DÄ internationalArchive41/2014Physical Examination in Child Sexual Abuse

cme

Physical Examination in Child Sexual Abuse

Approaches and Current Evidence

Dtsch Arztebl Int 2014; 111: 692-703. DOI: 10.3238/arztebl.2014.0692

Herrmann, B; Banaschak, S; Csorba, R; Navratil, F; Dettmeyer, R

Background: The worldwide prevalence of child sexual abuse is 12–13% (18% of girls, and just under 8% of boys). Many doctors are nevertheless unsure of the proper procedures to follow and the scientific basis of the physical findings that are associated with sexual abuse. This article is focused on the physical findings of abuse, rather than its emotional and psychiatric consequences.

Method: This article is based on a selective review of pertinent literature retrieved from various databases, including PubMed and the overall index of the Quarterly Update.

Results: The great majority of sexually abused children do not have any abnormal physical findings. The proper determination and documentation of physical findings and their interpretation based on current scientific knowledge are essential for the protection of abused children.

Conclusion: Sexually abused children can only receive proper medical care if the involved physicians have the requisite knowledge in the areas of child and adolescent gynecology and forensic medicine, are aware of the limited informative value of the physical findings, and are able to apply the pertinent recommendations, guidelines, and classifications that are currently in effect. Although physical examination is important, the diagnosis of child sexual abuse is generally based on the affected child’s statements, which should be obtained according to the proper procedure. All physicians should know that the physical findings are normal in more than 90% of cases and understand why this is so. Physical examination can have the benefit of restoring the child’s bodily self-image from a pathological to a normal state by confirming physical normality and integrity.

LNSLNS

“Child sexual abuse is more common than childhood cancer, juvenile diabetes, and congenital heart disease combined...” (1).

The combined data of 39 prevalence studies from 28 countries covering the years 1994–2007 reveal that 10–20% of girls and 5–10% of boys are victims of child sexual abuse. These figures accord with those of earlier studies (2, e1). In a meta-analysis of 323 studies from around the world, involving a total of 9.9 million affected children, the worldwide prevalence was found to be 12.7% (18.0% for girls, 7.6% for boys) (3). In the USA, where the reporting of child abuse is mandatory, 60 000 to 80 000 confirmed cases are reported annually, with a downward trend (4). The available data from Germany are sparse, and it is assumed that many cases go unreported; reliable data on the frequency of subtypes of sexual abuse are sparse as well. The literature documents a lifelong association between sexual victimization in childhood and adolescence and chronic mental and physical illness in adulthood (e2). Only in recent years has the medical profession’s involvement in this area resulted in evidence-based research and consensus-based determination of best clinical practice (5, e3e6), with increasing acceptance in Germany as in other countries (6, 7, e7, e8). This is also true of the psychiatric and psychosomatic aspects of child sexual abuse (e9).

The learning objectives of this article are:

  • a greater appreciation of the value of medical diagnosis and of the obligatory multiprofessional approach to child sexual abuse, which comprises the requisite provision of comprehensive medical care to the affected child;
  • an understanding of the utility of the physical examination and its potential benefit for the affected child, even though positive findings that definitively indicate diagnosis are rare;
  • an improved ability to assess medical findings in the light of their varying informativeness and the limitations of the evidence that they provide.

Definition

Child sexual abuse is the involvement of children and adolescents in sexual activities that they cannot fully comprehend and to which they cannot consent as a fully equal, self-determining participant, because of their early stage of development. Social taboos are violated, and the offending adults exploit the difference of age and power through verbal persuasion and/or physical compulsion. The intent, on the part of adults, to use children for their own sexual stimulation and satisfaction is the central feature of child sexual abuse. The spectrum ranges from noninvasive activities that do not involve any touching of the child (hands-off contacts) all the way to rape. Sexual abuse is usually a chronic, complex, and often markedly traumatizing occurrence for the victim, frequently perpetrated by family members or other trusted persons in the setting of relationship dependence and strong authority relationships (e10). The abuse is frightening and deeply emotionally disturbing for the victim and brings about a fundamental disturbance of sexual development. It can give rise to profound feelings of guilt and shame, as well as low self-esteem and familial and social isolation (e11). It has a marked, albeit variable, effect on the victim’s mental, emotional, and physical health (5, e7).

Dealing with suspected sexual abuse

Dealing with children who may be victims of sexual abuse requires time, training, and commitment. The physician must be sympathetic but must also proceed in a rational, scientifically well-founded manner (“cool science for a hot topic”). A basic requirement is, of course, that the problem of potential child abuse must be recognized as such: this demands attentiveness on the physician’s part as well as a familiarity with the relevant historical, physical, and mental clues to abuse. Even though more than 90% of abused children have no abnormal findings on physical examination (8, 9), the forensic diagnostic aspect of the examination must not be neglected, because the absence of positive findings can also be forensically relevant. In most cases, the diagnosis is based on the statements of the child, obtained through sympathetic and non-suggestive questioning by a physician or other forensic expert who is qualified to do this. Although many types of mental disturbance and behavioral anomaly can be consequences of sexual abuse, a single such abnormality or even multiple ones in combination cannot reliably establish the diagnosis. Nonetheless, the proper determination, documentation, and interpretation of the findings on the basis of the current recommendations, guidelines, and classifications can have major implications for the protection of the victims. The evaluating physician must have the requisite knowledge in the area of child and adolescent gynecology; moreover, the involvement of persons from multiple professions is essential—the relevant medical specialties, the governmental child-protection authorities, and other groups (5, 10, 11, e8, e12). The treatment of the medical consequences of abuse (injuries, infections) and the prevention of sexually transmitted disease and pregnancy are further medical aspects. The confirmation of bodily normality, integrity, and health by the physician, in his or her role as an expert on the human body, can serve as a primary therapeutic goal of the examination, with the aim of correcting the pathological body image from which many victims suffer. This, in turn, can set the stage for the the victim’s ongoing coping with the psychological trauma of abuse, often aided by psychotherapy. Thus, it is important that the physical examination should be considered as the provision of all-around medical care to a patient in need, and not merely as an information-gathering assignment.

Medical history

The general and pediatric-gynecological history should cover all relevant aspects of the patient’s physical, emotional, and social condition. Although it is usually not necessary to inquire (again) about all details of the abuse while examining the patient, a knowledge of what happened is important so that the physical findings can be properly assessed. If possible, the facts should first be obtained from another informant. Sometimes, the trusting nature of the doctor-patient relationship enables the child to divulge something that would otherwise be held back: “I can tell you, because you are a doctor” (8, 12, e13). Thus, separate history-taking from the child is advisable. One may begin by asking the child whether she or he knows why the examination is being performed, or whether there is anything the child is worried or unhappy about. The history should be taken in calm surroundings, and the examiner’s attitude should be friendly, open, accepting, and non-judgmental. The questions should be simple and neither leading nor suggestive; the answers should be documented verbatim, if possible. The child’s emotional reaction to the history and physical examination will be determined partly by the quality of these procedures themselves and by the empathy shown by the examiner, and largely by pre-existing factors such as general anxiety, previous experiences with doctors, age, developmental stage, and the type of abuse that was suffered. In general, children tolerate the examination well as long as it is gently conducted, rather than forcibly imposed (13). History-taking and the verbal preparation of the child for physical examination take much more time than the physical examination itself, which usually requires no more than a few minutes. 30–45 minutes will be needed overall.

