Sexual Abuse in the Child and Adolescent
M. Ranee Leder
S. Jean Emans
In 2009, there were an estimated 67,000 substantiated cases of sexual abuse (1). Adolescents have the highest rates of sexual assault of any age group. In a nationwide survey of approximately 14,000 9th to 12th graders, 11.3% of girls and 4.5% of boys reported having been physically forced to have sexual intercourse when they did not want to (2). In 2008, the National Crime Victimization Survey reported 164,240 rapes and sexual assaults in females age 12 years or older and 39,590 rapes and sexual assaults in males age 12 years or older (3). Approximately 19% of adolescents have been solicited for sex by strangers through the Internet (4). The percentage of adult women disclosing histories of sexual abuse ranged from 30% to 40%, and was 13% of adult men in one analysis (5). The health care provider may be involved in the diagnosis of sexual abuse or sexual assault; determination of the need to report suspected abuse; assessment of the physical, psychological, and behavioral consequences of abuse; and coordination of treatment and follow-up with professionals of multiple disciplines.
Sexual abuse is generally defined as the involvement of developmentally immature children or adolescents in sexual activities that they do not fully comprehend, to which they are unable to give informed consent, or that violate societal taboos. Sexual abuse may include exhibitionism, fondling, genital viewing, production of pornography, oral–genital contact, insertion of objects, or vaginal/anal penetration. The contact may be a single event between the child and a stranger occurring with or without the use of force, or it may be a long-standing sexualized relationship with a parent, stepparent, or other known individual involving repeated encounters over months to years. In the “grooming” process, which perpetrators often use with victims, the sexual interaction may start with fondling and progress over the course of months to vulvar coitus and penetration.
Sexual assault is defined as any sexual act performed by one person on another without that person’s consent. The use or threat of force may be involved, or the person may not be able to give consent because of age, mental or physical capacity, or impairment with drugs or alcohol. Definitions of sexual abuse and assault may overlap. The age of consent for sexual contact varies by state. Reporting requirements to child protective agencies, law enforcement, and parents are also variable. Medical providers should be familiar with the laws of their state (6).
Reported cases of sexual abuse are believed to represent a small percentage of actual events. Clinicians should ask questions that would reveal the possibility of sexual abuse, especially in children and adolescents with somatic complaints or behavioral changes such as regression, nightmares, running away, school failure, or pregnancy. Girls with vaginal bleeding, foreign bodies in the vagina, condylomata acuminata, genital herpes, Trichomonas vaginalis or Chlamydia trachomatis infection, or gonococcal vulvovaginitis need an especially careful history for sexual abuse, which is often best obtained without the parents present.
Questions about unwanted or forced sexual contact should be part of health supervision. For adolescents, these questions can be included in the menstrual and sexual history: “Have you ever been touched in your private parts or sexually when you did not want to be touched?” “Have you ever been forced to have sex?” (see also Chapters 1 and 2). Acknowledging that some youngsters are embarrassed or unable to tell another person can relieve anxiety. Younger children with unexplained somatic symptoms or any evidence of genital infection, pain, or bleeding can be asked: “Has an adult or someone you know ever touched your vaginal area or your private parts?” “If you were ever touched, whom would you tell?” If a child can mention her parent or other trusted adult without hesitation, clinicians can feel at least some reassurance that lines of communication are available.
The recognition of sexual abuse is frequently prompted by a child’s disclosure to a parent, friend, teacher, or health professional. The disclosure may be intentional or accidental. For example, a child may have told a peer about abuse, and the peer may subsequently tell her own parent, who reports the case. The child usually does not anticipate the consequences of the allegation. Disclosure of abuse may be a gradual process with the child giving a few details initially in order to determine the degree of support from those around her. It is not unusual for a child to be pressured by family members to recant a disclosure, particularly in the case of incest.
Because clinicians frequently feel uncomfortable about making the diagnosis of sexual abuse, even obvious problems are sometimes overlooked (7). Most children who disclose sexual abuse are telling the truth, and it is highly unlikely for a child to make up the concrete details of sexual involvement unless a sexually stimulating experience has occurred. Even if one encounters the rare circumstance in which a child has not had the sexual experience alleged, most likely something sexually stimulating such as exposure to pornography occurred that is unhealthy for the child’s development. The development of child advocacy centers (CACs), which use multidisciplinary teams composed of forensic interviewers, mental health professionals, members of child protective services, law enforcement staff, legal advocates, and child abuse pediatricians, are extremely helpful in sorting out the complex issues involved in sexual abuse cases. The goals of most CACs include decreasing the number of interviews for the child, identifying the perpetrator, referring the patient and family for mental health treatment, and assisting with legal questions.
