Click here to view next page of this article


Sexual Abuse 

Approximately 38% of girls are sexually victimized before age 18 years. The incidence in boys is even higher but less reported than with girls. The scars of unresolved sexual trauma are manifest in physical symptoms sooner or later in life and may be a source of considerable gynecologic resource utilization. Therefore, sexual abuse identification and accessing local resources are mandatory for every child.

Differential Diagnosis of Genital Trauma

A prominent characteristic of genital trauma caused by sexual abuse is a mismatch between the history and physical findings. Whenever the findings are not consistent with the history, it is imperative that appropriate forensic information is collected on the initial physical examination. Prepubescent pubic fat pads are thin and undeveloped, making girls' vulva much more susceptible to molestation.

Such innocent trauma is associated with virtually no damage to the perineum, or "6-o'clock area," between the hymen and rectum.

Sexual abuse shows more findings on the perineum than in the 12-o'clock area . If there is a 6-o'clock transection of the hymen, a full collection of forensic information by means of an examination under general anesthesia is mandatory, even when the presenting history raises no question of sexual abuse. A minor hymeneal tear can hide a vaginal sulcus laceration.

The Forensic Examination Under Anesthesia

With the patient under general anesthesia, the examination begins with a detailed inspection of physical findings before any operative disruption, particularly of the hymeneal ring. Photographic documentation with the medical record number in the picture is mandatory. Vaginoscopy can be performed with a lighted nasal speculum or hysteroscope. Culture samples, using a precise technique (culture plates warmed to body temperature), are obtained for gonorrhea (GC) from the cervix, and separate cultures are taken from the rectum and throat. GC must have an anaerobic environment.

The forensic evaluation preferably is performed using a specifically designed rape kit with specific procedural instructions and materials for collecting samples. Evidence obtained is sealed in the operating room and turned over directly to the appropriate police authority in a documented chain of evidence. Forensic testing, such as DNA analysis of semen.