical approach to your testimony; and discuss possible cross-examination issues, potential weaknesses in the case, and visual aids.
  • Do not discuss the case casually or publicly.
  • In the courtroom, listen carefully to the entire question before responding, do not answer a question that you do not understand (ask for clarification or restatement), give simple answers, and do not volunteer information.
  • Do not offer additional explanation beyond the direct question. That is, keep your answers as simple as possible.
  • Concentrate on the truth (do not worry about whether your answer is going to hurt or help the case).
  • If a question is beyond your area of expertise, say so.
  • Do not speak after an attorney objects until the judge rules.
  • Ignore inflection and innuendo.

Special Concerns

• Children may present to the emergency department with a vague history of genital complaints and a parental concern of child abuse but no other findings or specific disclosure. Evaluation for other genital problems, including urethral prolapse, urinary tract infection, accidental straddle injury, vaginitis due to poor hygiene or pinworms, and masturbation should be considered.
• Children repeatedly presenting to the emergency department for evaluation of sexual abuse should raise suspicion of parental misuse of the examination for secondary gain (eg, false allegations in custody situations, maternal mental illness).

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

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3. Palusci VJ, Palusci JV. Screening tools for child sexual abuse. J Pediatr (Rio J). Nov-Dec 2006;82(6):409-10. [Medline].
4. Berson NL, Herman-Giddens ME, Frothingham TE. Children's perceptions of genital examinations during sexual abuse evaluations. Child Welfare. Jan-Feb 1993;72(1):41-9. [Medline].
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8. Kellogg ND, Menard SW, Santos A. Genital anatomy in pregnant adolescents: "normal" does not mean "nothing happened". Pediatrics. Jan 2004;113(1 Pt 1):e67-9. [Medline].
9. Adams JA, Botash AS, Kellogg N. Differences in hymenal morphology between adolescent girls with and without a history of consensual sexual intercourse. Arch Pediatr Adolesc Med. Mar 2004;158(3):280-5. [Medline].
10. Hammerschlag MR. Appropriate use of nonculture tests for the detection of sexually transmitted diseases in children and adolescents. Semin Pediatr Infect Dis. Jan 2003;14(1):54-9. [Medline].
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16. Botash AS. Examination for sexual abuse in prepubertal children: an update. Pediatr Ann. May 1997;26(5):312-20. [Medline].
17. Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines 2006. MMWR. 2006;Vol. 55:1-84. [Full Text].
18. Christian CW, Lavelle JM, De Jong AR, et al. Forensic evidence findings in prepubertal victims of sexual assault. Pediatrics. Jul 2000;106(1 Pt 1):100-4. [Medline].
19. Emans SJ, Woods ER, Flagg NT, et al. Genital findings in sexually abused, symptomatic and asymptomatic, girls. Pediatrics. May 1987;79(5):778-85. [Medline].
20. Evans H. Vaginal discharge in the prepubertal child. Pediatr Case Rev. Oct 2003;3(4):194-202. [Medline].
21. Finkel MA. Anogenital trauma in sexually abused children. Pediatrics. Aug 1989;84(2):317-22. [Medline].
22. Finkelhor D. Current information on the scope and nature of child sexual abuse. In: Sexual Abuse of Children: The David and Luc Center for the Future of Children. Vol 4. 1994:31-53.
23. Kellogg N. The evaluation of sexual abuse in children. Pediatrics. Aug 2005;116(2):506-12. [Medline]. [Full Text].
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25. Siegel RM, Schubert CJ, Myers PA, Shapiro RL. The prevalence of sexually transmitted diseases in children and adolescents evaluated for sexual abuse in Cincinnati: rationale for limited STD testing in prepubertal girls. Pediatrics. Dec 1995;96(6):1090-4. [Medline].

Article Last Updated: Jul 2, 2008