Guidelines for medical care of children evaluated for suspected

sexual abuse: an update for 2008

Joyce A. Adams
Department of Pediatrics, University of California-San
Diego, San Diego, California, USA
Correspondence to Joyce A. Adams, MD, Professor of
Clinical Pediatrics, UCSD Pediatric Associates, 7910
Frost Street, Suite 350, San Diego, CA 92123, USA
Tel: +1 858 496 4823; fax: +1 858 496 4851;
e-mail: jadams@ucsd.edu
Current Opinion in Obstetrics and Gynecology
2008, 20:435–441
Purpose of review
Child sexual abuse is a common problem in our society and medical professionals who
provide evaluations of children who may have been abused need to be updated as to
recent research findings and recommendations for conducting examinations and
interpreting results.
Recent findings
Research studies have provided important new information regarding the qualifications
of examiners, the recovery of forensic evidence in children, the frequency of
abnormal findings in children and adolescents, the healing of genital injuries, and
the interpretation of medical findings and sexually transmissible infections with respect
to abuse.
Summary
The recommendations for the timing and type of examinations for prepubertal children,
in contrast to adolescent sexual assault victims, may need to be changed. Studies
showing that partial tears of the hymen, as well as abrasions and contusions, may heal to
leave very little or no sign of previous injury emphasize the importance of urgent
evaluations. There is a need for standardization of the training of medical professionals
who perform child sexual abuse evaluations to ensure continuing competence.

Keywords
child sexual abuse, genital injuries, interpretation of medical findings

Curr Opin Obstet Gynecol 20:435–441

ß 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins
1040-872X

no signs of residual injury such as scars, unless the injuries

Introduction
Physicians with an interest and expertise in the field of
child sexual abuse medical evaluation met at conferences
and collaborated through the Internet, between 2003 and
2007, to develop and revise recommended guidelines for
medical care for children with suspected sexual abuse.
These guidelines were published in 2007 [1] and
included a table listing an approach to the interpretation
of medical and laboratory findings in children, which was
based on research studies published before 2006 [2–20].
The interpretation table is included here as Table 1.
were severe.
McCann et al. [21] published the first of three articles
reporting the results of a multicenter retrospective study
of acute and healing genital trauma in children and
adolescents in 2007. The cases for this study were soli-
cited from colleagues by an electronic listserv. The final
sample included photographs and case information for
113 prepubertal girls and 126 pubertal girls who had
sustained a genital injury and had at least one follow-
up examination.

The present article will review research studies and
commentaries published in the past 2 years and discuss
recommendations for changing the guidelines to reflect
new knowledge.
Healing of genital trauma
Before 2007, there were a limited number of studies
looking at the healing of genital and anal injuries in
children. These studies [11–13] showed that injuries
heal very rapidly, within days or weeks, and usually leave
Because of the study design, it was not possible to have
photographs taken at defined time periods after the first
acute examination. The timing of the follow-up examin-
ations, number and type of photographs, and examination
techniques were variable. The photographs collected
were reviewed by three team members together, and
the authors report that agreement was reached before
the findings were classified. There was no external review
of the photographs, however, and the method of describing
five levels of hymen lacerations (superficial, intermediate,
deep, complete, transection, transection with extension)

1040-872X ß 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins DOI:10.1097/GCO.0b013e32830866f4

Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 436 Adolescent and pediatric gynecology

Table 1 Approach to interpretation of medical findings in suspected child sexual abuse

