The Medical Evaluation of the Sexually Abused Child: Lessons From a
Decade of Research
Shireen Atabaki, MD, MPH, and Jan E. Paradise, MD
ABBREVIATIONS. CSA, child sexual abuse; GEDS, Genital Ex-
amination Distress Scale; STD, sexually transmitted disease;
HIV, human immunodeficiency virus; HPV, human papilloma-
virus; CDC, Centers for Disease Control and Prevention.
T
he problem of child sexual abuse (CSA) has
engendered lively interest among physicians
and other health care providers for more than
20 years. The number of cases of sexual abuse
known to child protection service agencies in the
United States rose sharply from 1977 to 1988, then
leveled off and declined between 1988 and 1996
(Fig 1).1 Since the mid-1970s, accumulating clinical
experience and research have considerably ex-
panded and refined our understanding of this
common problem.
Several investigators have provided comprehen-
sive reviews of CSA and of the role of the physician
in diagnosis and management.2– 4 A partial list of
epidemiologic, psychological, and legal topics in
the area of CSA that have been investigated and
reviewed during the past decade includes the effec-
tiveness and accuracy of various techniques for
obtaining histories of sexual abuse (repeated inter-
views, standardized questionnaires, drawings, an-
atomically correct dolls)5–7; the sexual abuse of
boys8,9; the impact of sexual abuse on children’s
subsequent psychosocial wellbeing10,11; the rela-
tionship of CSA to sexual aggression in children
and appropriate treatment for offending chil-
dren12,13; the criminal prosecution of CSA cases14;
and the effectiveness of CSA prevention programs.2
In this article, we will highlight research pub-
lished during the past decade that deals particu-
larly with topics in the medical evaluation of sex-
ually abused children and that has advanced our
understanding of those topics. We have divided our
discussion into three sections: the conduct of the
physical examination, the interpretation of physi-
cal examination findings, and selected sexually
transmitted infections in children.
From the Department of Pediatrics, Boston University School of Medi-
cine, Boston, Massachusetts.
Received for publication Feb 16, 1999; accepted Mar 22, 1999.
Address correspondence to Jan E. Paradise, MD, Maternity 403, Boston
Medical Center, 818 Harrison Ave, Boston, MA 02118-2393. E-mail: jan.
paradise@bmc.org
PEDIATRICS (ISSN 0031 4005). Copyright © 1999 by the American Acad-
emy of Pediatrics.
178 PEDIATRICS Vol. 104 No. 1 July
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CONDUCTING THE PHYSICAL EXAMINATION
Special Examination Techniques
The immediate goals of the medical assessment
of the sexually abused child are to identify injuries
that require treatment, to screen for or to diagnose
sexually transmitted infections, to evaluate and if
possible to reduce the risk of pregnancy, and to
document findings of potential forensic value. We
review three special forensic techniques that re-
cently have been assessed or reassessed: colpos-
copy, the Foley catheter technique for hymenal ex-
amination, and Wood’s lamp illumination for the
detection of seminal fluid.
Colposcopy
Forensic examination using the colposcope was
introduced by Teixeira15 in the 1980s. Since then,
only two studies have compared colposcopy di-
rectly with inspection. Muram and Elias16 com-
pared the rate of abnormal genital findings in 130
prepubertal girls identified as having been sexually
abused when examined by inspection and by col-
poscopy. Forensically important findings were
identified by colposcopy but not by inspection in 4
patients (3%). The investigators concluded that un-
aided examination is sufficient in most cases.
Adams and co-workers17 obtained clear, usable
colposcopic photographs of the genitalia of only 88
(46%) of a series of 190 patients. The colposcopic
photographs confirmed anogenital findings (same
findings seen by both methods) in 54% of the 88
patients, clarified findings (additional findings
noted on colposcopy when compared with unaided
examination) in 12%, and failed to confirm find-
ings seen during inspection in the remaining 34%.
For identifying anal gaping, the authors considered
direct inspection more accurate than colposcopy.