Patterns of Sexual Abuse
It is important for clinicians to be aware of the patterns of sexual abuse. Most sexual abuse perpetrators are known to the victim. These individuals are a heterogeneous group. The majority of these are male. Juveniles make up about 15% of arrests for
sex-related crimes. The term pedophile is classified under paraphilias in the Diagnostic and Statistical Manual of Mental Health Disorders, fourth edition, text revision (DSM-IV-TR). It is characterized by more than 6 months of recurrent, intense, sexual fantasies, urges, or behaviors with children, and acting on these urges or marked distress or interpersonal difficulty in an individual at least 16 years of age and at least 5 years older than the child; it does not include older adolescents involved in a sexual relationship with a younger adolescent (8). Within these criteria are several subtypes of pedophiles including those who are sexually attracted to males, to females, or to both; those who perpetrate abuse limited to incest; an exclusive type (those attracted only to children); and a nonexclusive type (those attracted to both children and adults). A study of pedophiles as compared to a control group of nonoffenders found that pedophiles were more likely to have a history of childhood abuse, particularly physical abuse, and were more likely to have insecure attachments in relationships (9).
sex-related crimes. The term pedophile is classified under paraphilias in the Diagnostic and Statistical Manual of Mental Health Disorders, fourth edition, text revision (DSM-IV-TR). It is characterized by more than 6 months of recurrent, intense, sexual fantasies, urges, or behaviors with children, and acting on these urges or marked distress or interpersonal difficulty in an individual at least 16 years of age and at least 5 years older than the child; it does not include older adolescents involved in a sexual relationship with a younger adolescent (8). Within these criteria are several subtypes of pedophiles including those who are sexually attracted to males, to females, or to both; those who perpetrate abuse limited to incest; an exclusive type (those attracted only to children); and a nonexclusive type (those attracted to both children and adults). A study of pedophiles as compared to a control group of nonoffenders found that pedophiles were more likely to have a history of childhood abuse, particularly physical abuse, and were more likely to have insecure attachments in relationships (9).
Sexual offender is a legal term used to describe anyone convicted of a sex crime. Some sex offenders are adolescents. A small percentage of juvenile offenders continue to offend as adults and most of these are non–sex-related crimes (10). A review of 17 studies from 1995 to 2005 looking at juvenile sex offenders as compared to non-sex offenders found few consistent differences between the groups because of methodologic issues and because they are a heterogeneous group (11). This analysis found that juvenile sex offenders were more likely to have been sexually abused than non-sex offenders.
In its broadest definition, incest means a sexual relationship between people who are related and cannot legally marry. It generally refers to relationships between members of the immediate nuclear family, such as between father and daughter, mother and son, father and son, mother and daughter, or siblings. Although sexual involvement between a stepparent and child is not traditional incest, it has many of the same psychodynamics and problems for treatment as do other forms of incest. A sexual relationship between a stepparent and child or between a parent’s partner and child is sometimes called functional parent incest. In parental incest, there is some form of major family dysfunction. Isolation and depression are frequently present. The child learns to adapt to the sexual expectations of the relationship. The nonoffending parent may be involved in conscious or unconscious complicity.
Incestuous relationships may start in the early childhood years and continue through adolescence. Often, the child feels the threat of family disruption if she were to tell the secret. A crisis may occur if there is sudden disclosure of the situation when the child is in late puberty or adolescence; the youngster may begin to feel that her involvement is no longer age appropriate and may wish to have more meaningful relationships with her peer group. The secret may remain within the family for years, and it may be disclosed only when a young adult is in psychotherapy. Clearly, incest occurs in all socioeconomic groups.
Patient Assessment
Due to the potential legal implications, medical data should be carefully collected and recorded in all cases of sexual abuse (12,13). The purpose of the evaluation is to document what has happened, perform the medical evaluation, collect forensic evidence if indicated, and provide patients with medical and psychological follow-up. Clinicians should avoid trying to decide whether sexual abuse actually occurred or whether there is sufficient evidence for a verdict.