Findings documented in newborns or commonly seen in nonabused children (the presence of these findings generally neither confirms nor
discounts a child’s clear disclosure of sexual abuse)
Normal variants
1. Periurethral or vestibular bands
2. Intravaginal ridges or columns
3. Hymenal bumps or mounds
4. Hymenal tags or septal remnants
5. Linea vestibularis (midline avascular area)
6. Hymenal notch/cleft in the anterior (superior) half of the hymenal rim (prepubertal girls), on or above the 3 o’clock to 9 o’clock line,
patient supine
7. Shallow/superficial notch or cleft in inferior rim of hymen (below 3 o’clock to 9 o’clock line)
8. External hymenal ridge
9. Congenital variants in appearance of hymen, including: crescentic, annular, redundant, septate cribiform, microperforate, imperforate
10. Diastasis ani (smooth area)
11. Perianal skin tag
12. Hyperpigmentation of the skin of labia minora or perianal tissues in children of color, such as Mexican–American and
African–American children
13. Dilation of the urethral opening with application of labial traction
14. ‘Thickened hymen’ (may be due to estrogen effect, folded edge of hymen, swelling from infection, or swelling from trauma.
The latter is difficult to assess unless follow-up examination is done)
Findings commonly caused by other medical conditions
15. Erythema (redness) of the vestibule, penis, scrotum or perianal tissues (may be due to irritants, infection or traumaa)
16. Increased vascularity (‘dilatation of existing blood vessels’) of vestibule and hymen (may be due to local irritants, or normal pattern in the
non estrogenized state)
17. Labial adhesion (may be due to irritation or rubbing)
18. Vaginal discharge (many infectious and noninfectious causes; cultures must be taken to confirm if it is caused by sexually transmitted
organisms or other infections)
19. Friability of the posterior fourchette or commisure (may be due to irritation, infection, or may be caused by examiner’s traction
on the labia majora)
20. Excoriations/bleeding/vascular lesions (these findings can be due to conditions such as lichen sclerosus, eczema or seborrhea,
vaginal/perianal Group A Streptococcus, urethral prolapse, hemangiomas)
21. Failure of midline fusion (also called perineal groove)
22. Anal fissures (usually due to constipation, perianal irritation)
23. Venous congestion, or venous pooling in the perianal area (usually due to positioning of child, also seen with constipation)
24. Flattened anal folds (may be due to relaxation of the external sphincter or to swelling of the perianal tissues due to infection or traumaa)
25. Partial or complete anal dilatation to less than 2 cm (anterior–posterior dimension), with or without stool visible.

Indeterminate findings: insufficient or conflicting data from research studies (may require additional studies/evaluation to determine significance)
(these physical/laboratory findings may support a child’s clear disclosure of sexual abuse, if one is given, but should be interpreted with
caution if the child gives no disclosure; report to Child Protective Services may be indicated in some cases)
Physical examination findings
26. Deep notches or clefts in the posterior/inferior rim of hymen, between 4 and 8 o’clock, in contrast to transections (see [41]).
27. Deep notches or complete clefts in the hymen at 3 or 9 o’clock in adolescent girls
28. Smooth, noninterrupted rim of hymen between 4 and 8 o’clock, which appears to be less than 1 mm wide, when examined in the
prone knee–chest position, or using water to ‘float’ the edge of the hymen when the child is in the supine position.
29. Wart-like lesions in the genital or anal area (biopsy and viral typing may be indicated in some cases)
30. Vesicular lesions or ulcers in the genital or anal area (infectious and noninfectious causes; cultures, serology, and/or nucleic acid
amplification tests should be done)
31. Marked, immediate anal dilation to an AP diameter of 2 cm or more, in the absence of other predisposing factors such as chronic
constipation, sedation, anesthesia, neuromuscular conditions.
Lesions with etiology confirmed: Indeterminate specificity for sexual transmission
32. Genital or anal Condyloma accuminata in a child, in the absence of other indicators of abuseb
33. Herpes type 1 or 2 in the genital or anal area in a child with no other indicators of sexual abuseb
Findings diagnostic of trauma and/or sexual contact (the following findings support a disclosure of sexual abuse, if one is given, and are highly
suggestive of abuse even in the absence of a disclosure, unless a clear, timely, plausible description of accidental injury is provided by the
child and/or caretaker)
Acute trauma to external genital/anal tissues
34. Acute lacerations or extensive bruising of labia, penis, scrotum, perianal tissues, or perineum (may be from unwitnessed accidental
trauma, or from physical or sexual abuse)
35. Fresh laceration of the posterior fourchette, not involving the hymen (must be differentiated from dehisced labial adhesion or failure
of midline fusion (see [21]); posterior fourchette lacerations may also be caused by accidental injury or consensual sexual
intercourse in adolescents)
Residual (healing) injuries (these findings are difficult to assess unless an acute injury was previously documented at the same location)
36. Perianal scar (rare, may be due to other medical conditions such as Crohn’s disease, accidental injuries, or previous
medical procedures)
37. Scar of posterior fourchette or fossa (pale areas in the midline may also be due to linea vestibularis or labial adhesions)
Injuries indicative of blunt force penetrating trauma (or from abdominal/pelvic compression injury if such history is given)
38. Laceration (tear, partial or complete) of the hymen, acute
39. Ecchymosis (bruising) on the hymen (in the absence of a known infectious process or coagulopathy)
40. Perianal lacerations extending deep to the external anal sphincter (not to be confused with partial failure of midline fusion)

