Key point to remember in evaluating children and adolescents
who may have been sexually abused:
As many as 85-95% of children who give a clear history of sexual abuse may have normal or nonspecific physical examinations, due to healing of trauma or acts that do not result in trauma.
Class 1 Normal or Unrelated to Abuse
Found in newborns:
|Class 1 Normal or Unrelated to Abuse
Tag at 6 oclock from redundant perineal raphe
Thickening of perineal raphe
Blue tint from underlying veins
Perianal skin tag
Increased perianal skin pigmentation
Anal dilation with stool present
Venous congestion, or venous pooling, in perianal tissues (vi)
|Class 1 Normal or Unrelated to Abuse
Circle of brown pigment around shaft of penis from healed circumcision
Raised, dark line along penis/scrotum (median raphe)
|Class 1 Not related to abuse:
Urinary tract infections
Vaginitis caused by enteric or respiratory organisms
Gardnerella vaginalis cultured from vagina, in the absence of any other signs of bacterial vaginosis
Also, conditions such as urethral prolapse, lichen sclerosis, genital hemangiomas, Crohns Disease, and Bechets Disease may be mistaken for abuse.
Class 2 Nonspecific
Class 2 Nonspecific
|Class 2 Nonspecific
Erythema of penis, lower abdomen or inner thighs
Edema of penis/scrotum
(These may result from self-manipulation, poor hygiene, contact irritation/inflammation, or infection)
Superficial abrasions on the penis/scrotum
Warty lesions or vesicular lesions on the penis/scrotum
|Class 2 Nonspecific: May be transmitted by
sexual or nonsexual means:
Herpes type I or II in a child who requires caretaker assistance with toileting or hygiene, or who may have self-innoculated from an oral lesion
Bacterial vaginosis in a child or adolescent
Any STD (including HPV or genital wards) in an infant who may have acquired it perinatally (vii)
Class 3 Concerning for Abuse
Class 3 Concerning for Abuse
|Class 3 Concerning for Abuse
Acute trauma - suspect physical or sexual abuse:
Banding of penis with childs hair or other objects (this may be accidental in infants, from hair of a caretaker)
Bite or pinch marks on penis, scrotum, or inner thighs near genitalia
Sucker/hickey marks on inner thighs near genitalia
|Class 3 Concerning for Abuse: Sexual transmission
is likely cause of infection:
Herpes type I or II lesions in the genital area in a child who has no oral lesions and requires no assistance with toileting or hygiene
Trichomonas infection diagnosed by wet mount preparation or culture of vaginal secretions
HPV infection in a child in whom perinatal transmission is considered unlikely (vii)
|Class 4 Clear evidence of blunt force or penetrating
trauma to or beyond the hymen:
Findings that can have no explanation other than trauma to the hymen or vaginal tissues.
Partial or complete tear of the hymen
Ecchymosis (bruising) on the hymen
Hymenal transection (healed), defined as an area where the hymen has been torn through, to the base, so there is no hymenal tissue remaining between the vaginal wall and the fossa or vestibular wall.(viii) This finding has also been referred to as a complete cleft in adolescent and young adult women.(x)
Wide areas in the posterior (inferior) half of the hymenal rim with an absence of hymenal tissue, extending to the base of the hymen, which is confirmed using additional examination technique (swab, Foley catheter, prone knee-chest position).
Class 4 Clear evidence penetration beyond the anal sphincter:
Perianal lacerations extending deep to the external anal sphincter (ix)
|Class 4 Clear Evidence: Sexual abuse/contact
Sperm or semen found in or on childs body
Video or photo documentation of child being abused
Confirmed positive genital, anal or pharyngeal cultures for Neisseria gonorrhea
Positive cultures (not rapid antigen tests) from genital or anal area for Chlamydia trachomitis
Positive serology for syphilis or HIV, if perinatal or blood transmission has been ruled out (vii)
This table was developed from multiple sources, including published classification scales authored by David Muram, MD and Joyce Adams, MD. Penis and scrotum classification and other by Charles Johnson, MD.
Muram D. Classification of genital findings in prepubertal girls who are victims of sexual abuse. Adolesc Pediatr Gynecol 1988; 1:151.
Adams JA. Evolution of a classification scale: Medical evaluation of suspected child sexual abuse. Child Maltreatment 2001;6:31-36.