Physical examination

The physical examination should only be performed after thorough explanation and with the child’s permission. Its main purpose is the assessment of the anogenital area. Because the tissues in this area are capable of rapid and usually complete regeneration, physical injuries caused by abuse become less evident over time; this accounts for the rarity of positive findings. The time elapsed between the abusive event and the physical examination is an important piece of the history. The examination is often delayed, and, therefore, most of the injuries that are initially present have healed by the time the patient is seen. Children who may have been abused should be examined by a physician at once for forensic reasons so that biological evidence (sperm) of recent abuse can be successfully secured (abuse within the past 24 hours if before puberty, within the past 72 hours in pubertal girls), and for medical reasons if there is any bleeding (e14). If the abuse is already several days old, the child should be seen by a physician soon, but not as an emergency. Sedation or general anesthesia is only indicated if there is acute bleeding; otherwise, the child should not be deprived of the opportunity to cope actively with the situation and to receive an emotionally beneficial confirmation of bodily integrity. Instrument-assisted vaginal examination is not indicated in prepubertal girls; though possible for adolescent girls, it is usually not indicated merely because abuse is suspected. Anal or vaginal palpation is contraindicated. Physical examination of the entire body is obligatory so that a psychologically excessive focusing on the anogenital region can be avoided and, not least, so that extragenital injuries will not be overlooked (8, 14, 15).

In essence, the physical examination in cases of suspected sexual abuse consists of inspection of the anogenital region through a variety of examining methods and techniques while the child is suitably positioned: supine, in the knee-chest position, and in the lateral decubitus position (5, 10, e6, e15). A combination of three standard techniques—labial separation, labial traction, and knee-chest position—increases the yield of positive findings and is also required by the current Adams classification for a finding to be designated as definitive evidence of abuse (11, 16) (Figure 1). All injuries should be meticulously documented (17). The use of a colposcope is now standard, as it combines the advantages of excellent lighting, magnification, and high-quality documentation. This also aids in the checking of definitive findings and their confirmation by a second examiner (as currently required) and obviates the need for further, repetitive follow-up examinations, which may be emotionally traumatizing (8, 10, 11, 1416, 18, e16).

Physical examination: a) supine position, b) nee-chest position, c) lateral decubitus position, d) labial traction, e) labial separation (reprinted from Herrmann et al.
Physical examination: a) supine position, b) nee-chest position, c) lateral decubitus position, d) labial traction, e) labial separation (reprinted from Herrmann et al.
Figure 1
Physical examination: a) supine position, b) nee-chest position, c) lateral decubitus position, d) labial traction, e) labial separation (reprinted from Herrmann et al.

Anogenital findings

Normal findings

The appearance of the external genitalia, and of the hymen in particular, depends on age and on constitutional and hormonal factors and varies across the different phases of life. In the neonatal and early postnatal period, the hymen is bright pink and bulging, because of the effect of estrogen; as this effect declines, the hymen changes from an anular to a characteristic semilunar (half-moon) configuration in the hormonal resting phase (Figure 2), which it retains until evidence of estrogenization reappears as the first sign of puberty. The normal anatomical variants of the genital region (in girls) and the perianal region are listed in Box 1 and Box 2 and correspond to class 1 findings in the Adams classification (Box 3) (11).

Normal variants of genital anatomy in girls
Normal variants of genital anatomy in girls
Box 1
Normal variants of genital anatomy in girls
Normal perianal findings that do not constitute evidence of sexual abuse
Normal perianal findings that do not constitute evidence of sexual abuse
Box 2
Normal perianal findings that do not constitute evidence of sexual abuse
Simplified version of the Adams classification*
Simplified version of the Adams classification*
Box 3
Simplified version of the Adams classification*
Normal finding – a semilunar hymen with Intravaginally visible longitudinal ridges and mild periurethral dilatation.
Normal finding – a semilunar hymen with Intravaginally visible longitudinal ridges and mild periurethral dilatation.
Figure 2
Normal finding – a semilunar hymen with Intravaginally visible longitudinal ridges and mild periurethral dilatation.

Many findings that were once misinterpreted as evidence of abuse are now considered normal findings and variants. In particular, the width of the hymenal opening is of no informative value whatsoever. Tampons can widen the hymenal opening, but do not cause injury. Gymnastics, running, jumping, stretching, and “splits” do not injure the hymen; nor does masturbation (e6, e11, e17e24).

Normal findings despite penetration

The medically documented fact that penetrating abuse may not be associated with any subsequently abnormal physical findings must be known and understood by the treating personnel and the government authorities (police, prosecutors), so that the credibility of the victims will not be unjustly put in doubt. The technical term “virgo intacta” falsely suggests to non-physicians (particularly lawyers) the notion of “intact virginity,” above and beyond the mere anatomical finding. The highly questionable utility of this term in the context of potential sexual abuse is highlighted by a study in which only 2 (6%) of 36 pregnant teenagers manifested clear evidence of a prior penetration injury, and only 4 (11%) had suspicious, though not definitive, findings: “‘Normal’ does not mean ‘nothing happened’” (19). Normal findings are the rule, not the exception, in victims of child sexual abuse, with or without penetration, whether chronic or acute. Thus, the use of the term “virgo intacta” in the context of sexual abuse is obsolete (9, 2022).

Anogenital findings in abused children

The anogenital findings in child sexual abuse are highly variable and depend on the type and frequency of the abuse. They are influenced by the objects used (if any), the degree of force that was applied, the age of the victim, and the intensity of self-defense (e25). The only factors that are significantly correlated with the diagnosis of findings associated with child abuse are

  • reported pain
  • vaginal bleeding
  • elapsed time since the last traumatic event (1).

The classification of findings is helpful for their assessment, understanding, and interpretation. The three-level Adams classification has met with widespread acceptance and is now the main guideline for the assessment of anogenital findings in the context of suspected child abuse. In the past decade, this classification has been consensus-based and continually updated and further developed, most recently in 2011 (Box 3) (11, e26).

Findings of genital injury in sexually abused girls

The spectrum of findings ranges from nonspecific erythema and abrasions to severe penetrating injury. Most findings that are due to abuse are found in the posterior area of the hymen and introitus. Interruption of the the peripheral edge of the hymen between the 3 and 9 o’clock positions with the patient in the supine position is caused by (penile or other) penetration and can often be seen most clearly in the knee-chest position. As a consequence of such trauma, a V-shaped notch (Figure 3) or cleft appears, which, in its further course, can assume the shape of a U and is then called a “concavity.” Hymenal tears, even in the prepubertal hymen, can heal fully (23, 24).

Complete notching at 6 o’clock (arrow) – an Adams class III finding (reprinted from Herrmann et al. 2010 with the kind permission of Springer Verlag)
Complete notching at 6 o’clock (arrow) – an Adams class III finding (reprinted from Herrmann et al. 2010 with the kind permission of Springer Verlag)
Figure 3
Complete notching at 6 o’clock (arrow) – an Adams class III finding (reprinted from Herrmann et al. 2010 with the kind permission of Springer Verlag)

Findings of genital injury in sexually abused boys

Findings of genital injury are rare in sexually abused girls (5–10% [1, 22]) and even rarer in sexually abused boys (ca. 1–3%). In boys, they take the form of fissures, abrasions (epidermal or cuticular detachment) of the penile shaft or glans penis, tears of the frenulum of the glans penis, petechiae, or marks due to biting or sucking (25, e27, e28).

Injuries of the anal region due to sexual abuse

Acute and massive injuries of the anal region, such as deep perianal tears and hematomas, are immediately evident consequences of acute anal penetration. Internal injuries can be diagnosed by anoscopy, which can also serve for the securing of biological evidence. The significance of chronic changes in the anal region is controversial, particularly the finding called “reflex anal dilatation,” which constitutes potential (but not definitive) evidence of abuse only if the anal opening widens to more than 2 cm in the absence of stool in the ampulla. Anal fissures may be, but are not necessarily, due to anal penetration. Though often ascribed to constipation, they are not commonly found in constipated individuals (11, 26, 27).

Definitive findings

Pregnancy, Adams class III findings, and the demonstration of the abuser’s DNA (see “The securing of evidence,” below) are considered definitive evidence that sexual intercourse has taken place (11).

Problems of scientific method regarding the evidence for child sexual abuse

A basic problem that besets evidence in the area of medical child protection is the lack of a gold standard. The information obtained from the child can be assessed psychologically for its plausibility and credibility, but a definitive test of its veracity is generally not possible.

As as result, child sexual abuse is often diagnosed on the basis of:

  • information obtained from the child,
  • previously specified criteria,
  • and assessment by a multiprofessional child-protection team.

