Genital examinations for alleged sexual abuse of prepubertal girls: findings by pediatric emergency medicine physicians compared with child abuse trained physicians

Abstract

Objective: This study compares abnormal genital examination findings made by pediatric emergency medicine (PEM) physicians to examinations by physicians with training in child sexual abuse in the evaluation of prepubertal girls for suspected sexual abuse.

Method: A prospective study was performed following the genital examination by a PEM physician of prepubertal girls suspected of being sexually abused. A physician with training in child sexual abuse re-examined those girls whose examinations were interpreted as abnormal by the PEM physicians. The findings and interpretations of the PEM physician were then compared to those by the physicians with training in child abuse.

Results: Between October 1994 and October 1998, 46 patients diagnosed by PEM physicians with nonacute genital findings indicative of sexual abuse were re-examined by a physician with training in child abuse. The follow-up examinations were done 2 days–16 weeks (mean 2.1 weeks) after the emergency department visit. The physicians with training in child abuse concluded that only eight of these children (17%) showed clear evidence of abuse. Normal findings were noted in 32 children (70%), nonspecific changes were noted in 4 children (9%), and 2 children (4%) had findings that are more commonly seen in abused children than nonabused children but are not diagnostic for abuse (concerning for abuse).

Conclusions: There was poor agreement between the pediatric emergency medicine physicians and the physicians with training in child sexual abuse. This study suggests that emergency medicine physicians should consider additional training in this area. In addition, all children with abnormal ED examinations should have follow-up examinations by a child abuse trained physician.

Résumé

Objectif: Cette étude compare les résultats d’examens génitaux anormaux chez des filles prépubères susceptibles d’avoir subi des abus sexuels pratiqués par des médecins des urgences pédiatriques (PEM) avec ceux pratiqués par des médecins formés à l’évaluation des abus sexuels.

Méthode: On a réalisé une étude prospective à la suite de l’examen génital par un médecin PEM des filles susceptibles d’avoir subi des abus sexuels. Un médecin formé dans ce domaine a réexaminé les filles dont les examens avaient été interprétés comme anormaux par les médecins PEM. On a ensuite comparé les résultats et les interprétations des médecins PEM avec ceux des médecins ayant suivi une formation.

Résultats: Entre octobre 1994 et octobre 1998, 46 patients diagnostiqués par des médecins PEM comme présentant des symptomes nonaigus d’abus sexuels ont été à nouveau examinés par un médecin formé. Les examens complémentaires ont été pratiqués entre deux jours et 16 semaines (moyenne de 2.1 semaines) après la consultation en urgence. Les médecins formés ont conclu que seulement 8 de ces enfants (17%) montraient des signes d’abus évidents. Des résultats normaux ont été trouvés chez 32 enfants (70%), des changements nonspécifiques ont été notés chez 4 enfants (9%) et 2 enfants (4%) montraient des signes fréquemment observés chez des enfants victimes d’abus plus que chez des enfants nonabusés mais qui n’imposent pas un diagnostic d’abus.

Conclusions: Il y a eu peu d’accord entre les médecins du service d’urgence pédiatrique et ceux qui avaient subi une formation concernant les abus sexuels. Cette étude suggère que les médecins des urgences devraient envisager de suivre une formation supplémentaire dans ce domaine. De plus, tous les enfants présentant un examen anormal devraient subir un examen complémentaire avec un médecin formé dans le domaine des abus sexuels.

Resumen

Objetivo: Este estudio compara los hallazgos de exámenes genitales anormales realizados para evaluar a chicas prepúberes con sospecha de abuso sexual por médicos del servicio de urgencia pediátrica (SUP) con los exámenes realizados por médicos con formación sobre abuso sexual infantil.

Método: Se llevó a cabo un estudio prospectivo posterior al examen genital realizado por médicos del SUP en chicas prepúberes con sospechas de haber sido vı́ctimas de abuso sexual. Un médico con formación en abuso sexual infantil rexaminó a aquellas chicas cuyos exámenes fueron interpretados como anormales por los médicos del SUP. Los hallazgos y las interpretaciones de los médicos del SUP fueron comparados con los realizados por los médicos con formación en maltrato infantil.