The timing of the physical examination depends on the history. Any child who has anogenital symptoms such as pain, bleeding, discharge, ecchymosis, laceration, or other injury, who reports sexual contact within the past 72 hours, or who may not be safe should be seen immediately for an assessment. Physical findings that may corroborate a sexual assault must be documented. Since children often have difficulty disclosing a full history of the nature of the abuse, a complete physical examination is always indicated. Referral to a child advocacy center that specializes in the multidisciplinary assessment of child sexual abuse may be indicated if available. If such a referral is not possible, a standard protocol is available in most emergency departments. It is essential that forensic evidence be passed directly to a police officer to maintain a legal “chain of evidence” and that physical findings are adequately documented (14).
Patients who were abused weeks to months before seeking help should be interviewed and examined as soon as is practical provided that they are safe. Medical providers who evaluate and treat victims of sexual abuse and assault, particularly adolescents, should be aware while most positive semen and DNA tests occur in girls evaluated at <24 hours and the recommended cut-off for forensic testing has been 72 hours, DNA amplification technology (used to identify assailants) may occasionally yield positive results beyond 72 hours, usually from non-body sources such as clothes, sheets, etc., particularly in prepubertal patients (14,15,16,17,18,19,20).
Sexually Transmitted Infections and Sexual Assault
Parents and health care providers often ask about the risk of acquiring a sexually transmitted infection (STI) as the result of sexual abuse. Factors that influence the likelihood of STI acquisition after sexual assault include the prevalence of STIs in the adult population of the particular region, number of assailants, type and frequency of physical contact, infectivity of the microorganisms, patient susceptibility to infection, and intercurrent antimicrobial treatment. The timing between the assault and the medical examination also influences the likelihood that the patient will exhibit signs or symptoms of an STI. The implications of commonly encountered STIs from the 2005 American Academy of Pediatrics statement are shown in Table 30-1.
The Committee on Infectious Diseases of the American Academy of Pediatrics reports that approximately 5% of patients acquire an STI as the result of sexual abuse (21). In a recent multicenter study of 485 girls ages 0 to 13 years evaluated for sexual abuse, 8.2% were diagnosed with at least one STI (22). Adolescent assault victims who come to medical attention in hospital settings may have a preexisting STI from consensual sexual activity. However, not all infections noted at baseline are necessarily preexisting infections since it is possible that the very sensitive screening tests now used can be positive as a result of exposure to infected secretions from the assailant (23).
The risk of acquiring Neisseria gonorrhoeae after sexual assault has been estimated to be 6% to 12% (24). In sexually abused children, a positive culture for gonorrhea has been reported in 3% to 7% (22,25). Gonorrhea infection in prepubertal girls
is almost always associated with vaginitis at presentation or by history (21).
is almost always associated with vaginitis at presentation or by history (21).
Table 30-1 Implications of the Diagnosis of Sexually Transmitted Infections (STIs) for the Reporting of Sexual Abuse of Infants and Prepubertal Children | ||||||||||||||||||||||||||||||
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The risk of acquiring chlamydial infection has been estimated to be 3% to 17% (24). C. trachomatis has been reported in <5% prepubertal girls (22,26). C. trachomatis may persist after birth for a number of months. Rectal or genital chlamydial infection in young children may be the result of perinatally acquired infection; and perinatal infection has persisted for 2 to 3 years in some cases (27). Because many children will have been treated with macrolide antibiotics to which the organism is sensitive, the issue of persistence in older children becomes less likely, and the potential for sexual transmission as the source of infection becomes much greater.
The risk of acquiring syphilis appears to be low and is estimated at 0.3% to 3% (22,24), although in patients with other STIs the risk is increased. A serologic test for syphilis can be done initially and then 6 weeks, 3 months, and 6 months after the assault if prophylactic antibiotics are not administered (28). Because of the low risk of acquiring this infection, many centers do selective testing.