Among other risks, this process is vulnerable to contamination by circular reasoning: a diagnosis made on the basis of currently accepted criteria leads to a judicial finding that abuse has taken place, which, in turn, is taken to imply that the diagnosis is correct and that the diagnostic criteria that led to it are valid (20). A further methodological difficulty arises from the need to correlate the child’s subjective perceptions (e.g., “He stuck a knife in there”) with the actual course of events, and to match the history with the physical findings. There are no available studies to tell us in which developmental stage children become able to distinguish, e.g., the concepts of “there” and “in there.”

In view of the obvious ethical impossibility of randomized trials, the assessment of medical findings in suspected child abuse can only be based on so-called lower-level evidence from case-control studies, cohort studies, and case series. High-level evidence, according to the classic criteria, remains unavailable. It is a misunderstanding, however, to suppose that evidence-based medicine (EBM) is uniquely based on randomized, controlled trials. When justly considered, EBM simply means the conscious, explicit, and well-thought-out use of the best available evidence as an aid to decision-making in the care of the individual patient. As long as its limitations are kept in mind, EBM can indeed be applied to the diagnosis of sexual abuse (28, 29). A number of current publications on this topic address the fundamental considerations and contain a critical overview of the present state of the evidence (15, 30, 31, e12).

The state of the evidence regarding the sexual abuse of children and adolescents

In a review of the literature on evidence-based research up to 2008, Pillai discussed 10 studies of normal anogenital anatomy (including a total of just under 1000 children), 6 case-control studies comparing abused and non-abused children, and 6 studies on the course of healing (30). The evidence was considered to be limited; the data originated nearly exclusively in the USA. The main conclusions of the review were as follows:

  • A large majority of child and adolescent victims of sexual abuse have no positive physical findings.
  • A peripheral posterior margin measuring at least 1 mm is nearly always present except for single cases of abused girls, but its evaluation is methodologically problematic.
  • Genital measurements are generally unsuitable for determining whether abuse has occurred.
  • Genital injuries usually heal rapidly and completely, including superficial and intermediate-grade hymenal tears. Complete hymenal tears, in contrast, usually persist.
  • Scarring was never seen after hymenal injury.

Berkoff et al., in their systematic review of the literature on sexual abuse of prepubertal girls, published in 2008, found only 11 articles that were suitable for inclusion (31). Their conclusions were as follows:

  • The anogenital findings, taken in isolation, are generally too imprecise and unreliable to permit a definitive conclusion that sexual abuse has taken place.
  • Deep or complete interruption of the hymenal edge between the 4 and 8 o’clock positions strongly suggests sexual abuse.

Heppenstall-Heger et al. (2003) prospectively studied 94 cases of sexual abuse of girls involving penetration over a period of 10 years and found hymenal injuries in 37 cases (32). 15 complete hymenal tears were still demonstrable on follow-up examination. In contrast, partial tears, hematomas, and abrasions healed fully, without exception. Anal injuries healed fully in 29 of 31 cases; scarring was seen in only 2 cases. In a case-control study by Berenson et al. (2000), involving 192 3- to 8-year-old sexually abused girls and a carefully selected control group, only minor differences in the anogenital findings were seen; 5% had suggestive evidence of abuse, and 2.5% had definitive evidence of abuse (33). The types of definitive evidence include deep or complete posterior notching of the hymen, perforations, acute tears of the vulva, and ecchymoses. Superficial hymenal notching was seen in both groups (34).

The largest multicenter study to date is that of McCann et al. (2007), with two relevant publications concerning hymenal and extrahymenal findings of acute anogenital injury, in a total of 239 cases (23, 24). The study group consisted of 113 prepubertal and 126 adolescent girls. With the exception of deep, complete hymenal tears, all injuries healed completely:

  • abrasions and small hematomas in 3–4 days,
  • petechiae in 48 hours (prepubertal) and 72 hours (pubertal),
  • larger hematomas in 11–15 days,
  • bullous raised lesions on the skin with blood-tinged contents were seen for up to 34 days,
  • many hymenal tears (superficial and deep) healed without any further consequences (prepubertal 15/18, pubertal 30/34), and scarring was not seen in any case.

Sexually transmitted diseases

Sexually transmitted diseases are rare (1–4%), but they are, in some cases, the only medical evidence of sexual abuse. Screening is generally not indicated in the absence of a vaginal discharge, specific lesions, or a history of mucosal contact (34). The demonstration of HIV, syphilis, or gonorrhea is considered definitive evidence of sexual contact if perinatal infection or, in case of HIV, acquisition from a blood transfusion can be ruled out (8, 11, 14, e29e32). Anogenital warts (condylomata acuminata), though not in themselves evidence of sexual abuse, should prompt a search for associated findings and for concomitant sexually transmitted disease. Lesions after the age of 6 to 8 years may be more highly suspect (e33, e34). The demonstration of trichomonas should also arouse suspicion of sexual abuse.

Differential diagnosis

Accidental anogenital injury is among the more common differential diagnoses (35, e35). Typical hallmarks of accidental injury are listed in Box 4.

Accidental anogenital injuries
Accidental anogenital injuries
Box 4
Accidental anogenital injuries

Further differential diagnoses include various dermatologic diseases and infections, e.g., with group A β-hemolytic streptococcus. Irritation (and potential misdiagnosis) can also be caused by an anogenital lichen sclerosus et atrophicus (e36); this entity causes skin atrophy and sometimes marked subcutaneous hematoma formation in the genital area (Figure 4). Vaginal bleeding is most commonly due to infection (in about 70% of cases), with less common causes including foreign bodies, hemangioma, and precocious puberty. Sarcoma botryoides can only be ruled out by vaginoscopy. The major differential diagnoses of anal abuse include fissures that may, occasionally, arise in chronic constipation or Crohn’s disease, rectal prolapse, or proctitis due to CMV infection (35).

Lichen sclerosus et atrophicus with perivaginal and perianal lightening of the skin (“hourglass” appearance) and cutaneous hematoma formation
Lichen sclerosus et atrophicus with perivaginal and perianal lightening of the skin (“hourglass” appearance) and cutaneous hematoma formation
Figure 4
Lichen sclerosus et atrophicus with perivaginal and perianal lightening of the skin (“hourglass” appearance) and cutaneous hematoma formation

The securing of evidence

The forensic demonstration of the abuser’s DNA is possible only in exceptional cases, because, typically, days to weeks elapse between the last abuse and the physical examination. If the victim comes to medical attention right after the event, the chance of demonstrating the abuser’s DNA is much higher (a specimen is taken on a dry cotton swab which is left to dry in the air, or else it is smeared onto another carrier surface and then left to dry). DNA traces are rarely found in prepubertal victims, and only in exceptional cases more than 24 hours after the event; more forensic attention should be directed to the victim’s clothing and bedclothes (3537, e3436).

If the securing of evidence is indicated after an acute event, it should be recalled that multiple studies have not shown any correlation between the demonstration of the abuser’s DNA on the one hand, and the victim’s description of the abuse or the detection of injuries by physical examination on the other (e37e39). Specimens to be used as legal evidence should be taken by an experienced physician as part of the physical examination. The swab should be unequivocally labeled, as directed by the forensic authorities, and it should be sealed and stored in a dry place. The German Society of Legal Medicine (Deutsche Gesellschaft für Rechtsmedizin) has published recommendations for what should be done in cases where child sexual abuse is suspected (38).

The legal framework of medical intervention

According to German law, the confidentiality of the physician-patient relationship is a binding duty in the case of treatment of a sexually abused child (§ 203 StGB), and it can only be abrogated if there is a legally recognized justification for doing so. If the consent of a parent or legal guardian cannot be obtained as such a justification, then a legal empowerment to release information may need to be obtained, e.g., under the provision of a so-called justifying emergency (rechtfertigender Notstand) according to § 34 StGB. The new Federal Child-Protection Act (Bundeskinderschutzgesetz, BKiSchG), which went into effect on 1 January 2012, basically allows the release of information to the Youth Welfare Office (Jugendamt) as long as the prescribed stepwise procedure is followed (§ 4, see Box 5).