(continued overleaf )

Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 Guidelines for medical care of sexually abused children Adams 437

Table 1 (continued )
41. Hymenal transection (healed). An area between 4 and 8 o’clock on the rim of the hymen where it appears to have been torn through,
to or nearly to the base, so there appears to be virtually no hymenal tissue remaining at that location. This finding has also been referred
to as a ‘complete cleft’ in sexually active adolescents and young adult women.
42. Missing segment of hymenal tissue. Area in the posterior (inferior) half of the hymen, wider than a transection, with an absence
of hymenal tissue extending to the base of the hymen, which is confirmed using additional positions/methods
Presence of infection confirms mucosal contact with infected and infective bodily secretions, contact most likely to have been sexual in nature
43. Positive confirmed culture for gonorrhea, from genital area, anus, and throat, in a child outside the neonatal period
44. Confirmed diagnosis of syphilis, if perinatal transmission is ruled out
45. Trichomonas vaginalis infection in a child older than 1 year of age, with organisms identified by culture or in vaginal secretions by
wet-mount examination
46. Positive culture from genital or anal tissues for Chlamydia, if child is older than 3 years at time of diagnosis, and specimen was tested
using cell culture or comparable method approved by the Centers for Disease Control.
47. Positive serology for HIV, if perinatal transmission, transmission from blood products, and needle contamination has been ruled out
Diagnostic of sexual contact
48. Pregnancy
49. Sperm identified in specimens taken directly from a child’s body
AP, anterior-posterior.
a
Follow-up examination is necessary before attributing these findings to trauma.
b
Changes made since the publication of the table in 2007.
Adapted from Adams et al. [1].

had not been previously described or validated. In spite of
these limitations, the study is important because it was the
first to review such a large number of cases and document
how rapidly acute injuries can heal.
In prepubertal girls, findings of hymenal abrasions, pete-
chiae, ‘mild’ submucosal hemorrhages, and hematomas at
the first acute examination appeared to have healed
completely by 2–3 days in most of the cases reviewed.
When the submucosal hemorrhages were rated by the
reviewers as being ‘moderate’ or ‘marked’, some were
still identified at follow-up visits up to 15 days later.
The authors identified and classified 40 lacerations of the
hymen among the prepubertal girls. Of the 19 hymen
lacerations that were classified as less than complete, four
healed with no evidence of injury. Among pubertal girls,
there were more cases in which the hymen defect at the
site of the initial laceration appeared to be deeper at the
follow-up examination; for example, a deep laceration
initially would be revealed as a transection at follow-up,
due to the decrease in swelling of the tissues.
An interesting difference was found between the location
of the hymen lacerations between prepubertal and pub-
ertal girls. In the prepubertal girls, 35/40 lacerations
(88%) were in the posterior location, below the 3
o’clock–9 o’clock line, whereas in adolescents, 50/80
(60%) were posterior and 18/80 (23%) were lateral, at
either the 3 o’clock or 9 o’clock location.
In another article, the authors describe nonhymenal
findings in the same group of prepubertal and pubertal
girls whose photographs they reviewed [22]. Similar to
the findings on the hymen, abrasions resolved within 3
days, petechiae within 24 h, and submucosal hemorrhage
and hematomas within 7–14 days, depending on the
severity. Deep lacerations of the posterior fourchette
or perineum took 2–3 weeks to heal in prepubertal girls.
Examination techniques
The study including a subset of the cases reviewed for
the healing of injuries was analyzed by Boyle et al. [23] to
compare the effectiveness of three examination methods
used by the participating centers to detect the acute and
healing genital injuries. The authors found that the prone
knee–chest position was the most successful method for
detecting hymen lacerations in both prepubertal and
pubertal girls. Of 10 hymen lacerations identified in nine
prepubertal girls, 6/10 were identified when labial trac-
tion was used and 10/10 with the use of the prone knee–
chest position. In pubertal girls, 35/49 hymen lacerations
were identified using labial traction and 44/49 with the
prone knee–chest position.
This is useful information for medical providers who
examine children and adolescents following genital injury
or acute sexual assault, though techniques other than the
prone knee–chest position can be used with adolescent
girls. Cotton swabs and Foley catheters can also be used to
stretch out the edge of the redundant hymen in order to
look for acute or healing injuries in pubertal girls.
Cross-sectional studies of injuries and
forensic evidence
Table 2 summarizes the results of nine studies
[24,25,26–31,32] conducted at various centers with
a large number of child or adolescent sexual assault cases,
analyzing the prevalence of abnormal physical findings,
positive test results for sexually transmitted diseases,
and/or rates of recovery of forensic material. In general,
these studies showed that abnormal physical examination

Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 Table 2 Summary of findings from cross-sectional studies of sexually abused children and adolescent girls
Timing of Abnormal medical Positive forensic
N Age range examination examinations (% ) Positive STIs (% ) results (%) Special characteristics or findings

Drocton et al. [24] 1674 women 12–20 years <72 h 53 overall, 63 positive NA NA Adolescents, virgins, history of
anal finding if anal penetration, alcohol use had
abuse described more injuries
Hobbs and Osman [25] 86 men 1 month to 15 years, Variable All (sample selected NA NA Boys with genital injuries referred
mean 5 years for injury) for suspected abuse. Lacerations,
bruises, abrasions most common
finding
Palusci et al. [26] 190 <13 years, mean <72 h 13 5% 9 (17/93 tested) Positive forensics from body
438 Adolescent and pediatric gynecology

age 6.5 years swabs only recovered from

girls aged 10–13 who had
not bathed.
Palusci et al. [26] 586 <13 years, mean >72 h 4 NA NA Positive examinations more
age 7.0 years common in women, after
puberty, and with h/o
genital contact
Young et al. [27] 48 4 months to 11 years <72 h NA NA 6 No swabs from child’s body
were positive, only clothing,
bedding in three children
Young et al. [27] 31 12–16 years <72 h NA NA 42 All positive swabs collected
within 24 h of assault
Christian et al. [28] 273 <10 years Most cases 23 (only cases reviewed NA 25 No body swabs positive
<72 h were those with forensic after 18 h
swabs taken and analyzed)
Edinburgh et al. [29] 226 women 10–14 years <72 h Hmong: 63 other: 21 Hmong: 36 positive NA Hmong girls were significantly
(32 of Hmong Chlamydia; other: 4 more likely to be victims of
ethnicity) multiple assailants, be
runaways, depressed and
suicidal
Kelly et al. [30] 2134 1 month to 17 years Variable 6 3 NA Abnormal findings more
common in adolescents
Kelly and Koh [31] 1392 <10 years Variable NA 1 NA No STI was found in prepubertal
child without symptoms
770 10–17 years Variable NA 6
Kohlberger and 180 girls 1–16 years Variable 24 (‘hymen vaginal tear’) 0 (HIV, syphilis) to NA Gardnerella vaginalis found in
Bancher-Todesca [32] 2 (gonorrhea) 25%, no correlation with
‘hymen vaginal tear’
NA, not available; STI, sexually transmitted infection.

Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 Guidelines for medical care of sexually abused children Adams 439
findings, positive tests for sexually transmitted diseases,
and positive forensic specimen results were more com-
mon in adolescent than prepubertal children. Impor-
tantly, both Palusci et al. [26] in reviewing 190 cases
and Young et al. [27] reviewing 80 cases found that no
forensic evidence was recovered from a prepubertal
child’s body, even if they had been brought for examin-
ation within 6 h of the last episode of abuse. These two
studies support the findings of Christian et al. [28].
Change the ‘72-hour’ rule?
As Palusci et al. [26] and Christian et al. [28] describe, this
rule evolved as a result of data from a few studies showing
that sperm could be recovered from the adult female
genital tract up to 72 h following penile vaginal intercourse.
If the goal of performing an urgent examination is to collect
swabs for forensic evidence, this author would argue that
the ‘72-hour rule’ should be changed to the ‘24-hour rule’
for prepubertal children. Prepubertal children who are
brought in within 24 h of an alleged episode of abuse, have
not been bathed, and have a history or possibility of having
been exposed to the alleged perpetrator’s semen or saliva
should have samples taken for forensic evidence. Those
who have been bathed, or in whom the last contact was
more than 24 h prior to the request for an examination, and
have no symptoms or signs of injury or infection would
most likely be better served, if the examination could be
scheduled, during the day, at the facility with the most
experienced medical providers. These examinations
should be expedited and performed as soon as possible
by medical providers with specific training in order to
increase the chances of finding signs of minor injury that
tend to heal within a few days.
Commenting on the need for urgent examinations when
children have been sexually abused, Dubowitz ([33], p.
998) states: ‘Too often, the perceived need for an immedi-
ate evaluation leads to an emergency department, in the
middle of the night, with staff not trained to evaluate these
children and in a setting that may exacerbate their stress.’
If there is little or no likelihood of recovering forensic
evidence from the child’s body, the examination could just
as easily be scheduled within the next day or two and still
accomplish the most important goal: reassurance of the
child and family that the child is not ‘damaged’.
Expertise in interpreting genital findings with
respect to abuse
Physicians in several specialties may have difficulty in
interpreting genital examination findings in children.
Muram and Simmons [34] showed color photographs
of normal anatomy and common pediatric gynecologic
conditions to 20 faculty members and 40 residents in
pediatrics, family medicine, and obstetrics and gyne-
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
cology at one large medical school. The mean correct
response rate ranged from 42% for residents to 58% for
faculty, in spite of the fact that regular seminars and
lectures in pediatric gynecology were provided at the
teaching hospital. The authors also report that many of
the residents and faculty members had a tendency to
label examinations, both normal and abnormal, as indica-
tive of sexual abuse.
Botash et al. [35] found that even after participating in a
comprehensive educational intervention for generalist
pediatric providers on evaluating suspected child sexual
abuse, 59% of the participants could not correctly identify
the medical findings on presented case photographs.
The conclusion of the consensus group who developed
the guidelines for child sexual abuse medical evaluation
[1] is that medical providers should have formal medical
education in the field, including didactic education,
practical experience in performing medical evaluations,
and mentoring by an established expert; be familiar and
keep up to date with published research and recommen-
dations from relevant professional organizations; be able
to demonstrate substantial experience and proficiency in
performing medical evaluations of children and under-
stand the process of differential diagnosis of physical
findings that could be mistaken for abuse; and have a
system in place to consult with established experts when
a second opinion is needed regarding the interpretation of
a medical finding.
Rethinking herpes, vulvar ulcers, and
gonorrhea
Ongoing education of medical providers is particularly
important when considering the diagnosis of sexually
transmissible infections. Shapiro and Makoroff [36]
reviewed the topic of sexually transmitted diseases in
children and adolescents who are evaluated for suspected
sexual abuse, focusing on research related to human
papilloma virus transmission and indications for HIV
prophylaxis following sexual assault.
Herpes simplex virus type 1 and 2
Studies of the prevalence of antibodies to herpes type 1
and 2 (HSV-1, HSV-2), among children and young ado-
lescents have been published in the last year. Xu et al.
[37] analyzed sera from 2989 children between age 6 and
13 who participated in the National Health And Nutrition