Resultados: Entre Octubre de 1994 y Octubre de 1998, un total de 46 pacientes diagnosticados por médicos del SUP con hallazgos genitales no agudos indicativos de abuso sexual fueron examinadas por un médico con formación en abuso sexual. Los exámenes de seguimiento fueron hechos entre dos dı́as y 16 semanas después (media de 2.1 semanas) de la visita al departamento de urgencias. Los médicos con formación en maltrato infantil concluyeron que sólo 8 de esas niñas (17%) mostraron clara evidencia de maltrato. En 32 niñas (70%) se observaron hallazgos normales, en 4 niñas (9%) se observaron cambios no especı́ficos y en 2 niñas (4%) se presentan hallazgos que se observan más frecuentemente en niñas abusadas que en niñas no abusadas pero que no son razón para el diagnóstico de maltrato.

Conclusiones: Se observó un grado bajo de acuerdo entre los médicos del servicio de urgencia pediátrica y los médicos con formación en abuso sexual. Este estudio sugiere que los médicos de urgencia deben considerar el disponer de formación adicional en este ámbito. Además, se sugiere que todas las niñas con examen anormal de abuso sexual deben recibir un nuevo examen realizado por médicos con formación en maltrato infantil.

Introduction

Child sexual abuse is a critical social and medical problem. In 1999, there were over 93,000 reported victims of child sexual abuse in the US (US Department of Health and Human Services, 2001).

Pediatric emergency medicine physicians often evaluate children for alleged sexual abuse. Because anxious parents and/or primary care physicians want the child to be evaluated immediately, the emergency department (ED) is often the site of the initial evaluation. The ED is also utilized when urgent collection of forensic evidence is indicated, acute symptoms need evaluation, or when a child abuse specialty clinic is not available.

Serious legal interventions can occur subsequent to an examination for child abuse. The medical examination may assist in protecting a child from further abuse and may identify medical and psychological needs. However, if the examiner misinterprets the examination, the child, the family and the agencies mandated to protect the child will be misinformed. This can result in adverse social and legal consequences for the child, the family and the alleged offender. Thus, the physician must make an accurate assessment.

Medical professionals do not always agree on the presence or the significance of certain anogenital findings in children who are examined for suspected child sexual abuse. Brayden, Altemeier, Yeager, and Muram (1991) showed that professionals who have a high level of involvement in the field of child sexual abuse had more accurate interpretations of pictures of prepubescent female genitalia than did professionals who do not routinely evaluate patients for suspected sexual abuse. Ladson demonstrated that on a picture of the genitalia of a 6-year-old female, the hymen was identified correctly by only 59.1% of pediatricians and family practitioners (Ladson, Johnson, & Doty, 1987). In a similarly designed study 10 years later, Lentsch and Johnson (2000) again showed that a majority of physicians who evaluate children do not perform a complete genital examination and had inadequate knowledge of normal anatomy.

More recent studies compare the agreement and interpretation of anogenital findings in children who are examined for sexual abuse among professionals who are involved in the field of child sexual abuse. Roberts and Moran (1995) demonstrated 93% agreement between two child sexual abuse teams when the two teams looked at colposcopic photographs of female genitalia. Paradise et al. (1997) compared the descriptions and interpretations of genital examination findings of 206 physicians who rated themselves as skilled in assessing children for sexual abuse with the descriptions and interpretations of genital examination findings by a consensus expert panel. Forty-five percent of the self-rated skilled physicians agreed with the consensus panel’s descriptions of genital findings, and 72.6% agreed with the interpretations. In Paradise’s study, the most experienced physicians in assessing children for sexual abuse conformed more closely to the consensus expert panel. In another study, Paradise, Winter, Finkel, Berenson, and Beiser (1999) examined whether clinical history influenced physicians’ interpretations of genital findings by sending the physicians two questionnaires 4 months apart. The histories in the two questionnaires differed to the degree in which they suggested sexual abuse. The most experienced physicians were least likely to be affected by a change in history and the least experienced physicians were most likely to be affected by a change in history.

There has been no published evaluation of the level of agreement between pediatric emergency medicine physicians and physicians with training in child sexual abuse regarding prepubertal genital findings in suspected sexual abuse examinations. Because these children often present first to the emergency department for evaluation, this is an important question. This study compares the prepubertal genital examination findings of pediatric emergency medicine physicians and physicians with training in child abuse.