Summary of the stepwise procedure to be followed if child abuse is suspected, according to the German Federal Child-Protection Act (BKiSchG)
Summary of the stepwise procedure to be followed if child abuse is suspected, according to the German Federal Child-Protection Act (BKiSchG)
Box 5
Summary of the stepwise procedure to be followed if child abuse is suspected, according to the German Federal Child-Protection Act (BKiSchG)

Thus, the new BKiSchG has made it permissible, though by no means obligatory, to report suspected child abuse, without abrogating the physician’s duty of confidentiality. Further help can be obtained from the guidelines of the Federal Ministry of Justice concerning the activation of the criminal prosecution authorities in the pursuit of sex crimes (39).

Conclusions

The suspicion of child sexual abuse calls for a time-consuming diagnostic evaluation that is performed with all due care and with the requisite medical expertise. The physician carrying out this evaluation should be experienced both in child and adolescent gynecology and in forensic medicine. If biological evidence needs to be secured, advice should be sought from the responsible forensic medical authorities. The examiner should know the current state of the evidence regarding the medical findings of child sexual abuse as well as their current classification. Such examinations reveal only normal findings in 90–95% of cases and therefore only exceptionally lead to a definitive diagnosis or legal determination. The diagnosis of sexual abuse is usually based on a statement from the child, obtained in the correct way through sympathetic but not suggestive questioning.

Leading questions should be avoided, and the patient’s answers should be documented verbatim, by persons trained in the psychology of legal testimony whenever possible. The physical examination can have a beneficial therapeutic effect by confirming the bodily integrity and normality of the child, as long as it is carried out without any compulsion or pressure. In some cases, preventive measures may need to be taken against sexually transmitted disease or pregnancy. The German Federal Child-Protection Act specifies the circumstances in which the physician can breach the child’s confidentiality to give important information to the Youth Welfare Office.

Conflict of interest statement
Dr. Herrmann, Dr. Banaschak, and Prof. Dettmeyer receive royalties from Springer Verlag for their textbook “Kindesmisshandlung” (Child Abuse).

PD Dr. Csorba and Dr. Navratil state that they have no conflict of interest.

Manuscript submitted on 21 January 2014, revised version accepted on 23 July 2014.

Translated from the original German by Ethan Taub, M.D.

Corresponding author
Dr. med. Bernd Herrmann
Klinik für Kinder- und Jugendmedizin des Klinikum Kassel
Ärztliche Kinderschutz- und Kindergynäkologieambulanz
Mönchebergstr. 43, 34125 Kassel, Germany
herrmann@klinikum-kassel.de