Examination Surveys (NHANES) between 1999 and
2002. They found seroprevalence rate for HSV-1 of 31%
for the overall sample, with significantly higher rates
among older compared with younger children and among
those living below the poverty line compared with those
above the poverty line.
 440 Adolescent and pediatric gynecology
In another study from Sweden [38], sera from mothers
and infants was analyzed for antibodies to HSV-1 and
HSV-2. The seroprevalence of HSV-1 among mothers
was higher than HSV-2 (65 versus 19%), and at 30 months
of age, 30% of infants had seroconverted for HSV-1 after
being negative at an earlier testing. The peak time of
acquisition of antibodies to HSV-1 among infants was
found to be within the first 13 months of life. None of the
infants became positive for HSV-2 antibodies.
As both types of herpes virus infections can be, and are
usually, transmitted by individuals who do not know they
are infected [39], it is often not possible to know how and
from whom a child might have acquired HSV lesions or
antibodies. If the child is young enough that parents or
other caretakers are still assisting with hygiene or toilet-
ing activities (generally under the age 5 or 6 years), it is
not unreasonable to postulate that a young child with
genital ulcers found to be caused by HSV-1 or HSV-2 may
have been exposed through nonsexual contact.
How likely is it that a child with genital ulcers caused by
HSV-1 or HSV-2 acquired the infection as a result of
sexual versus nonsexual contact? There is little data from
research studies in this area to help answer that question.
Reading and Rannan-Eliya [40] found in a literature
review that investigators reported sexual transmission
more commonly in children who were 5 years of age or
older, who had genital lesions only, and in whom HSV-2
was isolated from the lesions. However, there are no large
studies comparing the seroprevalence of HSV-1 or HSV-2
among children with and without a suspicion of sexual
abuse. Consequently, genital herpes infections in chil-
dren should probably remain in the ‘indeterminate’
category with respect to sexual transmission.
Vulvar ulcers
Vulvar ulcers in children and adolescents can have many
causes other than herpes infection. Huppert et al. [41]
reviewed 20 cases of adolescent girls aged 10–19 years
who presented with vulvar ulcers and were negative for
herpes virus. Laboratory findings were nonspecific,
including testing for Epstein–Barr virus and cytomega-
lovirus, and the appearance and clinical course for these
young women was most consistent with apthosis. This
study emphasizes the importance of testing for herpes
virus and waiting for the result before concluding that
a young woman with vulvar ulcers might have been
sexually abused.
Is gonorrhea always sexually transmitted?
Sexually transmissible infections are not always sexually
transmitted. A review of studies of gonococcal infections
[42], dating back to 1904, describes over 40 epidemics of
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
gonococcal vulvovaginitis or conjunctivitis, involving
over 2000 children in Europe and the United States.
The article also reviews research studies that demon-
strated the viability of gonococcus organisms on various
surfaces for 2–72 h.
Although some expert clinicians disagree, the wording as
mentioned in Table 1 regarding infections with Neisseria
gonorrhea, Chlamydia trachomatis, syphilis, and HIV is as
follows: ‘Infection confirms mucosal contact with infec-
ted and infective genital secretions: contact most likely to
have been sexual’, not ‘Definite evidence of sexual
contact’.
Conclusion
Most genital injuries in sexually abused children heal
with little residua, unless the injuries are severe. More
information is needed on the prevalence of infections
with HSV-1 and HSV-2 in children with and without a
history of sexual abuse to help with the interpretation of
an infection in a child. Recommendations regarding the
timing of urgent forensic examinations for prepubertal
children should be revised, based on the low yield of
forensic evidence from the child’s body more than 24 h
after the last sexual contact.
References and recommended reading
Papers of particular interest, published within the annual period of review, have
been highlighted as:
 of special interest
 of outstanding interest
Additional references related to this topic can also be found in the Current
World Literature section in this issue (p. 507).
1 Adams JA, Kaplan RA, Starling SP, et al. Guidelines for medical care of
 children who may have been sexually abused. J Pediatr Adolesc Gynecol
2007; 20:163–172.
This article presents guidelines for how, when, and by whom children should be
examined and suggests an approach to the interpretation of physical and labora-
tory findings in children with suspected sexual abuse. Groups of experts used a
process of consensus development to arrive at the guidelines presented.
2 Berenson A, Heger A, Andrews S. Appearance of the hymen in newborns.
Pediatrics 1991; 87:458–465.
3 McCann J, Voris J, Simon M, Wells R. Perianal findings in prepubertal children
selected for nonabuse: a descriptive study. Child Abuse Negl 1989; 13:179–