For identifying anogenital scars, there were dis-
crepancies between inspection and colposcopy, but
the authors did not indicate which method they
considered more accurate.
Although colposcopy can increase physicians’
identification of genital and perineal abnormalities,
Paradise and colleagues18 found in a recent survey
that only 19.7% of physicians who do examine
children’s genitalia use colposcopy to examine
children for possible sexual abuse. Colposcopy was
used more frequently by physicians who rated
themselves skilled in sexual abuse examinations
than by physicians who rated themselves as having
lower than average skill (35.9% vs 3.4%; P , .001).
Fig 1. Estimated number of children reported to state child protective service agencies for suspected sexual abuse, 1978 –1996.
Reprinted with permission from the National Committee to Prevent Child Abuse.1
In some instances, colposcopy can increase the
accuracy of examiners’ descriptions of girls’ exter-
nal genitalia, and colposcopic photographs can fa-
cilitate consultation between examiners. On the
other hand, data we review below (see “Interpreta-
tion of Physical Examination Findings”) indicate
that few genital findings identifiable only by col-
poscopy have forensic importance and, conversely,
that most forensically important examination find-
ings are apparent using unaided inspection. Thus,
although colposcopic examination can be a helpful
adjunct, it need not be viewed as an obligatory
procedure.
Foley Catheter Technique
In the past decade, Ferrell19 and Starling and
Jenny20 have recommended using a Foley catheter
to spread out the estrogenized hymenal tissue of
postpubertal girls to facilitate complete examina-
tion of that structure. Persaud and co-workers21
reported success using this method in 17 patients.
None of the patients refused the examination or
complained of pain. This technique may facilitate
the identification of forensically significant physi-
cal findings in sexually abused and assaulted ado-
lescent girls.
Wood’s Lamp Illumination
Although Wood’s lamp illumination has been
recommended traditionally for identifying seminal
fluid on skin in cases of sexual assault and abuse,
Gabby and colleagues have highlighted previously
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unrecognized and substantial shortcomings of this
method.22 The patterns of Wood’s lamp fluores-
cence of semen and urine differ (semen fluoresces
irregularly, urine homogeneously), but they fluo-
resce with the same color. Furthermore, urine flu-
oresces considerably longer than does seminal
fluid, increasing the likelihood that urine might be
incorrectly identified as seminal fluid. Santucci et
al23 raised similar concerns about falsely positive
Wood’s lamp fluorescence. Using a Wood’s lamp,
none of 10 pediatric emergency physicians could
correctly distinguish semen from 13 other products
commonly found in the perineum of children un-
dergoing examination (eg, Balmex, Desitin, Surgi-
lube). Of various tests for the detection of seminal
fluid, enzyme-linked immunosorbent assay for the
prostate-specific protein p30 remains the most sen-
sitive and specific. If it is used, Wood’s lamp illu-
mination should be used only to identify suspi-
cious areas or specimens for more definitive
forensic testing.
Reducing Children’s Distress During CSA Evaluation
Many clinicians and researchers are concerned
that CSA evaluations constitute an additional
source of distress for some sexually abused chil-
dren. However, there are some data to indicate that
children and families consider the investigation
process as beneficial or at least not harmful.
Tedesco and Schnell24 highlighted a discrepancy
between families’ and clinicians’ perceptions in
that regard. Investigative interviewing and criminal
SUPPLEMENT 179
prosecution were rated as harmful to children by
five (71%) of seven treatment workers, but were
rated as helpful or neutral by 53% of 48 surveyed
children and families. Lazebnik et al25 found that of
99 3- to 17-year-old patients who had just received
physical examinations and genital cultures for sus-
pected sexual abuse, approximately one third re-
ported experiencing no associated pain and/or fear,
half reported some pain and/or fear, and 14% to
16% reported “a lot” of pain and/or fear. Twice as
many children reported some fear of the sexual
abuse examination compared with their expected
fear of an ordinary doctor visit (50% vs 27%). Fear
of the sexual abuse examination was significantly
associated with self-reported fear of ordinary doc-
tor visits (P , .05), but was not associated with pain
during the sexual abuse examination, the doctor’s
gender or perceived kindness, or the patient’s age.
