Original Studies
Guidelines for Medical Care of Children Who May Have Been Sexually Abused

https://doi.org/10.1016/j.jpag.2006.10.001Get rights and content

Abstract

Background

Children who may have been sexually abused are examined in many different settings by medical providers with variable levels of education and experience in this special area of practice. Therefore, there is a need for a consistent evidence-based approach that is agreed upon by medical experts.

Objectives

To develop and provide guidelines and recommendations for performing and interpreting findings of the medical evaluation of children referred for sexual abuse medical evaluations, and to provide guidelines for the education, oversight, and peer review process for clinicians who provide assessments for suspected child sexual abuse.

Methods

Participation from medical providers was solicited through postings on the Internet listserves administered by Cornell University (Special Interest Group in Child Abuse), and by the Ray E. Helfer Society, an honorary society for physician specialists in child abuse diagnosis and treatment. The guidelines were developed through review and critique of published research studies, discussions in focus group meetings at child abuse medical conferences, and ongoing communication leading to revision of draft documents.

Results

Groups of 10 to 40 physician experts met at child abuse conferences between January 2002 and January 2005 to revise the table summarizing the interpretation of physical and laboratory findings in suspected child sexual abuse and to develop guidelines for medical care for sexually abused children. Between January and December 2005, the guidelines were expanded and revised.

Conclusions

The guidelines presented here reflect the current knowledge, recommended clinical approaches, and required competencies in the field of child sexual abuse medical evaluation.

Introduction

Child sexual abuse is a common problem in our society. A recent study by Finkelhor and associates, using telephone surveys of a nationally representative sample of households in the United States, found prevalence rates for sexual victimization in the past year of 96/1000 for girls, and 67/1000 for boys between the ages of 2 and 17 years.1 Because of the high prevalence and the potential for short and long-term adverse medical outcomes, all medical providers who care for children and adolescents must be familiar with the problem of sexual abuse and with the type of evaluation needed for these children.

A comprehensive medical evaluation of a child who may have been sexually abused requires a specific set of skills and body of knowledge. The recent publication by the Committee on Child Abuse and Neglect of the American Academy of Pediatrics,2 a clinical report on the evaluation of sexual abuse of children, reviews the definition and presentation of child sexual abuse and offers an outline of suggestions for taking a history from the child and caretakers, performing the physical examination, and obtaining laboratory specimens as indicated. It also lists guidelines for making the decision to report suspected cases of sexual abuse to child protective services agencies and broadly reviews treatment, follow-up and legal issues.

The report does provide general recommendations on the medical evaluation, but does not list the specific competencies required for specialist medical providers who perform these evaluations and interpret the medical findings. This project was undertaken in order to clarify the type of specific training, oversight, peer review and ongoing education necessary for an individual to attain and maintain expertise as a specialist in the medical evaluation of suspected child and adolescent sexual abuse.

Section snippets

Methods

The following guidelines were developed by a group of physician experts who have met at conferences yearly since 2002. The initial work group was established through the Ray E. Helfer Society, an honorary society for physicians who devote a significant portion of their clinical and research efforts to improving the evaluation and treatment of abused children. Members of the Society were invited, through postings on the group's listserv, to participate in the process of developing guidelines,

The Medical Evaluation

All children who are suspected victims of child sexual abuse should be offered a medical evaluation. The timing and detail of the examination should be based on specific screening criteria developed by qualified medical providers or by local multidisciplinary teams, which include qualified medical representation. (See The Child Sexual Abuse Medical Provider or Nurse Examiner)

The goals of the medical evaluation are:

  • To obtain the history from the child and/or guardian

  • To consider alternative

Interpretation of Physical and Laboratory Findings

The interpretation of physical and laboratory findings in children and adolescents referred for suspected sexual abuse requires the medical provider to be familiar with the results of research studies of abused and non-abused children. The table included here as Table 1, with references, represents an analysis of published studies and recommendations. It has been subjected to peer review and ongoing revision by physician experts, and represents current knowledge at the time this article was

The Child Sexual Abuse Medical Provider or Nurse Examiner

The provision of medical care to victims of child sexual abuse is becoming increasingly specialized, and fellowships for training these specialists are growing in number. The need for special techniques and competencies is clear. A long-term goal is the development of standards for this specialty practice. While it is unrealistic to assume that all communities will have direct access to a medical sub-specialist, this document proposes baseline standards and activities for the medical

Medical Testimony

Providers of medical services to children alleged to have been sexually abused will, in some cases, be called upon to provide testimony by either the prosecution or the defense. It is the obligation of the health care provider to formulate an opinion that is supported by science, with an understanding of the limitations of what can and cannot be said with certainty. In the courtroom, the health care provider's role is to clearly explain and articulate the clinical and scientific issues involved

Conclusions

These guidelines are presented with the recommendation that they be utilized by organizations, communities, and individuals who are responsible for the provision and oversight of medical care provided to children presenting with a complaint of suspected sexual abuse. They may also be utilized as a basis for educational programs for the professional development of child abuse medical experts. The medical assessment of children who may have been sexually abused is important and addresses many

Acknowledgements

Many individuals have participated in the development and review of these guidelines, and the revision of the listing of findings in the Table. Attendees at the Midwest Providers Conference in Ely, Minnesota, sponsored by the National Children's Alliance, included: Daniel Broughton, MD, Mayo Clinic; Anne Cherek, BSW, Mark Hudson, MD, Rich Kaplan, MD, Carolyn Levitt, MD, from the Midwest Children's Resource Center, Children's Hospitals and Clinics of Minnesota, St. Paul, MN; Jordan Greenbaum,

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