193.
4 McCann J, Wells R, Simon M, Voris J. Genital findings in prepubertal girls
selected for nonabuse: a descriptive study. Pediatrics 1990; 86:428–439.
5 Berenson AB, Heger AH, Hayes JM, et al. Appearance of the hymen in
prepubertal girls. Pediatrics 1992; 89:387–394.
6 Myhre AK, Berntzen K, Bratlid D. Genital anatomy in nonabused preschool
girls. Acta Paediatr 2003; 92:1453–1462.
7 Heger AH, Ticson L, Guerra L, et al. Appearance of the genitalia in girls
selected for nonabuse: review of hymenal morphology and nonspecific
findings. J Pediatr Adolesc Gynecol 2002; 15:27–35.
8 Myhre AK, Berntzen K, Bratlid D. Perianal anatomy in nonabused preschool
children. Acta Paediatr 2001; 90:1321–1328.
9 Berenson AB, Grady JJ. A longitudinal study of hymenal development from 3
to 9 years of age. J Pediatr 2002; 140:600–607.
10 Berenson AB, Chacko MR, Wiemann CM, et al. A case-control study of
anatomic changes resulting from sexual abuse. Am J Obstet Gynecol 2000;
182:820–834.
11 McCann J, Voris J, Simon M. Genital injuries resulting from sexual abuse.
A longitudinal study. Pediatrics 1992; 89:307–317.
 Guidelines for medical care of sexually abused children Adams 441
12 McCann J, Voris J. Perianal injuries resulting from sexual abuse: a longitudinal
study. Pediatrics 1993; 91:390–397.
13 Heppenstall-Heger A, McConnell G, Ticson L, et al. Healing patterns in
anogenital injuries: a longitudinal study of injuries associated with sexual
abuse, accidental injuries, or genital surgery in the preadolescent child.
Pediatrics 2003; 112:829–837.
14 Boos SC. Accidental hymenal injury mimicking sexual trauma. Pediatrics
1999; 103:1287–1289.
15 Herrmann B, Crawford J. Genital injuries in prepubertal girls from inline skating
accidents. Pediatrics 2002; 110:e16; http://www.pediatrics.org/cgi/content/
full/110/2/e16.
16 Boos SC, Rosas AJ, Boyle C, McCann J. Anogenital injuries in child pedes-
trians run over by low-speed motor vehicles: four cases with findings that
mimic child sexual abuse. Pediatrics 2003; 112:e77; http://www.pediatrics.
org/cgi/content/full/112/1/e77.
17 Heger A, Ticson L, Velasquez O, Bernier R. Children referred for possible
sexual abuse: medical findings in 2384 children. Child Abuse Negl 2002;
26:645–659.
18 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 2004; 158:280–285.
19 Kellogg ND, Menard SW, Santos A. Genital anatomy in pregnant adoles-
cents: ‘normal’ doesn’t mean ‘nothing happened’. Pediatr 2004; 223:e67–
e69; http://www.pediatrics.org/cgi/content/full/113/1/e67.
20 Jones JS, Rossman L, Hartman M, Alexander CC. Anogenital injuries in
adolescents after consensual sexual intercourse. Acad Emerg Med 2003;
10:1378–1383.
21 McCann J, Miyamoto S, Boyle C, Rogers K. Healing of hymenal injuries in
 prepubertal and adolescent girls: a descriptive study. Pediatrics 2007; 119:
e1094–e1106; http://www.pediatrics.org/cgi/content/full/119/5/e1094.
Downloaded May 16, 2007.
The authors report the findings of a retrospective study reviewing photographs and
cases of genital trauma and healing in 113 prepubertal girls and 126 adolescent
girls. The presentation of the findings is somewhat difficult to understand, but the
study is important because of the large number of cases reviewed and the finding
that most minor injuries healed completely.
22 McCann J, Miyamoto S, Boyle C, Rogers K. Healing of nonhymenal genital
 injuries in prepubertal and adolescent girls: a descriptive study. J Pediatr
2007; 120:1000–1011.
This is the second article from the retrospective study reviewing photographs of
injuries. The main findings were that petechiae resolved within 24 h, ‘blood blisters’
persisted up to 24 days, and deep perineal lacerations took up to 20 days to heal,
following the initial injury.
23 Boyle C, McCann J, Miyamoto S, Rogers K. Comparison of examination
 methods used in the evaluation of prepubertal and pubertal female genitalia: a
descriptive study. Child Abuse Negl 2008; 32:229–243.
The authors reviewed a subset of cases in which photographs were taken using
labial separation, labial traction, and the prone knee–chest position. The latter
position was found to be the most effective in showing hymen lacerations.
24 Drocton P, Sachs C, Chu L, Wheeler M. Validation set correlates of anogenital
 injury after sexual assault. Acad Emerg Med 2008; 15:1–8.
The authors of this article used an electronic database to summarize demographic
data and medical findings in 2879 cases of acute sexual assault. Half of the cases
were of girls/women between age 12 and 20 years, and this group had the highest
rates of injury. Although limited in not being able to separate out the youngest
victims, this study is important because of the ability to correlate findings with
specific factors related to the assault.
25 Hobbs CJ, Osman J. Genital injuries in boys and abuse. Arch Dis Child 2007;
 92:328–331.
This article reports on the types of genital injuries in a population of boys in Leeds,
UK, who were referred for sexual abuse evaluations because of genital injuries. The
author’s listing of anal findings such as venous pooling and anal gaping as signs of
injury does not reflect current opinion in the United States regarding the non-