We have found no data about whether distress as-
sociated with genital examination is persistent or
short-lived.
For procedures such as surgery, laceration repair,
and dental treatment, techniques ranging from pre-
procedure patient education to films that model
coping skills26 and procedural sedation27–30 have
been used to reduce children’s discomfort and anx-
iety. Similarly, these interventions may be pre-
ferred for anxious or uncooperative children who
need genital examinations. In a controlled, single-
blinded study, Lynch and Faust investigated the
effect of a 10-minute teaching film on children’s
self-reported fear and observed behaviors during
genital examinations.31 The film taught children
coping techniques-breathing, guided imagery, and
positive self-statements. In comparison to children
who saw a control film about animals, the 21 chil-
dren who saw the study film were significantly less
fearful and showed significantly less distress dur-
ing their examinations. Hogan32 found that 35
(10%) of 338 children warranted conscious seda-
tion for genital examinations. Sedation with oral
midazolam was described as completely successful
in 28 cases (80%), although the treated children’s
emotional responses were not described or com-
pared with those of untreated children. Sedation
was unsuccessful in 4 children (11%) and compli-
cated by agitation or combative behavior in an ad-
ditional 3 children (9%).
Summary
The studies just cited add importantly to our
knowledge, but they have been small and have had
some methodologic shortcomings. The effective-
ness, ease of implementation, acceptability to pa-
tients and clinicians, risks, and costs of various
interventions to reduce children’s and families’
distress and discomfort during CSA evaluation
have yet to be elucidated fully. The recently devel-
oped Genital Examination Distress Scale (GEDS)33
may prove a useful tool for such research. The
GEDS was adapted from a scale (Observation Scale
of Behavioral Distress) measuring behavioral re-
sponses to painful procedures such as bone marrow
aspiration. The GEDS incorporates categories such
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as nervous behavior, cry, restraint, muscular rigid-
ity, verbal fear, verbal pain, and flail. Gully and
colleagues33 have established the interrater reliabil-
ity, internal consistency, and validity of this tool in
an outpatient setting with experienced staff and
scheduled appointments. This instrument has sev-
eral potential uses such as measurement of the ef-
ficacy of stress reduction techniques during the
examination, and evaluation of the examiner’s
level of experience on the child’s distress.
INTERPRETATION OF PHYSICAL EXAMINATION
FINDINGS
In published series in the late 1980s and early
1990s, a substantial proportion of sexually abused
children, both boys and girls, were reported to have
anatomic abnormalities of the external genitalia or
perineum.3,4 Investigators suggested that findings
such as hymenal clefts, bumps, attenuation, and
synechiae constituted physical evidence of the sex-
ual abuse the children had experienced. More re-
cently, observations about the relative frequency of
certain anatomic findings in children who have
and have not been sexually abused have refined our
understanding of the validity of physical examina-
tion findings as indicators of sexual abuse. Other
observations have considerably increased our
knowledge about the reliability of physical exami-
nation in the diagnosis of sexual abuse.
Validity: Physical Findings in Children Who Have and
Have Not Been Abused
Taken together, data from McCann and col-
leagues,34 Berenson and associates,35 Soifer,36 and
Gardner37 demonstrate conclusively that small vari-
ations in the size, contour, and appearance of the
external genitalia in girls who have not been sexu-
ally abused occur relatively frequently (Tables 1
and 2). Although fewer data are available about
boys, McCann and colleagues38 and Berenson and
associates39 have shown that erythema, hyperpig-
mentation, wedge-shaped smooth areas in the mid-
line, and other minor variations in appearance of
the perianal area are common both in boys and in
girls who have not been sexually abused. Accord-
ingly, the presence of these anatomic variations
should not be interpreted as evidence that sexually
abusive physical contact has occurred.
