AMERICAN ACADEMY OF PEDIATRICS Committee on Child Abuse and Neglect Guidelines for the Evaluation of Sexual Abuse of Children: Subject Review ABSTRACT. This statement serves to update guide- lines for the evaluation of child sexual abuse first pub- lished in 1991. The role of the physician is outlined with respect to obtaining a history, physical examination, and appropriate laboratory data and in determining the need to report sexual abuse. ABBREVIATIONS. AAP, American Academy of Pediatrics; STDs, sexually transmitted diseases; HIV, human immunodeficiency vi- rus. F ew areas of pediatrics have expanded so rap- idly in clinical importance in recent years as that of sexual abuse of children. What Kempe called a “hidden pediatric problem” 1 in 1977 is cer- tainly less hidden at present. In 1996, more than 3 million children were reported as having been abused to child protective service agencies in the United States, and almost 1 million children were confirmed by child protective service agencies as victims of child maltreatment. 2 According to a 1996 survey, physical abuse represented 23% of confirmed cases, sexual abuse 9%, neglect 60%, emotional mal- treatment 4%, and other forms of maltreatment 5%. 2 Other studies have suggested that approximately 1% of children experience some form of sexual abuse each year, resulting in the sexual victimization of 12% to 25% of girls and 8% to 10% of boys by age 18. 3 Children may be sexually abused by family members or nonfamily members and are more frequently abused by males. Boys may be victimized nearly as often as girls, but may not be as likely to disclose the abuse. Adolescents are perpetrators in at least 20% of reported cases; women may be perpetrators, but only a small minority of sexual abuse allegations involve women. The child care setting, an otherwise uncom- mon setting for abuse, may be the site for women offenders. Pediatricians may encounter sexually abused children in their practices and may be asked by parents and other professionals for consultation. These guidelines are intended for use by all health professionals caring for children. In addition, specific guidelines published by the American Academy of Pediatrics (AAP) for the evaluation of sexual assault of the adolescent by age group should be used. 5 Because pediatricians have trusted relationships with patients and families, they are often able to provide essential support and gain information that may not be readily available to others involved in the investigation, evaluation, or treatment processes. However, some pediatricians may not feel ade- quately prepared at present to perform a medical evaluation of a sexually abused child without ob- structing the collection of essential evidence. Pedia- tricians need to be knowledgeable about the avail- able resources in the community, including consultants with special expertise in evaluating or treating sexually abused children. DEFINITION Sexual abuse occurs when a child is engaged in sexual activities that the child cannot comprehend, for which the child is developmentally unprepared and cannot give consent, and/or that violate the law or social taboos of society. The sexual activities may include all forms of oral-genital, genital, or anal con- tact by or to the child, or nontouching abuses, such as exhibitionism, voyeurism, or using the child in the production of pornography. 1 Sexual abuse includes a spectrum of activities ranging from rape to physi- cally less intrusive sexual abuse. Sexual abuse can be differentiated from “sexual play” by determining whether there is a develop- mental asymmetry among the participants and by assessing the coercive nature of the behavior. 6 Thus, when young children at the same developmental stage are looking at or touching each other’s genitalia because of mutual interest, without coercion or in- trusion of the body, this is considered normal (ie, nonabusive) behavior. However, a 6-year-old who tries to coerce a 3-year-old to engage in anal inter- course is displaying abnormal behavior, and the health and child protective systems should be con- tacted although the incident may not be legally con- sidered an assault. Children or adolescents who ex- hibit inappropriate sexual behavior may be reacting to their own victimization. PRESENTATION Sexually abused children are seen by pediatricians in a variety of circumstances: 1) They may be seen for a routine physical examination or for care of a med- ical illness, behavioral condition, or physical finding that would include child sexual abuse as part of the differential diagnosis. 2) They have been or are thought to have been sexually abused and are brought by a parent to the pediatrician for evalua- This statement has been approved by the Council on Child and Adolescent Health. The recommendations in this statement do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate. PEDIATRICS (ISSN 0031 4005). Copyright © 1999 by the American Acad- emy of Pediatrics. 186 PEDIATRICS Vol. 103 No. 1 January 1999 by guest on June 17, 2020 www.aappublications.org/news Downloaded from