Physical Examination - Child sexual abuse
The preparation and conduct of the physical examination of sexually abused children requires ‘time, patience and a gentle manner…’ [Horowitz, 1987].

Appropriate timing of the examination is the first step. Most examiners agree to perform immediate examinations due to forensic reasons if the alleged contact took place less than 72h ago. The same goes for acute bleeding anogenital injuries. Due to typically delayed disclosure, most examinations are nonemergency.

The issue of sedation or anesthesia for the examination remains controversial. Although some argue in favor because of a reduction of immediate stress, it is not routinely warranted. General anesthesia is usually required in cases of acute bleeding anogenital injuries [Harari and Netzer, 1994; Rogers and Murdoch, 1994; Sury, 1994; Hogan, 1996; Leventhal, 1998].

Anticipating and addressing children’s fears concerning the medical examination are crucial for a successful exam. Younger children rarely have problems with issues of shame. They rather are fearful of painful and unknown procedures. Any form of force or coercion is strictly contraindicated. The child should be given as much choice as possible in the procedure to ensure a sense of control. It is important to explain all steps of the examination in an age appropriate terminology. The child should be reassured that the purpose of the examination is to check if everything is ‘alright’, that it is healthy and ‘okay’.

Clinical experience indicates that at least for prepubertal children the style and gentleness of the exam are far more important factors for the emotional impact than the gender of the examiner [Horowitz, 1987; Lazebnik et al., 1994; Leventhal, 1998].

The sense of control may be enhanced by examining a ‘fearful’ doll which expresses all the potential fears which children might have in this situation.

Asking the child to help the doctor examine the doll lets them anticipate their own examination, gain a sense of control and power and actively cope with their own fears by comforting the doll [B. Herrmann, personal observations].

Even for non-pediatricians, a complete head-to-toe examination is mandatory.

It should always precede the anogenital examination in order not to focus on the anogenital area (like the abuser has done). The implicit message is that the whole child is important. It also allows estimating the developmental stage and avoids missing extragenital signs of sexual or physical abuse.

The anogenital examination in cases of suspected sexual abuse of the prepubertal child is principally an external visualization by varying techniques of separation, traction and positioning. It does not require anal or vaginal palpation or the use of specula. In adolescents the use of specula is appropriate but not mandatory. Stirrups may be used in older consenting children, while often increasing unfamiliarity and fear in younger children [Emans, 2000; Horowitz, 1987; Finkel and De Jong, 2001].

The genital examination begins in the most comfortable and least frightening position, the supine position with abducted legs (‘frogleg position’).

Especially younger children may prefer to be examined on the caretaker’s lap. The separation technique of the labia majora allows an overview over the external genital structures.

The traction technique is the mandatory next step and markedly improves visualization and opening of the hymenal orifice, especially when redundant hymenal tissue is present. In this technique the labia majora are grasped between thumb and index finger exerting slight traction down and outwards. Meanwhile, most examiners agree to routinely include the prone knee-chest position into the examination except in those cases when visualization in the supine position is complete and satisfactory. In cases with unclear or suspicious findings in the supine position, the knee-chest position is invaluable as it markedly improves unfolding of the hymen due to gravity.

The examiner’s hands rest on the buttocks with thumbs pointing inwards and slightly pulling upwards and laterally. The persistence of suspicious findings in the knee-chest position improves their validity. Also the visualization of the inner vagina up to the cervix can be achieved without specula in a significant number of cases. Children who have experienced anal penetration may feel uncomfortable and frightened in this position. The response and affect of the child have to be carefully monitored when requesting this position [Finkel and De Jong, 2001].

The inspection of the anus is mandatory and can be performed in the prone knee-chest position or in the left lateral decubitus position. The latter is preferable in boys who tend to be abused anally [Horowitz, 1987; McCann et al., 1990a; Emans, 2000].

Pubertal children are preferably examined in the lithotomy position.
Visualization of the redundant pubertal hymen can be difficult. Running behind the inner aspect of the membrane circumferentially with a moistened cotton swab can help to identify traumatic changes of the hymenal rim.

Explaining each step of the examination and talking with the child throughout the examination on non-abuse-related issues, or motivating the child to tell a story, allows the child to relax. This enhances cooperation and improves visualization by less muscular tension to the genital tissues [McCann et al., 1990a]. Generally, all visualization and photo documentation should be done before taking swabs. The unestrogenized prepubertal hymen is very sensitive. In cases when screening for sexually transmitted diseases is indicated, the use of small urethral swabs which are moistened with sterile saline helps to avoid a potentially painful contact with the hymen. Large cotton swabs should be avoided in prepubertal children. Alternatively a small urethral catheter can be used to irrigate the posterior portion of the vagina with a small amount of saline which then is aspirated again for further processing.

The colposcope is nowadays frequently used for the external visualization of the anogenital area of possibly abused children and adolescents. Mostly equipped with a 35-mm camera or a video system it enhances visualization by incorporating a powerful lighting source, fixed or variable magnification and the possibility of accurate documentation.

Photo or video documentation of all abnormal findings allow preservation of visual evidence, later detailed reviewing and discussion of findings and a second opinion or peer review. It also lays the foundation of any research and is an excellent tool for education of students, residents and colleagues. Documented visual evidence may be presented in court and may help to avoid potential further emotional trauma by repeated examinations. Although colposcopy improves the incidence of positive findings only slightly and the unaided examination is sufficient in most cases, it has become a valuable tool in the evaluation of possibly abused children [Teixeira, 1981; Muram and Elias, 1989; Muram et al., 1999; Adams et al., 1990; McCann, 1993; Finkel, 1998].