Reports by Adams and co-workers,40 Muram,41
DeJong and Rose,42 and Kerns and Ritter (ab-
stract),43 albeit involving small numbers of cases
with detailed data, indicate that the majority of
children who have been legally proven, by confes-
sion, guilty plea, or criminal conviction, to have
been sexually abused have no genital or perineal
abnormality. Thus, it is not accurate to interpret a
normal genital examination as evidence that sexu-
ally abusive physical contact did not occur. The
most common reason for normal genital anatomy in
sexually abused children is that the abusive phys-
ical contact produced no injury. Alternatively, and
probably less commonly, abusive contact produced
an injury that healed completely before physical
examination was performed.
TABLE 1. Cross-sectional Prevalence of Selected Genital Findings in Premenarcheal Girls Who Have Not Been Sexually Abused
Finding % Prevalence With Supine % Prevalence With Knee-
Labial Traction* Chest Position†
Thick hymenal edge 54–90 26
Hymenal notch‡ 2–8 2
Longitudinal intravaginal ridge 25 No data
Hymenal tag 2–24 20
Hymenal bump 7–34 18
Increased hymenal vascularity 31–37 29
Increased PF§ vascularity 5–15 4
Linear, midline PF§ avascularity 16–23 26
Friable posterior fourchette 2–6 5
Labial adhesions 17–39 14
* References 34, 35, and 37.
† Reference 34.
‡ In reference 35, all notches were located between the 8 o’clock and 4 o’clock positions in supine patients. In references 34 and 37,
locations of notches were not specified.
§ PF indicates posterior fourchette.

TABLE 2. Hymenal Dimensions in Girls Who Have Not Been Sexually Abused, Examined in the Supine Position Using Labial
Traction
Age of Girl
#12 Months* 13–24 Months* 25–48 Months* 4–7 Years† 8–10 Years‡
Width of transverse hymenal orifice (mm)
Mean 2.5 2.9 2.9 3.6–5.6 6.9
Maximum 3.5 6.5 6.5 9.0 10.5
Width of vertical hymenal orifice (mm)
Mean 3.4 2.8 3.6 3.9–6.1 8.3
Maximum 6.0 4.3 6.0 10.0 15.0
Width of inferior hymenal rim (mm)§
Mean 2.8 2.7 2.7 2.7 —
Minimum 1.5 0.9 0.9 1.0 —
* Adapted from reference 35.
† Adapted from references 34 and 35.
‡ Adapted from reference 34.
§ The tissue between the hymen’s attachment to the introitus at the 6 o’clock position and its free edge, while the patient is supine.

Reliability of Genital Examination in the Context of
Sexual Abuse
Roberts and Moran reported recently that two
child abuse teams, one in Australia and one in New
Zealand, had good interobserver reliability (weight-
ed k statistic: 0.67– 0.70) in rating genital findings
with respect to sexual abuse using a three-point
scale.44 In contrast, in a sample of seven experi-
enced clinicians, Sinal et al found low interob-
server reliability (overall k statistic: 0.20) for ratings
of genital findings on a five-point scale.45 In the
largest study of this question to date, Paradise and
colleagues compared an expert panel’s assessments
of genital findings in seven simulated cases with
assessments by 206 US physicians who rated them-
selves skilled in examining children for suspected
sexual abuse.18 There was considerable interob-
server variability. Across the seven cases, 14% to
79% of the physicians agreed with the expert pan-
el’s descriptions of important genital findings and
42% to 96% of the physicians agreed with the
expert panel’s interpretations of those findings.
Factors shown to affect interobserver reliability
include examination method46 and clinician aware-
ness of patients’ clinical histories.45,47,48 Ashworth
and associates reported that histories incongruent
with genital examination findings reduced interob-
server agreement among 23 pediatric residents us-
ing a dichotomous rating system.47 Paradise and
colleagues found that the extent to which a pa-
tient’s history suggested sexual abuse influenced
604 physicians’ interpretations of genital examina-
tion findings.48 Physicians more often interpreted
genital examination findings as indicative of sexual
abuse when the accompanying history suggested
sexual abuse, and vice versa. Physicians with more
experience evaluating cases of suspected abuse
evinced less diagnostic suspicion bias than did
physicians with less experience.