Johnson CF. Is it normal or not? SCAN 2001;13:4-5.
The following factors may influence the intensity and type of reaction a child has to the experience of sexual abuse (although some important issues related to any one childs experience may not be included in this list):
Identity of perpetrator
Childs developmental status, including whether or not the child has any developmental disabilities
History of prior, or concurrent maltreatment, trauma or stress
Relationship with alleged perpetrator
Duration (time span) of the abuse
Circumstances/context of the abuse (i.e. has the child been afraid, embarrassed, etc?)
Type and intensity of abuse or neglect
Family, social and community support
Childs coping strategies, and generality personal characteristics (i.e. temperament)
A childs reactions may involve behaviors that can be observed by other people, or may simply involve the childs innermost thoughts and/or subjective emotional feelings. Some of the reactions to sexual abuse can be similar across age groups, while other reactions may be more common in younger or in older children. In general, it may be difficult to differentiate children who have been sexually abused from children who have experienced other kinds of stressful experiences. It is important to remember that research in the area of child maltreatment suggests that many abused children do not exhibit any obvious reactions to sexual abuse. Therefore, if a child is not exhibiting concerning behaviors, but you have reason to suspect sexual abuse (for instance, if the child has been exposed to a known sexual offender), it is strongly recommended that you consult a professional with expertise in the area of child maltreatment for guidance.
The following list includes general signs and symptoms that may sometimes be observed in sexually abused children. When reviewing this list, it is very important to remember that fears and behavioral difficulties are commonly associated with normal child development. Many of the following are concerning only when behavioral changes are extreme or occur suddenly. If you have concerns, it is often helpful to consult a professional with expertise in this area.
While there is no one symptom which is diagnostic of sexual abuse, with the exception of pregnancy or a sexually transmitted disease in a non-sexually active child or adolescent, the literature indicates that the symptoms most commonly associated with sexual abuse are sexualized behaviors, particularly trying to engage other children in sexual behaviors, and indicators of age-inappropriate sexual knowledge. However, it is extremely important to understand that many children who have been sexually abused do not exhibit sexualized behaviors. It is equally important to understand that children who have never been sexually abused may exhibit sexual behaviors.(4)
Risk Factors for Sexualized Behaviors
As a general comment, it is important to note that there are numerous factors that may be associated with age-inappropriate acting out sexually. The following life circumstances are thought to increase the risk of children engaging in inappropriate sexual behaviors:
Exposure to individuals (adults, adolescents or other children) known to have committed prior sexual offenses
Living in a highly sexualized/over-stimulating atmosphere where personal boundaries are lacking
Exposure to adult/adolescent sexual intimacy
Exposure to sexually explicit materials including printed materials, videotapes, or pornography
Living with needy adults who may turn to children to meet their emotional needs or unmet needs for affection
Function of Sexualized Behaviors
The function of sexualized behaviors varies from child to child. Sexualized behaviors are thought to serve the following functions:
To decrease a childs anxiety, fear or overall distress; to reduce tension or other unpleasant internal sensations
To retaliate or hurt others
To reflect re-experiencing behaviors consistent with reactions often noted in children who have been sexually abused
To elicit an intense reaction from other children or adults
To be motivated by needs of attention or power.
To reflect natural curiosity at times, but be misinterpreted on occasion as deviant
Sometimes sexual behaviors in children may actually be age-appropriate and likely contribute to normal and healthy sexual development. Sometimes children may not understand social expectations, or that the sexualized behaviors are socially unacceptable.
Distinguishing Worrisome from Healthy Sexual
A number of authors have written about sexualized behaviors in children. Friedrich has done considerable research in this area and has begun to identify which sexual behaviors are most likely to occur in boys and girls of different ages.(5) For instance, touching sexual parts (private parts) at home is common for most children and usually not a worrisome behavior.
Toni Cavanaugh Johnson has identified characteristics that can help a parent or adult figure out if a sexual behavior is cause for concern or is simply a normal part of growing up.(6) However, even if you think that a behavior is normal and unrelated to sexual abuse, it is often helpful to discuss the behaviors with a professional who has expertise in this area if you have any concerns.