specific nature of these findings.
26 Palusci VJ, Cox EO, Shatz EM, Schultze JM. Urgent medical assessment after
child sexual abuse. Child Abuse Negl 2006; 30:367–380.
27 Young KL, Jones JG, Worthington T, et al. Forensic laboratory evidence in
sexually abused children and adolescents. Arch Pediatr Adolesc Med 2006;
160:585–588.
28 Christian CW, Lavelle JM, De Jong AR, et al. Forensic findings in prepubertal
victims of sexual assault. Pediatrics 2000; 106:100–104.
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
29 Edinburgh L, Saewyc E, Thao T, Levitt C. Sexual exploitation of very young
Hmong girls. J Adolesc Health 2006; 39:111–118.
30 Kelly P, Koh J, Thompson JM. Diagnostic findings in alleged sexual abuse:
symptoms have no predictive value. J Paediatr Child Health 2006; 42:112–
117.
31 Kelly P, Koh J. Sexually transmitted infections in alleged sexual abuse of
children and adolescents. J Paediatr Child Health 2006; 42:434–440.
32 Kohlberger P, Bancher-Todesca D. Bacterial colonization in suspected
 sexually abused children. J Pediatr Adolesc Gynecol 2007; 20:289–
292.
This study from Vienna, Austria, reports on findings in 180 girls examined between
1996 and 2006 for suspected sexual abuse. Routine vaginal cultures were taken
from all girls and both Gardnerella vaginalis and Ureaplasma were recovered
significantly more often in adolescent compared with prepubertal girls.
33 Dubowitz H. Healing of hymenal injuries: implications for child healthcare
 professionals. Pediatrics 2007; 119:997–999.
This commentary to the article by McCann et al. [21] reviews the findings
reported in the article and also discusses larger issues related to the evaluation of
children who may have been sexually abused.
34 Muram D, Simmons KJ. Pattern recognition in pediatric and adolescent
 gynecology: a case for formal education. J Pediatr Adolesc Gynecol 2008;
21:103–108.
This is a report of a small but sobering study in which physicians reviewed color
photographs of common pediatric gynecologic conditions. The overall percentage
of correct interpretations ranged from 42% for residents to 58% for faculty. The
authors propose that there is a need for an easily accessible library of images to
assist physicians with accurate diagnosis of normal and abnormal gynecologic
conditions in children.
35 Botash AS, Galloway AE, Booth T, et al. Continuing medical education in child
sexual abuse: cognitive gain but not expertise. Arch Pediatr Adolesc Med
2005; 159:561–566.
36 Shapiro RA, Makoroff KL. Sexually transmitted diseases in sexually
abused girls and adolescents. Curr Opin Obstet Gynecol 2006; 18:
492–497.
37 Xu F, Lee FK, Morrow RA, et al. Seroprevalence of herpes simplex virus type 1
 in children in the United States. J Pediatr 2007; 151:374–377.
This important article reports the increasing rates of antibodies to HSV-1 among
children from 6 to 12 years of age and the high rates of positive antibodies among
children living below the poverty line (52%). The implication is that HSV-1 is
commonly spread by household contact rather than sexual contact, though this is
not specifically stated.
38 Tunback P, Bergstrom T, Claesson BA, et al. Early acquisition of herpes
 simplex virus type 1 antibodies in children: a longitudinal serological study.
J Clin Virol 2007; 40:26–30.
In this article from Sweden, the authors show that antibodies to HSV-1 and HSV-2
are common in mothers and decrease in the children up to the age of 1 year. None
of the infants had antibodies to HSV-2 after maternal antibodies disappeared, but
30% acquired antibodies to HSV-1, most between 12 and 30 months of age. This
study implies that HSV-2 infections in children may be more concerning for sexual
transmission and HSV-1 infections less concerning.
39 Gupta R, Warren T, Wald A. Genital herpes. Lancet 2007; 370:2127–
 2137.
The authors present a comprehensive and scholarly review of the epidemiology,
diagnosis, and treatment of genital herpes in adults.
40 Reading R, Rannan-Eilya Y. Evidence for sexual transmission of genital herpes
 in children. Arch Dis Child 2007; 92:608–618.
An attempt was made by the authors to systematically review published research
concerning the transmission of HSV in children. None of the studies had sufficient
details regarding the cases of genital herpes and the possible modes of transmis-
sion, so the authors concluded that the evidence concerning the likelihood of
sexual transmission of HSV in children is weak.
41 Huppert JS, Gerber MA, Deitch HR, et al. Vulvar ulcers in young females:
a manifestation of apthosis. J Pediatr Adolesc Gynecol 2006; 19:195–
204.
42 Goodyear-Smith F. What is the evidence for nonsexual transmission of
 gonorrhea in children after the neonatal period? A systematic review.
J Forensic Legal Med 2007; 14:489–502.
The author asks a legitimate question and this review with 116 references makes
very interesting reading. Although a vast majority of cases of genital gonorrhea in
children are due to sexual abuse, a careful reading of this article may convince
medical providers that transmission by mucosal contact with infected and infective
secretions can also spread gonorrhea.