Problems in the Validity, Reliability, and Predictive
Value of Physical Findings in the Diagnosis of
Sexual Abuse
The term sexual abuse includes many different
kinds of touching, each presumably with a different
likelihood of producing a discernible alteration in a
child’s physical status. Intrusion of an adult male’s
penis into the vaginal vault of a prepubertal girl
might produce a hymenal or vaginal laceration, but
intrusion of the penis only between the girl’s labia
majora (a circumstance that constitutes “penetra-
tion” in most states and is clearly a criminal of-
fense) seems less likely to produce a genital injury.
For example, in 19 cases of legally proven sexual
abuse reported by Adams and co-workers,40 the
children were reported to have stated, “He touched

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my private with his private.” The nonspecific na-
ture of statements like this illustrates the difficulty
of defining physical contacts precisely in cases of
CSA.
Relying on legal determinations of sexual abuse
to measure the prevalence of physical abnormali-
ties in sexually abused children constitutes a laud-
able and important effort to enhance validity, but
presents a potential logical difficulty. In unre-
ported proportions of cases selected in this man-
ner,40,43 physical examination findings have con-
tributed to the legal determination that sexual
abuse occurred. To argue that those same physical
abnormalities are valid indicators of sexual abuse
because the abuse was legally proven is thus circu-
lar.
Gardner has raised the question of whether re-
ports of “scars” of the posterior fourchette in sexu-
ally abused girls in fact represent midline areas of
avascularity that have been observed in a substan-
tial proportion of nonabused girls34,37 and that ap-
pear to be physiologic in nature. To distinguish
conclusively between normal tissue and scar tis-
sue, histologic examination of specimens would be
needed, but the ethical and logistic barriers to such
an investigation in humans seem substantial.
Fargason et al49 have noted that estimates taken
from the peer-reviewed medical literature of the
sensitivity of physical examination findings for the
diagnosis of “penetration” are very inconsistent.
These investigators concluded that current infor-
mation does not permit the physical examination to
generate a valid estimate of the likelihood that pen-
etration has occurred in cases of suspected sexual
abuse.
Summary
The past decade of research has clarified the
questions that remain to be answered about the
contribution of physical examination findings to
the diagnosis of sexual abuse in children. To pass
muster, new research aimed at describing the rela-
tionship of physical examination findings to sexual
abuse should consider children who have experi-
enced substantially different kinds of physical con-
tact separately, specify what physical examination
methods are used and use them consistently, care-
fully define physical examination findings, blind
clinicians to keep physical examination findings
independent from and unbiased by historical infor-
mation, not base conclusions about whether sexual
abuse has occurred on physical examination find-
ings, and specify the basis on which diagnoses of
sexual abuse are established. These criteria raise
the bar for sexual abuse research to a level that is
high and admittedly difficult to attain. Substantial
funding and collaborative research efforts are likely
to be helpful in such a challenging endeavor.
In the clinical arena, it remains true that only two
conditions, both rare in sexually abused children,
indisputably indicate sexual contact—pregnancy
and the identification of sperm or seminal fluid.
Two other conditions in children—fresh injuries of
the genitalia as evidenced by clearly apparent
182 SUPPLEMENT Downloaded from www.aappublications.org/news by guest on May 29, 2019
bleeding, ecchymosis, or tissue destruction and
sexually transmitted infections—require explana-
tion urgently. Sexually abusive contact is the most
likely explanation for either of these conditions if
the affected child reports such a contact or if no
alternative explanation is plausible. Physicians
who are not only aware that genital and perineal
anatomic variants are prevalent in nonabused chil-
dren but also familiar with the range of genital
diseases and conditions seen in prepubertal chil-
dren are best prepared to make clinical judgments
about the relationship of children’s physical exam-
ination findings to suspected sexual abuse.