@For eReferences please refer to:
www.aerzteblatt-international.de/ref4114

1.
Kaplan R, Adams JA, Starling SP, Giardino AP: Medical response to child sexual abuse. A resource for professionals working with children and families. St. Louis: STM Learning 2011.
2.
Peredaa N, Guilerab G, Fornsa M, Gómez-Benito J: The international epidemiology of child sexual abuse: A continuation of Finkelhor (1994). Child Abuse Negl 2009; 33: 331–42. CrossRef MEDLINE
3.
Stoltenborgh M, van Ijzendoorn MH, Euser EM, Bakermans-Kranenburg MJ: A global perspective on child sexual abuse: Meta-analysis of prevalence around the world. Child Maltreat 2011; 16: 79–101. CrossRef MEDLINE
4.
U.S. Department of Health & Human Services: Child Maltreatment 2012. www.acf.hhs.gov/programs/cb/resource/child-maltreatment-2012. (last accessed on 15. January 2014). CrossRef
5.
Herrmann B, Dettmeyer R, Banaschak S, Thyen U: Kindesmisshandlung. Medizinische Diagnostik, Intervention und rechtliche Grundlagen. 2nd. edition. Heidelberg, Berlin, New York: Springer Verlag 2010.
6.
Jacobi G, Dettmeyer R, Banaschak S, Brosig B, Herrmann B: Child abuse and neglect: Diagnosis and management. Dtsch Arztebl Int 2010; 107: 231–40 VOLLTEXT
7.
Herrmann B, Simon-Stolz L, Wilsch M, Eydam AK: Neue Entwicklungen im medizinischen Kinderschutz. Zwischen Interdisziplinarität und Spezialisierung. Pädiatrische Praxis 2013; 80: 461–70.
8.
American Academy of Pediatrics: The evaluation of children in the primary care setting when sexual abuse is suspected. AAP Clinical Report on the evaluation of sexual abuse in children. Pediatrics 2013; 132: e558–67. CrossRef MEDLINE
9.
Slaughter L, Henry T: Rape: when the exam is normal. J Pediatr Adolesc Gyn 2009; 22: 7–10.
10.
Herrmann B, Navratil F, Neises M: Sexueller Missbrauch an Kindern. Bedeutung und Stellenwert der medizinischen Diagnostik. Monatsschr Kinderheilkd 2002; 150: 1344–56. CrossRef
11.
Adams JA: Medical evaluation of suspected child sexual abuse: 2011 update. J Child Sexual Abuse 2011; 20: 588–605. CrossRef MEDLINE
12.
Schaeffer P, Leventhal JM, Asnes AG: Children’s disclosures of sexual abuse: Learning from direct inquiry. Child Abuse Negl 2011; 35: 343–52. CrossRef MEDLINE
13.
Hornor G, Scribano P, Curran S, Stevens J: Emotional response to the ano-genital examination of suspected sexual abuse. J Forensic Nurs 2009; 5: 124–30. CrossRef MEDLINE
14.
American Academy of Pediatrics (AAP), Kaufman M and the Committee on Adolescence: Care of the adolescent sexual assault victim. Pediatrics 2008; 122: 462–70. CrossRef MEDLINE
15.
Royal College of Paediatrics and Child Health (RCPH): The physical signs of child sexual abuse. An evidence-based review and guidance for best practice. 2008;/www.rcpch.ac.uk/rcpch-guidelines-and-standards-clinical-practice (last accessed on 15 January 2014).
16.
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: 229–43. CrossRef MEDLINE
17.
Verhoff MA, Kettner M, Lászik A, Ramsthaler F: Digital photo documentation of forensically relevant injuries as part of the clinical first response protocol. Dtsch Arztebl Int 2012; 109: 638–42. VOLLTEXT
18.
Adams JA, Phillips P, Ahmad M: The usefulness of colposcopic photographs in the evaluation of suspected child sexual abuse. Adolesc Pediatr Gynecol 1997; 3: 75–82. CrossRef
19.
Kellogg ND, Menard SW, Santos A: Genital anatomy in pregnant adolescents: “Normal” does not mean “Nothing happened.” Pediatrics 2004; 113: e67–69. CrossRef MEDLINE
20.
Adams JA, Harper K, Knudson S, Revilla J: Examination findings in legally confirmed child sexual abuse: it´s normal to be normal. Pediatrics 1994; 94: 310–17. MEDLINE
21.
Anderst J, Kellogg K, Jung I: Reports of repetitive penile-genital penetration often have no definitive evidence of penetration. Pediatrics 2009; 124: e403–e9. CrossRef MEDLINE
22.
Heger A, Ticson L, Velasquez O, et al.: Children referred for possible sexual abuse: Medical findings in 2384 children. Child Abuse Negl 2002; 26: 645–59. CrossRef MEDLINE
23.
McCann J, Miyamoto S, Boyle C, Rogers K: Healing of hymenal injuries in prepubertal and adolescent girls: A Descriptive study. Pediatrics 2007; 119: e1094–106. CrossRef MEDLINE
24.
McCann J, Miyamoto S, Boyie C, Rodgers K: Healing of nonhymenal genital injuries in prepubertal and adolescent girls: A descriptive study. Pediatrics 2007; 120: 1000–11. CrossRef MEDLINE
25.
Trubner K, Schubries M, Beintker M, Bajanowski T: Genital findings in boys suspected for sexual abuse. Int J Legal Med 2013; 127: 967–70. CrossRef MEDLINE
26.
Myhre AK, Adams JA, Kaufhold M, et al.: Anal findings in children with and without probable anal penetration: A retrospective study of 1115 children referred for suspected sexual abuse. Child Abuse Negl 2013; 37: 465–74. CrossRef MEDLINE
27.
Pierce AM: Anal fissures and anal scars in anal abuse—Are they significant? Pediatr Surg Int 2004; 20: 334–8. CrossRef MEDLINE
28.
Sibert J, Maguire SA, Kemp AM: How good is the evidence available in child protection? Arch Dis Child 2007; 92: 107–8. CrossRef MEDLINE PubMed Central
29.
Shapiro RA, Leonard AC, Makoroff KL: Evidence-based approach to child sexual abuse examination findings. In: Kaplan R, Adams JA, Starling SP, Giardino AP: Medical response to child sexual abuse. A resource for professionals working with children and families. St. Louis: STM Learning 2011, 103–15.
30.
Pillai M: Genital findings in prepubertal girls: What can be concluded from an examination? J Pediatr Adolesc Gynecol 2008; 21: 177–85. CrossRef MEDLINE
31.
Berkoff MC, Zolotor AJ, Makoroff KL, Thackeray JD,
Shapiro RA, Runyan DK: Has this prepubertal girl been sexually abused? JAMA 2008; 300: 2779–92. CrossRef MEDLINE
32.
Heppenstall-Heger A, McConnell G, 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: 829–37. CrossRef MEDLINE
33.
Berenson AB, Chacko MR, Wiemann CM, Mishaw CO, Friedrich WN, Grady JJ: A case-control study of anatomic changes resulting from sexual abuse. Am J Obstetr Gynecol 2000; 182: 820–34. CrossRef MEDLINE
34.
Girardet RG, Lahoti S, Howard LA, et al.: Epidemiology of sexually transmitteld infections in suspected child victims of sexual assault. Pediatrics 2009; 124: 79–86. CrossRef MEDLINE
35.
Kellog ND, Frasier L: Conditions mistaken for child sexual abuse. In: Reece RM, Christian CW (eds.) Child abuse: Medical diagnosis and management. American Academie of Pediatrics (AAP), Elk Grove Village, 3rd edition. 2009; 389–426.
36.
Christian C, Lavelle J, Dejong A, Loiselle J, Brenner L, Joffe M: Forensic evidence findings in prepubertal victims of sexual assault. Pediatrics 2000; 106: 100–4. CrossRef MEDLINE
37.
Thackeray JD, Hornor G, Benzinger EA, Scribano PV: Forensic evidence collection and DNA identification in acute child sexual assault. Pediatrics 2011; 28: 227–32. CrossRef MEDLINE
38.
Debertin, AS, Seifert D, Mützel E: Forensisch-medizinische Untersuchung von Mädchen und Jungen bei Verdacht auf Misshandlung und Missbrauch. Empfehlungen der Arbeitsgemeinschaft Klinische Rechtsmedizin der Deutschen Gesellschaft für Rechtsmedizin. Rechtsmedizin 2011; 21: 479–82. CrossRef
39.
Arbeitsgruppe II – „Durchsetzung staatlicher Strafanspruch – Rechtspolitische Folgerungen – Anerkennung des Leidens der Opfer sexuellen Missbrauchs in jeglicher Hinsicht“ des Runden Tisches „Sexueller Kindesmissbrauch in Abhängigkeits- und Machtverhältnissen in privaten und öffentlichen Einrichtungen und im familiären Bereich“. Leitlinien zur Einschaltung der Strafverfolgungsbehörden. Jugendamt 2012; 3: 140–45.
e1.
Finkelhor D: The international epidemiology of child sexual abuse. Child Abuse Negl 1994; 18: 409–17. CrossRef
e2.
De Bellis MD, Spratt EG, Hooper SR: Neurodevelopmental biology associated with childhood sexual abuse. J Child Sex Abuse 2011; 20: 548–87. CrossRef MEDLINE PubMed Central
e3.