Bacterial vaginosis and Trichomonas vaginalis infection have been found in 5% to 42% and 6% to 20%, respectively, of postpubertal assault victims (22,23). Data on prepubertal girls are sparse. Bacterial vaginosis has been noted at follow-up in children with a history of acute vaginal assault. Conflicting studies have provided data on the prevalence of Gardnerella vaginalis in prepubertal girls (see Chapter 4). The presence of bacterial vaginosis alone in children does not prove sexual abuse (12). Trichomonas is the second most common sexually transmitted infection in the United States and commonly coexists with gonorrhea and chlamydia infections and bacterial vaginosis (21). T. vaginalis must be distinguished from the four other nonpathogenic species of Trichomonas: T. tenax, which is normal oral flora; and T. faecalis, T. ardin delteili, and T. hominis, which are all normal fecal flora. T. vaginalis can be transmitted at the time of birth and cause vaginitis and nasal discharge in the newborn period, but the organism usually disappears spontaneously with waning estrogen effects on the vaginal mucosa or with treatment. The presence of T. vaginalis in a prepubertal child should raise suspicion of sexual abuse (21).
Herpes simplex virus (HSV) infections are common and can be acquired from individuals who are symptomatic or asymptomatic with primary or recurrent infections (21). Positive cultures have been reported in 2% of adolescents at the initial visit for sexual assault and none at follow-up (29). Studies in children have noted that genital herpes can be acquired through self-inoculation from oral–genital contact (HSV type 1 gingivostomatitis occurring simultaneously with genital lesions), but sexual abuse is the usual etiology of genital HSV type 1 or type 2.
Anogenital HPV is the most common STI in the United States. Most infections are transient, are subclinical, and clear spontaneously (21). The risk of acquiring HPV from sexual abuse is unknown, but adolescents with a single rape episode have been observed to develop cervical dysplasia associated with HPV infection (30). Condylomata have been reported in 12% of abused children (26). A study of forty 5- to 12-year-old girls found that genital HPV infection is more common among abused that nonabused girls (31). HPV can be acquired perinatally or nonsexually vertically (i.e., from hand to genitalia during caregiving activities); however, data on the risk of transmission are limited. The period of latency for the development of clinically apparent warts from perinatal transmission has not been definitively determined, but in one study clinically apparent warts were not seen beyond age 2 years (32). Many sexual abuse experts use age 3 or 4 years as the cutoff for perinatal HPV infection, but additional research is needed to determine the exact latency period for perinatal HPV infection. Genital warts have been diagnosed in children who have been sexually abused but also in children who have no other evidence of sexual abuse. The American Academy of Pediatrics considers anogenital warts suspicious for sexual abuse if they are not likely to be perinatally acquired and if rare nonsexual vertical transmission is excluded (12).
Hepatitis B is caused by infection with hepatitis B virus (HBV). The time from exposure to onset of symptoms ranges from 6 weeks to 6 months. HBV is transmitted percutaneously or by mucous membrane exposure to infected body fluids. Among
adults, sexual transmission accounts for most HBV infection in the United States. The frequency of HBV infection following sexual abuse or rape has not been determined. Fully vaccinated individuals do not need further doses of HBV vaccine. Unvaccinated victims of sexual assault should receive the HBV vaccine series (see Centers for Disease Control and Prevention [CDC] recommendations for regimens). If the perpetrator is known to have acute hepatitis B, then hepatitis B immune globulin (HBIG) should also be administered.
adults, sexual transmission accounts for most HBV infection in the United States. The frequency of HBV infection following sexual abuse or rape has not been determined. Fully vaccinated individuals do not need further doses of HBV vaccine. Unvaccinated victims of sexual assault should receive the HBV vaccine series (see Centers for Disease Control and Prevention [CDC] recommendations for regimens). If the perpetrator is known to have acute hepatitis B, then hepatitis B immune globulin (HBIG) should also be administered.
HIV seroconversion has occurred in persons whose only known risk factor was sexual abuse, although the frequency of this is likely low. The estimated probability of HIV transmission associated with unprotected vaginal intercourse is 0.1% to 0.2%, and for receptive anal intercourse, 0.5% to 3% (28,33). Patients who have been sexually abused and who have had exposure to semen through oral, genital, or anal sex acts are at increased risk of acquiring HIV. The possibility of HIV exposure from the assault should be assessed at the postassault examination. Determination of the perpetrator’s HIV status is usually impossible. When the perpetrator’s HIV status is unknown, factors that indicate increased risk for HIV transmission include vaginal or anal penetration, ejaculation on the mucous membranes, multiple perpetrators, a perpetrator who is a man who has sex with other men or has a history of injected drug/crack cocaine use, and mucosal trauma to either the patient or the perpetrator (28). When attempting to estimate risk of acquiring HIV from a sexual assault, clinicians should also review HIV epidemiology in their local area. If the patient appears to be at risk for HIV transmission from the assault, postexposure prophylaxis (PEP) should be discussed with the patient and/or caregiver (see Chapter 19). If PEP is considered in a child, consultation with a specialist should be considered. PEP should be started as soon as possible within 72 hours of the sexual assault (see CDC recommendations for regimens) (34). If PEP is prescribed for the patient, provide enough medication to last until a return visit with a specialist in 3 to 7 days (35,36). At that time, the patient should be reevaluated and tolerance for the medication should be assessed. If PEP is started, perform a complete blood count (CBC) and serum chemistry at baseline. HIV antibody testing should be performed at the initial assessment and at 6 weeks, 3 months, and 6 months.