SEXUALLY TRANSMITTED DISEASES (STDs) IN
ABUSED CHILDREN
The prevalence of all STDs in sexually abused
children ranges from 2% to 7% in girls and from
0% to 5% in boys.50 Generally paralleling their
relative prevalence in adults, chlamydial infec-
tions, genital warts, and gonorrhea are the most
prevalent clinically evident STDs in sexually
abused children.51 Human immunodeficiency virus
(HIV) infection and syphilis are rare. In the last
decade, Sirotnak52 and Hammerschlag53 have re-
viewed the indications for testing sexually abused
children for STDs. Here, we discuss three topics
that have seen advances during the past decade:
indications for STD screening, considerations relat-
ing to HIV infection, and the implications of human
papillomavirus (HPV) infection with respect to
CSA.
STD Screening
Recent research has focused on the efficiency of
diagnostic testing for STDs in children, particularly
since recommendations by the Centers for Disease
Control and Prevention (CDC) have evolved from
three-site STD screening of all abused children
(1989) to screening only for sexually abused chil-
dren with specific risk factors for acquiring STDs
(1993).54 Siegel et al55 selected sexually abused
children and adolescents to be tested for STDs,
based on specific criteria adapted from the 1991
American Academy of Pediatrics guidelines.56
Thirty-seven percent of 855 patients did not meet
the criteria for STD testing; 50% of those neverthe-
less received some diagnostic testing. At least some
testing also was performed in 85% of the patients
who did meet the criteria. An STD was identified in
5.7% of the children and adolescents who met the
criteria (all of them female), and in none of the
patients who did not meet them. Criteria for select-
ing sexually abused children and adolescents who
should be tested for STDs, based on data from Sie-
gel et al and Ingram et al57 and on the CDC’s 1998
Guidelines for Treatment of Sexually Transmitted
Diseases,58 are presented in Table 3.
HIV Infection in Sexually Abused Children: Screening
and Prophylaxis
Despite a few case reports in the 1980s suggesting
that HIV could be transmitted via sexual abuse,59 – 61
HIV transmission to children through sexual abuse
TABLE 3. Criteria for Testing Sexually Abused Children
and Adolescents for Sexually Transmitted Diseases
History of abuse Multiple perpetrators
Perpetrator has an STD
Other history Patient has an STD
Sibling of patient has an STD
Prior consensual sexual contact
Genital discharge
Examination Sexual maturity rating .III
Genital discharge present
Genital injury present
Adapted from Siegel et al55 and Ingram et al.57
was not studied in detail until the 1990s. No case of
HIV transmission was identified either in 126
abused children tested by Yordan and Yordan51 or
in 140 abused children tested by Siegel and col-
leagues.55 Gutman and associates identified sexual
abuse as a certain or possible source of infection in
10 (10.4%) of 96 HIV-infected, 2- to 15-year-old
children.62 Gellert and colleagues found that sexual
abuse was the most likely source of infection in 28
(68%) of 41 HIV-positive children identified during
evaluations for sexual abuse.63 In the largest study
to date, a retrospective review of 9136 HIV-positive
children younger than age 13 years reported to the
CDC HIV/AIDS surveillance system, Lindgren et al
found that 26 (0.3%) had been sexually abused and
that, of those, 14 (53.8%) had no identified risk
factor for HIV infection other than sexual victim-
ization by an adult male.64 Table 4 provides a sum-
mary of the children reported since 1990 to have
acquired HIV infection through sexual abuse.
Prophylaxis
At present, there are no data in children that can
answer the question of whether sexually abused
children potentially exposed to HIV should receive
prophylactic treatment.65,66 The risk of transmis-
sion of HIV to a child during a single episode of
sexual contact with an adult is unknown. In adult
women, the risk of transmission from one episode
of vaginal–penile contact is estimated to be be-
tween 0.1% and 0.2%.67 In adults, the risk from one
episode of receptive penile–anal contact is esti-
mated at 0.1% to 3.0%. The risk of oral– genital
contact is unknown but, although presumably
lower, is not zero. The increasing prevalence of HIV
in the general population and striking recent im-
TABLE 4. Child Sexual Abuse in HIV-positive Children
Investigator, Number of HIV- n (%) With
Publication Year Positive Children History of
(Reference Number) Sexual Abuse
Gellert 1990 (60) 2 of 1000 tested 2 (100)
Guttman 1991 (62) 96 14/96 (14)
Gellert 1993 (63) 41 of 5622 tested 41 (100)
Lindgren 1998 (64) 9136 26 (0.3)
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provements in the efficacy of therapeutic and pro-
phylactic regimens for this infection have under-
scored the importance of identifying patients with
HIV infection or exposure early.