Deutsche Gesellschaft für Sozialpädiatrie und Jugendmedizin (DGSPJ): Leitlinie Kindesmisshandlung und Vernachlässigung (Teil 1: Psychosoziale Faktoren, Prävention und Intervention; Teil 2: Somatische Diagnostik (AWMF-Leitlinien-Register Nr. 071/003 ; Entwicklungsstufe 2).-abgelaufen, derzeit in Revision; noch abrufbar unter: kindesmisshandlung.de/deutscheleitlinien.html
e4.
Adams JA: Guidelines for medical care of children evaluated for suspected sexual abuse: an update for 2008. Curr Opin Obstet Gynecol 2008; 20: 435–41. CrossRef MEDLINE
e5.
Herrmann B, Navratil F: Sexual abuse in prepubertal children and adolescents. Endocr Dev 2012; 22: 112–37. CrossRef MEDLINE
e6.
Adams JA: Interpretation of genital and anal findings in children and adolescents with suspected sexual abuse: State of the science. In: Kaplan R, Adams JA, et al. (eds.): Medical response to child sexual abuse: A resource for professionals working with children and families. St. Louis, MO: STM Learning, 2011; 117–44.
e7.
Wetzels P: Gewalterfahrungen in der Kindheit: Sexueller Missbrauch, körperliche Mißhandlung und deren langfristige Konsequenzen. Baden-Baden: Nomos Verlagsgesellschaft 1997.
e8.
Adams JA, Starling SP, Frasier LD, et al.: Diagnostic accuracy in child sexual abuse medical evaluation: Role of experience, training, and expert case review. Child Abuse Negl 2012; 36: 383–92. CrossRef MEDLINE
e9.
Egle UT, Hoffmann SO, Joraschky P: Sexueller Missbrauch, Misshandlung, Vernachlässigung. Stuttgart, New York: Schattauer 2005.
e10.
Zimmermann P, Neumann A, Celik F: Sexuelle Gewalt gegen Kinder in Familien. München: Deutsches Jugendinstitut, 2011.
e11.
Joraschky P, Pöhlmann K: Die Auswirkungen von Vernachlässigung, Misshandlung, Missbrauch auf Selbstwert und Körperbild. In: Egle UT, Hoffmann SO, Joraschky P (eds.): Sexueller Missbrauch, Misshandlung, Vernachlässigung. Stuttgart, New York: Schattauer 2005.
e12.
Herrmann B, Eydam AK: Leitlinien und Evidenz. Neue Entwicklungen im somatischen medizinischen Kinderschutz. Bundesgesundheitsbl 2010; 53: 1173–9. CrossRef MEDLINE
e13.
Finkel MA: „I can tell you, because you’re a doctor“ Commentary. Pediatrics 2008; 122: 422. CrossRef MEDLINE
e14.
Palusci VJ, Cox EO, Shatz EM, Schultze JM: Urgent medical assessment after child sexual abuse. Child Abuse Negl 2006; 30: 367–80.
e15.
Finkel MA: Medical aspects of prepubertal sexual abuse. In: Reece RM, Christian CW (eds.): Child abuse: Medical diagnosis and management. 3rd edition American Academy of Pediatrics, Elk Grove Village 2009; 269–320.
e16.
Adams J, Girardin B, Faugno D: Adolescent sexual assault: documentation of acute injuries using photo-colposcopy. J Pediatr Adolesc Gynecol 2001; 14: 175. MEDLINE
e17.
Berenson AB: A longitudinal study of hymenal morphology in the first 3 years of life. Pediatrics 1995; 95: 490–6. MEDLINE
e18.
Berenson AB: Normal anogenital anatomy. Child Abuse Negl 1998; 22: 589–96. CrossRef MEDLINE
e19.
Berenson AB, Heger A, Andrews S: Appearance of the hymen in newborns. Pediatrics 1991; 87: 458–65. MEDLINE
e20.
Berenson AB, Grady JJ: A longitudinal study of hymenal development from 3 to 9 years of age. J Pediatr 2002; 140: 600–7. CrossRef MEDLINE
e21.
Berenson AB, Heger A, Haynes JM, Bailey RK, Emans SJ: Appearance of the hymen in prepubertal girls. Pediatrics 1992; 89: 387–94. MEDLINE
e22.
Berenson AB, Somma-Garcia A, Barnett S: Perianal findings in infants 18 months of age or younger. Pediatrics 1993; 91: 838–40. MEDLINE
e23.
McCann J, Wells R, Simon M, Voris J: Genital findings in prepubertal girls selected for nonabuse: a descriptive study. Pediatrics 1990; 86: 428–39. MEDLINE
e24.
Myhre AK, Berntzen K, Bratlid D: Genital anatomy in non-abused preschool girls. Acta Paedriatr 2003; 92: 1453–62. CrossRef MEDLINE
e25.
Csorba R, Lampé R, Póka R: Surgical repair of blunt force penetrating anogenital trauma in an 18-month-old sexually abused girl: a case report. Eur J Obstet Gynecol Reprod Biol 2010; 153: 231. CrossRef MEDLINE
e26.
Herrmann B: Übersetzte und kommentierte Adams Klassifikation 2008–2011. Info KiM (Zeitschrift der AG Kinderschutz in der Medizin) 2014; 4: 2–4.
e27.
Kadish HA, Schunk JE, Britton H: Pediatric male rectal and genital trauma: Accidental and nonaccidental injuries. Pediatr Emerg Care 1998; 14: 35–98. MEDLINE
e28.
Hobbs CJ, Osman J: Genital injuries in boys and abuse. Arch Dis Child 2007; 92: 328–31. CrossRef MEDLINE PubMed Central
e29.
Girardet Lemme S, Biasona TA, Boltona K, Lahoti S: HIV post-exposure prophylaxis in children and adolescents presenting for reported sexual assault. Child Abuse Negl 2009; 33: 173–8. CrossRef MEDLINE
e30.
Bechtel K: Sexual abuse and sexually transmitted infections in children and adolescents. Curr Opin Pediatr 2010; 22: 94–9. CrossRef MEDLINE
e31.
Hammerschlag MR: Sexual assault and abuse of children. Clin Infect Dis 2011; 53: 103–9. CrossRef MEDLINE
e32.
Hammerschlag MR, Guillén CD: Medical and legal implications of testing for sexually transmitted infections in children. Clin Microbiol Rev 2010; 23: 493–506. CrossRef MEDLINE PubMed Central
e33.
Unger ER, Fajman NN, Maloney EM, et al.: Anogenital human papillomavirus in sexually abused and nonabused children: a multicenter study. Pediatrics 2011; 128: e658. MEDLINE
e34.
Clarke J: How did she get these warts? Anogenital warts and sexual abuse. Child Abuse Rev 1998; 7: 206–11. CrossRef
e35.
Herrmann B, Crawford J: Genital injuries in prepubertal girls from inline skating accidents. Pediatrics 2002; 110: e16. pediatrics.org/cgi/content/full/110/2/e16 (last accessed on 15 January 2014). MEDLINE
e36.
Herrmann B, Veit S, Neises M: Lichen sclerosus et atrophicus. Wichtige Differentialdiagnose zu sexuellem Mißbrauch von Kindern. Pädiat Prax 1998; 55: 319–24.
e37.
Young KL, Jones JG, Worthington T, Simpson P, Casey PH: Forensic laboratory evidence in sexually abused children and adolescdents. Arch Pediatr Adolesc Med 2006; 160: 585–8. CrossRef MEDLINE
e38.
Bode-Jänisch S, Voigt S, Günther D, Debertin AS: Klinisch-forensische Untersuchungsergebnisse und rechtliche Folgen bei sexuellem Kindesmissbrauch. Arch Krim 2011; 228: 20–38. MEDLINE
e39.
Girardet R, Bolton K, Lahoti S, et al.: Collection of forensic evidence from pediatric victims of sexual assault. Pediatrics. 2011; 128: 233–8. CrossRef MEDLINE
Department for Pediatric and Adolescent Medicine, Kassel Hospital Dr. med. Herrmann
Institute of Legal Medicine, University Hospital of Cologne: Dr. med. Banaschak
Institut für Rechtsmedizin, Justus-Liebig-Universität Gießen: Prof. Dr. med. Dr. jur. Dettmeyer
Outpatient clinic for Pediatric and Adolescent Gynecology, Zurich, Switzerland: Dr. med. Navratil
Department of Obstetrics and Gynecology, University of Debrecen, Hungary: PD Dr. med. Csorba
Normal variants of genital anatomy in girls
Normal variants of genital anatomy in girls
Box 1
Normal variants of genital anatomy in girls
Normal perianal findings that do not constitute evidence of sexual abuse
Normal perianal findings that do not constitute evidence of sexual abuse
Box 2
Normal perianal findings that do not constitute evidence of sexual abuse
Simplified version of the Adams classification*
Simplified version of the Adams classification*
Box 3
Simplified version of the Adams classification*
Accidental anogenital injuries
Accidental anogenital injuries
Box 4
Accidental anogenital injuries
Summary of the stepwise procedure to be followed if child abuse is suspected, according to the German Federal Child-Protection Act (BKiSchG)
Summary of the stepwise procedure to be followed if child abuse is suspected, according to the German Federal Child-Protection Act (BKiSchG)
Box 5
Summary of the stepwise procedure to be followed if child abuse is suspected, according to the German Federal Child-Protection Act (BKiSchG)