Although recognizing constraints within the legal system, the importance of testing the perpetrator to avoid venipuncture in the child has been suggested (37,38,39). Not only are prospective studies of HIV risk in sexually abused children needed, but also clinicians must remain vigilant in exploring the possibility of sexual abuse in any child who tests positive for HIV and in maintaining surveillance of other children in the households of index cases of HIV infection.
Selective criteria have been suggested in order to limit unnecessary STI testing in prepubertal patients given the low prevalence of disease in this population (40). Factors such as genital discharge or history of discharge, urinary symptoms, genital itching or odor, contact with a person thought to have an STI or at high risk of STI, presence of suspicious anogenital findings, a sibling or another child in the household with an STI, and disclosure of genital–genital or anal–genital contact (including penetration or ejaculation) are associated with increased risk of acquiring either gonorrhea and/or chlamydia. Most but not all prepubertal sexual abuse patients with positive cultures for gonorrhea have vaginal discharge or a history of discharge (22,41,42). The CDC recommendations for considering testing are outlined in Table 30-2. In contrast to selective testing of prepubertal girls, it has been suggested that all pubertal girls be tested because of the high prevalence of STIs in the adolescent population.
Table 30-2 Recommendations for Testing Prepubertal Girls for Sexually Transmitted Infections (STIs) | ||||
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The CDC recommends specimen collection for N. gonorrhoeae culture from the pharynx, vagina, and anus in prepubertal girls. All presumptive isolates should be confirmed by a test that involve different principles (such as biochemical, enzyme substrate, serologic, or nucleic acid hybridization test methods) and isolates should be preserved to allow for further testing (28). Although N. gonorrhoeae culture from the vagina in prepubertal girls has been the standard, the CDC now states that NAATs can be used as an alternative to culture with vaginal specimens or urine from prepubertal girls. In consultation with an expert to minimize the possibility of cross reaction with nongonococcal Neisseria species and other commensals. If a NAAT is used for testing urine or a vaginal specimen from a prepubertal girl for N. gonorrhoeae, positive specimens should be retained for additional testing.
Cultures for Chlamydia have a low sensitivity, and the use of NAATs on urine or vaginal samples of the prepubertal girl has been important in detecting more cases of chlamydia infection (43,44,45,46). The CDC recommends that NAATs be used for detection of C. trachomatis in vaginal specimens or urine from prepubertal girls. Positive NAATs in prepubertal girls should be retained for additional testing if necessary (28) which may include confirmation with a second NAAT (47). In adolescents and adults, NAATs are routinely used for vaginal, cervical and urine testing.
If STI screening is obtained, the recommended laboratory tests are given in Table 30-2. Vaginal secretions are examined with wet mount for T. vaginalis and clue cells. A sample can be sent for T. vaginalis culture if indicated by clinical circumstances or by wet mount. NAATs have been developed for T. vaginalis but have not been tested in the sexually abused population. Lesions suggestive of HSV infection should be swabbed for viral culture and/or polymerase chain reaction (PCR).
Forensic Evidence Collection
The American Academy of Pediatrics recommends forensic evidence collection (completion of a rape evidence kit) when sexual abuse has occurred within 72 hours or when there is bleeding or acute injury (12). Evidence collection may include swabs from the genital, anal, and oral areas as well as from areas of stained skin. Swabs are tested for blood, sperm, and chemical evidence of semen in an attempt to identify the perpetrator of a sexual assault. Hair and blood standards as well as clothing and foreign debris may also be collected. These items are labeled and sealed in a designated container and sent to the appropriate state crime laboratory with documentation of the individuals who handled the kit in order to maintain a “chain of evidence.”