The US Public Health Service recommends anti-
retroviral prophylaxis for occupational exposures
to HIV, but notes that “no data exist regarding the
efficacy of this therapy for persons with nonoccu-
pational HIV exposure.”66 Some clinicians recom-
mend prophylaxis after selected, high-risk episodes
of sexual exposure to HIV.68 Factors that parents
and clinicians should consider in deciding whether
a sexually abused child or adolescent should re-
ceive antiretroviral prophylaxis include the likeli-
hood that the perpetrator is HIV-positive; the esti-
mated riskiness of the particular physical contact;
the time elapsed since the first contact; whether the
patient has other, ongoing risk factors for HIV in-
fection such as unsafe voluntary sexual inter-
course; the patient’s and family’s ability to adhere
to the prophylactic regimen; and the regimen’s tox-
icity. The demonstrated effectiveness of postexpo-
sure prophylaxis for occupational HIV exposure
suggests that, in certain high-risk instances, its ben-
efits for sexually abused children and adolescents
will outweigh its costs and risks.
Screening
The considerations to be weighed in deciding
whether to screen a sexually abused child or ado-
lescent for HIV infection are essentially the same as
those for the other sexually transmitted infections
(Table 3), with one exception. If HIV infection is
discovered in a young child, vertical transmission
from the mother is an important possible explana-
tion. This possibility and its implications for the
mother (and her sexual partner) should be dis-
cussed with parents before their children are
screened for HIV infection.
Genital Warts, HPV Infection, and Sexual Abuse
The interrelationships among HPV infection,
genital warts, and sexual abuse are complex. Not all
patients with HPV infection develop clinically ev-
ident anogenital warts,53 and the time from infec-
tion to the appearance of visible lesions in those
who do can be as long as 5 months, if not longer.69
Siegfried et al detected HPV DNA in only 2 (5%) of
n (%) With No Comments
Other HIV Risk
Factor
Not reported Number of children tested is
approximate, determined
retrospectively by telephone
interviews.
4/14 (28.6) Sexual abuse a possible source of
HIV for 6 more of the 14 abused
children.
28/41 (68) Number of children tested is
approximate, determined
retrospectively.
23/26 (88.5)
SUPPLEMENT 183
40 sexually abused children, none of whom had
genital warts.70 Thus, although HPV is surely nec-
essary, its presence is not always sufficient to pro-
duce warts. The factors that determine whether and
when a child with the virus will develop anogenital
disease are unknown.
Do Warts Indicate Abuse?
Sexual contact is the most likely source of infec-
tion for anogenital warts that appear in children
after the age of 2 or 3 years and an important po-
tential source in younger children. Gutman et al71
detected genital HPV DNA in 5 of 15 sexually
abused girls who had vaginal signs or symptoms,
but in none of 17 nonabused controls (P , .02).
Vertical transmission of HPV to infants and tod-
dlers is possible in theory. However, in the most
comprehensive investigation to date of the possi-
bility of vertical transmission, Watts et al found
only unclassified HPV DNA (not typed as common
genital types) in the anogenital areas of only 5% of
151 infants, each of whom had been evaluated pro-
spectively on several occasions between birth and
36 months of age.72 Several observations in that
study argue against vertical transmission: women
with no specimen positive for HPV DNA were just
as likely as women positive for HPV DNA to have
infants with positive specimens; infants’ positive
specimens occurred late rather than during the neo-
natal period; infants delivered by Cesarean section
were just as likely as those delivered vaginally to
have detectable HPV DNA; and the HPV DNA types
in mother–infant pairs were not concordant. The
maximum likelihood of perinatal transmission of
HPV to infants’ anogenital areas was estimated at
2.8% (upper 95% CI).