Physical examination: a) supine position, b) nee-chest position, c) lateral decubitus position, d) labial traction, e) labial separation (reprinted from Herrmann et al.
Physical examination: a) supine position, b) nee-chest position, c) lateral decubitus position, d) labial traction, e) labial separation (reprinted from Herrmann et al.
Figure 1
Physical examination: a) supine position, b) nee-chest position, c) lateral decubitus position, d) labial traction, e) labial separation (reprinted from Herrmann et al.
Normal finding – a semilunar hymen with Intravaginally visible longitudinal ridges and mild periurethral dilatation.
Normal finding – a semilunar hymen with Intravaginally visible longitudinal ridges and mild periurethral dilatation.
Figure 2
Normal finding – a semilunar hymen with Intravaginally visible longitudinal ridges and mild periurethral dilatation.
Complete notching at 6 o’clock (arrow) – an Adams class III finding (reprinted from Herrmann et al. 2010 with the kind permission of Springer Verlag)
Complete notching at 6 o’clock (arrow) – an Adams class III finding (reprinted from Herrmann et al. 2010 with the kind permission of Springer Verlag)
Figure 3
Complete notching at 6 o’clock (arrow) – an Adams class III finding (reprinted from Herrmann et al. 2010 with the kind permission of Springer Verlag)
Lichen sclerosus et atrophicus with perivaginal and perianal lightening of the skin (“hourglass” appearance) and cutaneous hematoma formation
Lichen sclerosus et atrophicus with perivaginal and perianal lightening of the skin (“hourglass” appearance) and cutaneous hematoma formation
Figure 4
Lichen sclerosus et atrophicus with perivaginal and perianal lightening of the skin (“hourglass” appearance) and cutaneous hematoma formation
1. Kaplan R, Adams JA, Starling SP, Giardino AP: Medical response to child sexual abuse. A resource for professionals working with children and families. St. Louis: STM Learning 2011.
2. Peredaa N, Guilerab G, Fornsa M, Gómez-Benito J: The international epidemiology of child sexual abuse: A continuation of Finkelhor (1994). Child Abuse Negl 2009; 33: 331–42. CrossRef MEDLINE
3. Stoltenborgh M, van Ijzendoorn MH, Euser EM, Bakermans-Kranenburg MJ: A global perspective on child sexual abuse: Meta-analysis of prevalence around the world. Child Maltreat 2011; 16: 79–101. CrossRef MEDLINE
4. U.S. Department of Health & Human Services: Child Maltreatment 2012. www.acf.hhs.gov/programs/cb/resource/child-maltreatment-2012. (last accessed on 15. January 2014). CrossRef
5.Herrmann B, Dettmeyer R, Banaschak S, Thyen U: Kindesmisshandlung. Medizinische Diagnostik, Intervention und rechtliche Grundlagen. 2nd. edition. Heidelberg, Berlin, New York: Springer Verlag 2010.
6.Jacobi G, Dettmeyer R, Banaschak S, Brosig B, Herrmann B: Child abuse and neglect: Diagnosis and management. Dtsch Arztebl Int 2010; 107: 231–40 VOLLTEXT
7. Herrmann B, Simon-Stolz L, Wilsch M, Eydam AK: Neue Entwicklungen im medizinischen Kinderschutz. Zwischen Interdisziplinarität und Spezialisierung. Pädiatrische Praxis 2013; 80: 461–70.
8.American Academy of Pediatrics: The evaluation of children in the primary care setting when sexual abuse is suspected. AAP Clinical Report on the evaluation of sexual abuse in children. Pediatrics 2013; 132: e558–67. CrossRef MEDLINE
9. Slaughter L, Henry T: Rape: when the exam is normal. J Pediatr Adolesc Gyn 2009; 22: 7–10.
10.Herrmann B, Navratil F, Neises M: Sexueller Missbrauch an Kindern. Bedeutung und Stellenwert der medizinischen Diagnostik. Monatsschr Kinderheilkd 2002; 150: 1344–56. CrossRef
11.Adams JA: Medical evaluation of suspected child sexual abuse: 2011 update. J Child Sexual Abuse 2011; 20: 588–605. CrossRef MEDLINE
12.Schaeffer P, Leventhal JM, Asnes AG: Children’s disclosures of sexual abuse: Learning from direct inquiry. Child Abuse Negl 2011; 35: 343–52. CrossRef MEDLINE
13.Hornor G, Scribano P, Curran S, Stevens J: Emotional response to the ano-genital examination of suspected sexual abuse. J Forensic Nurs 2009; 5: 124–30. CrossRef MEDLINE
14. American Academy of Pediatrics (AAP), Kaufman M and the Committee on Adolescence: Care of the adolescent sexual assault victim. Pediatrics 2008; 122: 462–70. CrossRef MEDLINE
15. Royal College of Paediatrics and Child Health (RCPH): The physical signs of child sexual abuse. An evidence-based review and guidance for best practice. 2008;/www.rcpch.ac.uk/rcpch-guidelines-and-standards-clinical-practice (last accessed on 15 January 2014).
16.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: 229–43. CrossRef MEDLINE
17.Verhoff MA, Kettner M, Lászik A, Ramsthaler F: Digital photo documentation of forensically relevant injuries as part of the clinical first response protocol. Dtsch Arztebl Int 2012; 109: 638–42. VOLLTEXT
18.Adams JA, Phillips P, Ahmad M: The usefulness of colposcopic photographs in the evaluation of suspected child sexual abuse. Adolesc Pediatr Gynecol 1997; 3: 75–82. CrossRef
19.Kellogg ND, Menard SW, Santos A: Genital anatomy in pregnant adolescents: “Normal” does not mean “Nothing happened.” Pediatrics 2004; 113: e67–69. CrossRef MEDLINE
20.Adams JA, Harper K, Knudson S, Revilla J: Examination findings in legally confirmed child sexual abuse: it´s normal to be normal. Pediatrics 1994; 94: 310–17. MEDLINE
21. Anderst J, Kellogg K, Jung I: Reports of repetitive penile-genital penetration often have no definitive evidence of penetration. Pediatrics 2009; 124: e403–e9. CrossRef MEDLINE
22. Heger A, Ticson L, Velasquez O, et al.: Children referred for possible sexual abuse: Medical findings in 2384 children. Child Abuse Negl 2002; 26: 645–59. CrossRef MEDLINE
23.McCann J, Miyamoto S, Boyle C, Rogers K: Healing of hymenal injuries in prepubertal and adolescent girls: A Descriptive study. Pediatrics 2007; 119: e1094–106. CrossRef MEDLINE
24.McCann J, Miyamoto S, Boyie C, Rodgers K: Healing of nonhymenal genital injuries in prepubertal and adolescent girls: A descriptive study. Pediatrics 2007; 120: 1000–11. CrossRef MEDLINE
25.Trubner K, Schubries M, Beintker M, Bajanowski T: Genital findings in boys suspected for sexual abuse. Int J Legal Med 2013; 127: 967–70. CrossRef MEDLINE
26.Myhre AK, Adams JA, Kaufhold M, et al.: Anal findings in children with and without probable anal penetration: A retrospective study of 1115 children referred for suspected sexual abuse. Child Abuse Negl 2013; 37: 465–74. CrossRef MEDLINE
27.Pierce AM: Anal fissures and anal scars in anal abuse—Are they significant? Pediatr Surg Int 2004; 20: 334–8. CrossRef MEDLINE
28.Sibert J, Maguire SA, Kemp AM: How good is the evidence available in child protection? Arch Dis Child 2007; 92: 107–8. CrossRef MEDLINE PubMed Central
29.Shapiro RA, Leonard AC, Makoroff KL: Evidence-based approach to child sexual abuse examination findings. In: Kaplan R, Adams JA, Starling SP, Giardino AP: Medical response to child sexual abuse. A resource for professionals working with children and families. St. Louis: STM Learning 2011, 103–15.
30. Pillai M: Genital findings in prepubertal girls: What can be concluded from an examination? J Pediatr Adolesc Gynecol 2008; 21: 177–85. CrossRef MEDLINE
31.Berkoff MC, Zolotor AJ, Makoroff KL, Thackeray JD,
Shapiro RA, Runyan DK: Has this prepubertal girl been sexually abused? JAMA 2008; 300: 2779–92. CrossRef MEDLINE
32.Heppenstall-Heger A, McConnell G, 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: 829–37. CrossRef MEDLINE
33.Berenson AB, Chacko MR, Wiemann CM, Mishaw CO, Friedrich WN, Grady JJ: A case-control study of anatomic changes resulting from sexual abuse. Am J Obstetr Gynecol 2000; 182: 820–34. CrossRef MEDLINE
34.Girardet RG, Lahoti S, Howard LA, et al.: Epidemiology of sexually transmitteld infections in suspected child victims of sexual assault. Pediatrics 2009; 124: 79–86. CrossRef MEDLINE