Several tests are available for identifying the presence of semen in assault victims. The methods used vary around the country. Acid phosphatase tests may be negative during the first 3 hours; the test is positive in about 50% of vaginal swabs at 12 hours and can be positive for up to 48 hours (48,49,50,51). Acid phosphatase may give false-positive results, and thus the test is presumptive, not diagnostic, evidence of semen. The semen protein antigen p30 of prostatic origin is found in the semen of normal and vasectomized men, but not in body fluids of women, and is thus more sensitive and specific than acid phosphatase (50). p30 is undetectable in the vagina by 48 hours after intercourse. A monoclonal antibody (MHS-5) to seminal vesicle–specific protein has been devised for use in an enzyme-linked immunosorbent assay (ELISA). This assay is highly sensitive and specific for seminal fluid (49) and can be detected in dry semen stains at room temperature for up to 6 months.
Blood group antigens can also be evaluated by many forensic laboratories. DNA mapping of semen, blood, and other biologic material is now commonly used in forensic medicine. DNA typing is potentially the most useful form of forensic evidence due to the high specificity and biochemical stability of DNA, making possible the analysis of extremely small samples. DNA evidence can exonerate a person who is falsely accused and can provide courts with a more precise estimation of the odds for a particular perpetrator (49,52). A specific type of DNA analysis, Y-short tandem repeat (Y-STR) analysis, may be used in the detection of male DNA in evidentiary samples collected from sexual abuse victims. The presence of male DNA in the genitalia of a child victim who has no previous sexual history is a clear indication of sexual contact (20).
Data vary on the length of time that motile and nonmotile sperm may be found in the vagina or cervical mucus. One study (48) found that in adults with voluntary intercourse only 50% of the specimens examined had motile sperm 3 hours later, whereas at 72 hours nonmotile sperm could be detected on a fixed preparation in nearly 50%. All specimens contained whole sperm up to 18 hours after intercourse and sperm heads up to 24 hours. A previous study (51) found motile sperm in 31.7% of the victims within 6 hours of the alleged sexual assault and in 18% of those examined 7 to 24 hours after the incident. However, the latter group contained three patients in whom the sperm were detected in cervical mucus, where sperm may remain motile longer (up to 2 to 5 days). Nonmotile sperm may be present in the vagina for 3 to 5 days and in the endocervical canal for up to 17 days (15,53). It should be remembered that the absence of sperm is not evidence against a sexual assault. Up to 50% of specimens obtained from victims of acute rape may have no motile sperm either because the offender has had a vasectomy, has a sexual dysfunction, or has oligospermia or because detection techniques are insensitive (54).
Despite the history of using Wood lamps for the detection of semen, Santucci and colleagues (55) have shown that the four models they tested did not cause semen to fluoresce and other substances such as creams and ointments fluoresced nonspecifically. An alternate light source, Bluemaxx BM 500 (Sirche Finger Print Laboratories, Raleigh, NC), has the correct wavelength for semen fluorescence and can aid trained clinicians in detection of evidence. However, for forensic evaluation, swabs of the umbilical area, perineal area, inner thighs, and buttocks should be obtained for definitive confirmatory studies (DNA analysis) regardless of the light source examination.
Selective completion of the sexual assault kit in the child has been advocated, thereby allowing submission of those parts of the evidence collection kit that are pertinent to the history and physical examination. Studies using older tests for detection of sperm and semen suggested that swabbing a prepubertal child’s body for evidence was unnecessary after 24 hours and that clothing and linens (even long after the event) yielded the majority of evidence (17,18,19). However, use of newer DNA analysis techniques may identify the perpetrator in cases in which evidence is present in the anogenital area or on clothing; while most positive DNA tests still occur in the first 24 hours, evidence may be found in the 24–72 hour interval and even after 72 hours, particularly from non-body sources. Therefore, in certain cases, selected parts of the forensic kit may be completed after 72 hours. Further research is needed in order to prospectively determine utility of forensic evidence collection in children and adolescent sexual abuse patients when newer DNA analysis techniques are employed.
Normal and Abnormal Anogenital Findings in Children and Adolescents
The percentage of sexually abused children with a normal examination has been found to be higher than 90%, depending on the case mix, age of patients, definition of normal versus abnormal, and examiners (56,57,58,59,60,61
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