In the absence of a history of sexual contact, the
mode of HPV transmission in a child with genital
warts may be impossible to determine. Child pro-
tective service agency investigations of children
whose presenting problem is genital warts (or an-
other STD) have frequently been unrevealing.73 Be-
cause HPV infection is not incontrovertible proof of
sexual abuse and because HPV DNA without visi-
ble disease does not warrant any change in patient
management, screening sexually abused children
for HPV infection is not advisable. Physical exam-
ination to detect genital warts is sufficient. Chil-
dren found to have genital warts should be
screened for other STDs (see “STD Screening”).
Interviews of children with genital warts in an ef-
fort to identify the source of infection should be
developmentally appropriate for the children’s age
and are best conducted by clinicians with skill and
experience in this area.
HPV DNA Types and Sexual Abuse
Individual HPV DNA genotypes are associated
closely with either skin or genital disease, but these
associations do not help to identify sexually abused
children.74 Because HPV infection in adults is
widespread, and many adults with HPV DNA do
not have clinical disease, the identification of HPV
DNA in an adult is unlikely to shed any light on the
184 SUPPLEMENT Downloaded from www.aappublications.org/news by guest on May 29, 2019
source of genital type HPV DNA in a child with
genital warts. Furthermore, three possible explana-
tions exist for anogenital warts with skin-associ-
ated DNA types—autoinoculation from common
skin warts and either abusive or nonabusive hori-
zontal contact with a person who has common
warts. Even autoinoculation through fomites has
been postulated, although not demonstrated.
Bergeron and colleagues detected HPV DNA in the
underwear of 17% of 74 adult patients, most of
whom had vulvar condylomata.75
Summary
Research is needed to evaluate the positive and
negative predictive values and cost:benefit ratios of
various criteria for screening sexually abused chil-
dren for each of the sexually transmitted diseases.
Assessing the appropriateness of less invasive
screening methods, such as urine ligase chain reac-
tion testing for Neisseria gonorrhoeae and Chla-
mydia trachomatis,76 is another potentially fruitful
area for research.
With respect to the two infections we have high-
lighted, issues that merit particular attention in-
clude estimates of the risk of HIV infection result-
ing from CSA and the efficacy and effectiveness of
postexposure prophylaxis in the context of sexual
abuse or assault. Because these questions will be
difficult and expensive to answer in prospective
studies, it will be important to consider inferences
from animal research, surveillance data concerning
occupational exposures, and case– control studies.
Finally, Hammerschlag has underscored the impor-
tance and complexity of the challenge of elucidat-
ing the relationship of HPV infection to the devel-
opment of clinically apparent anogenital disease in
children.53
CONCLUSION
We have reviewed research published during the
last decade that has advanced our understanding
about sexually abused children in three important
areas: methods for examining children’s external
genitalia, the validity and reliability of interpreta-
tions of girls’ examination findings, and sexually
transmitted infections. Potentially fruitful areas for
subsequent research include the effectiveness,
risks, and costs of interventions to reduce chil-
dren’s distress during genital examination, Bayes-
ian analyses of the contribution of physical exam-
ination findings to the diagnosis of sexual abuse,
the benefits and costs of and indications for nonin-
vasive STD screening in sexually abused children,
and the effectiveness and costs of postexposure
prophylaxis to prevent HIV infection in sexual as-
sault and abuse victims.
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The Medical Evaluation of the Sexually Abused Child: Lessons From a Decade of
Research
Shireen Atabaki and Jan E. Paradise
Pediatrics 1999;104;178

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The Medical Evaluation of the Sexually Abused Child: Lessons From a Decade of
Research
Shireen Atabaki and Jan E. Paradise
Pediatrics 1999;104;178

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