35. Kellog ND, Frasier L: Conditions mistaken for child sexual abuse. In: Reece RM, Christian CW (eds.) Child abuse: Medical diagnosis and management. American Academie of Pediatrics (AAP), Elk Grove Village, 3rd edition. 2009; 389–426.
36.Christian C, Lavelle J, Dejong A, Loiselle J, Brenner L, Joffe M: Forensic evidence findings in prepubertal victims of sexual assault. Pediatrics 2000; 106: 100–4. CrossRef MEDLINE
37.Thackeray JD, Hornor G, Benzinger EA, Scribano PV: Forensic evidence collection and DNA identification in acute child sexual assault. Pediatrics 2011; 28: 227–32. CrossRef MEDLINE
38. Debertin, AS, Seifert D, Mützel E: Forensisch-medizinische Untersuchung von Mädchen und Jungen bei Verdacht auf Misshandlung und Missbrauch. Empfehlungen der Arbeitsgemeinschaft Klinische Rechtsmedizin der Deutschen Gesellschaft für Rechtsmedizin. Rechtsmedizin 2011; 21: 479–82. CrossRef
39.Arbeitsgruppe II – „Durchsetzung staatlicher Strafanspruch – Rechtspolitische Folgerungen – Anerkennung des Leidens der Opfer sexuellen Missbrauchs in jeglicher Hinsicht“ des Runden Tisches „Sexueller Kindesmissbrauch in Abhängigkeits- und Machtverhältnissen in privaten und öffentlichen Einrichtungen und im familiären Bereich“. Leitlinien zur Einschaltung der Strafverfolgungsbehörden. Jugendamt 2012; 3: 140–45.
e1. Finkelhor D: The international epidemiology of child sexual abuse. Child Abuse Negl 1994; 18: 409–17. CrossRef
e2. De Bellis MD, Spratt EG, Hooper SR: Neurodevelopmental biology associated with childhood sexual abuse. J Child Sex Abuse 2011; 20: 548–87. CrossRef MEDLINE PubMed Central
e3. Deutsche Gesellschaft für Sozialpädiatrie und Jugendmedizin (DGSPJ): Leitlinie Kindesmisshandlung und Vernachlässigung (Teil 1: Psychosoziale Faktoren, Prävention und Intervention; Teil 2: Somatische Diagnostik (AWMF-Leitlinien-Register Nr. 071/003 ; Entwicklungsstufe 2).-abgelaufen, derzeit in Revision; noch abrufbar unter: kindesmisshandlung.de/deutscheleitlinien.html
e4. Adams JA: Guidelines for medical care of children evaluated for suspected sexual abuse: an update for 2008. Curr Opin Obstet Gynecol 2008; 20: 435–41. CrossRef MEDLINE
e5.Herrmann B, Navratil F: Sexual abuse in prepubertal children and adolescents. Endocr Dev 2012; 22: 112–37. CrossRef MEDLINE
e6. Adams JA: Interpretation of genital and anal findings in children and adolescents with suspected sexual abuse: State of the science. In: Kaplan R, Adams JA, et al. (eds.): Medical response to child sexual abuse: A resource for professionals working with children and families. St. Louis, MO: STM Learning, 2011; 117–44.
e7. Wetzels P: Gewalterfahrungen in der Kindheit: Sexueller Missbrauch, körperliche Mißhandlung und deren langfristige Konsequenzen. Baden-Baden: Nomos Verlagsgesellschaft 1997.
e8. Adams JA, Starling SP, Frasier LD, et al.: Diagnostic accuracy in child sexual abuse medical evaluation: Role of experience, training, and expert case review. Child Abuse Negl 2012; 36: 383–92. CrossRef MEDLINE
e9.Egle UT, Hoffmann SO, Joraschky P: Sexueller Missbrauch, Misshandlung, Vernachlässigung. Stuttgart, New York: Schattauer 2005.
e10.Zimmermann P, Neumann A, Celik F: Sexuelle Gewalt gegen Kinder in Familien. München: Deutsches Jugendinstitut, 2011.
e11.Joraschky P, Pöhlmann K: Die Auswirkungen von Vernachlässigung, Misshandlung, Missbrauch auf Selbstwert und Körperbild. In: Egle UT, Hoffmann SO, Joraschky P (eds.): Sexueller Missbrauch, Misshandlung, Vernachlässigung. Stuttgart, New York: Schattauer 2005.
e12.Herrmann B, Eydam AK: Leitlinien und Evidenz. Neue Entwicklungen im somatischen medizinischen Kinderschutz. Bundesgesundheitsbl 2010; 53: 1173–9. CrossRef MEDLINE
e13.Finkel MA: „I can tell you, because you’re a doctor“ Commentary. Pediatrics 2008; 122: 422. CrossRef MEDLINE
e14.Palusci VJ, Cox EO, Shatz EM, Schultze JM: Urgent medical assessment after child sexual abuse. Child Abuse Negl 2006; 30: 367–80.
e15.Finkel MA: Medical aspects of prepubertal sexual abuse. In: Reece RM, Christian CW (eds.): Child abuse: Medical diagnosis and management. 3rd edition American Academy of Pediatrics, Elk Grove Village 2009; 269–320.
e16. Adams J, Girardin B, Faugno D: Adolescent sexual assault: documentation of acute injuries using photo-colposcopy. J Pediatr Adolesc Gynecol 2001; 14: 175. MEDLINE
e17.Berenson AB: A longitudinal study of hymenal morphology in the first 3 years of life. Pediatrics 1995; 95: 490–6. MEDLINE
e18.Berenson AB: Normal anogenital anatomy. Child Abuse Negl 1998; 22: 589–96. CrossRef MEDLINE
e19.Berenson AB, Heger A, Andrews S: Appearance of the hymen in newborns. Pediatrics 1991; 87: 458–65. MEDLINE
e20.Berenson AB, Grady JJ: A longitudinal study of hymenal development from 3 to 9 years of age. J Pediatr 2002; 140: 600–7. CrossRef MEDLINE
e21.Berenson AB, Heger A, Haynes JM, Bailey RK, Emans SJ: Appearance of the hymen in prepubertal girls. Pediatrics 1992; 89: 387–94. MEDLINE
e22.Berenson AB, Somma-Garcia A, Barnett S: Perianal findings in infants 18 months of age or younger. Pediatrics 1993; 91: 838–40. MEDLINE
e23.McCann J, Wells R, Simon M, Voris J: Genital findings in prepubertal girls selected for nonabuse: a descriptive study. Pediatrics 1990; 86: 428–39. MEDLINE
e24.Myhre AK, Berntzen K, Bratlid D: Genital anatomy in non-abused preschool girls. Acta Paedriatr 2003; 92: 1453–62. CrossRef MEDLINE
e25.Csorba R, Lampé R, Póka R: Surgical repair of blunt force penetrating anogenital trauma in an 18-month-old sexually abused girl: a case report. Eur J Obstet Gynecol Reprod Biol 2010; 153: 231. CrossRef MEDLINE
e26.Herrmann B: Übersetzte und kommentierte Adams Klassifikation 2008–2011. Info KiM (Zeitschrift der AG Kinderschutz in der Medizin) 2014; 4: 2–4.
e27.Kadish HA, Schunk JE, Britton H: Pediatric male rectal and genital trauma: Accidental and nonaccidental injuries. Pediatr Emerg Care 1998; 14: 35–98. MEDLINE
e28.Hobbs CJ, Osman J: Genital injuries in boys and abuse. Arch Dis Child 2007; 92: 328–31. CrossRef MEDLINE PubMed Central
e29.Girardet Lemme S, Biasona TA, Boltona K, Lahoti S: HIV post-exposure prophylaxis in children and adolescents presenting for reported sexual assault. Child Abuse Negl 2009; 33: 173–8. CrossRef MEDLINE
e30.Bechtel K: Sexual abuse and sexually transmitted infections in children and adolescents. Curr Opin Pediatr 2010; 22: 94–9. CrossRef MEDLINE
e31.Hammerschlag MR: Sexual assault and abuse of children. Clin Infect Dis 2011; 53: 103–9. CrossRef MEDLINE
e32.Hammerschlag MR, Guillén CD: Medical and legal implications of testing for sexually transmitted infections in children. Clin Microbiol Rev 2010; 23: 493–506. CrossRef MEDLINE PubMed Central
e33.Unger ER, Fajman NN, Maloney EM, et al.: Anogenital human papillomavirus in sexually abused and nonabused children: a multicenter study. Pediatrics 2011; 128: e658. MEDLINE
e34.Clarke J: How did she get these warts? Anogenital warts and sexual abuse. Child Abuse Rev 1998; 7: 206–11. CrossRef
e35.Herrmann B, Crawford J: Genital injuries in prepubertal girls from inline skating accidents. Pediatrics 2002; 110: e16. pediatrics.org/cgi/content/full/110/2/e16 (last accessed on 15 January 2014). MEDLINE
e36.Herrmann B, Veit S, Neises M: Lichen sclerosus et atrophicus. Wichtige Differentialdiagnose zu sexuellem Mißbrauch von Kindern. Pädiat Prax 1998; 55: 319–24.
e37.Young KL, Jones JG, Worthington T, Simpson P, Casey PH: Forensic laboratory evidence in sexually abused children and adolescdents. Arch Pediatr Adolesc Med 2006; 160: 585–8. CrossRef MEDLINE
e38.Bode-Jänisch S, Voigt S, Günther D, Debertin AS: Klinisch-forensische Untersuchungsergebnisse und rechtliche Folgen bei sexuellem Kindesmissbrauch. Arch Krim 2011; 228: 20–38. MEDLINE
e39.Girardet R, Bolton K, Lahoti S, et al.: Collection of forensic evidence from pediatric victims of sexual assault. Pediatrics. 2011; 128: 233–8. CrossRef MEDLINE