The following information has been adapted from the work of Toni Cavanaugh Johnson regarding Natural and Healthy Sexual Behaviors exhibited by children. It is her view that sexualized behaviors classified as natural and healthy represent an information gathering process. It is important to note that children engaging in normative sexual behaviors are:
of similar age, size and/or developmental status
engaged in mutual sexual exploration
likely to display a lighthearted emotional expression
limited in time and frequency
balanced by curiosity about other aspects of his/her life
may result in embarrassment when discovered by someone else
ceases (in the presence of adults) when children are instructed to stop engaging in the behaviors
Dr. Johnson has also identified Problematic Sexual Behaviors in children. The list that follows is not exhaustive which means that other characteristics that are not included on the list can also be worrisome. Even worrisome behaviors do not mean that a child has been sexually abused. However, if you are concerned about a childs sexual behavior, it is often a good idea to consult a professional with expertise in this area. The following sexualized behaviors are thought to be problematic:
Sexual behaviors engaged in by children of different ages and/or developmental levels
Sexual behaviors which are significantly different than those of same age peers
Sexual behaviors that progress in frequency, intensity and intrusiveness over time
Sexual behaviors that include animals
Sexual behaviors that are intended to inflict pain or hurt others
Sexual behaviors that have been coerced by other children by the use of force, bribery, manipulation or threats
Sexual behaviors that cause children to react with fear, anxiety, shame or guilt
Sexually abused children may exhibit a range of emotional or behavioral problems as a result of their abuse experience. The type and degree of disturbance varies from child to child ranging from no obvious reaction to very mild reactions to extreme behavior changes. According to one published article, up to 40% of sexually abused children are asymptomatic.(4) This means that no symptoms or concerning behaviors were observed. It is important to note that no single symptom or behavioral profile can distinguish a maltreated child from his/her age-mates who have not been maltreated. Most of the behaviors exhibited by abused or neglected children are often associated with non-abuse related difficulties or other types of trauma experienced by children. Of the behaviors that may be seen in sexually abused children, most are also linked to extreme stress reactions in children and/or general child trauma. That means that a childs behavioral changes can cause concern and be quite alarming because he or she has been sexually abused, but can also be caused by circumstances completely unrelated to child abuse.
The following behaviors are sometimes be seen in sexually children. They are significant when they occur in conjunction with a childs disclosure and/or if the child has been exposed to a known sexual offender. These symptoms and behaviors in and of themselves do not necessarily indicate sexual abuse, but may be indicative of some other problem or trauma.
Sleep distiurbances: night terrors; nightmares; trouble falling asleep; trouble staying asleep or sleeping alone.
Changes in eating habits: compulsive or overeating; loss of appetite
Changes in toileting habits including urinary or bowel accidents
Increased aggression: directed toward self (including suicide attempts) or others
Increased impulsivity and activity
Academic problems: distractibility, concentration problems, lack of focus
Reluctance or refusal to go home or to other environments
Easily startled; seems to be tense quite often; difficulty relaxing and calming down
Unexplained fears of, or avoidance of, specific individuals, places, objects or situations
Separation anxieties: clinginess, school refusal
Negative statements about oneself; a negative or pessimistic outlook
Somatic/medical complaints: commonly include gastrointestinal complaints, headaches, pain and general physical malaise
Antisocial acts, such as hurting animals, setting fires and stealing
Running away from home
Daydreaming and fantasizing
Negative thoughts about oneself, related to low self-esteem, guilt embarrassment and self-blame
Pessimism regarding the future and/or a difficulty imagining oneself in the future
Some emotional reactions can be associated with the behavioral and cognitive reactions described above, as well as physiological changes that are more difficult to observe (e.g., increased heart rate). Children who have been sexually abused or otherwise exposed to extreme stress are often described as anxious, depressed, or as labile (having unusually strong mood swings) and they may have difficulty calming down or soothing themselves when they are upset. They can also appear to be very needy of adult attention, fearful of inciting adult displeasure, and/or unusually suspicious or fearful in situations that might not cause discomfort in others.
(1) Massachusetts Department of Social Services. Investigation Training: Evidence and Indicators of Maltreatment. March 2002.
(2) U.S. Department of Justice. Portable Guides to Investigating Child Abuse: Child Neglect and Munchausen Syndrome by Proxy. September 1996.
(3) U.S. Department of Justice. Portable Guides to Investigating Child Abuse: Recognizing When a Childs Injury or Illness is Caused by Abuse. Link is now down. June 1996.
(4) Kendall-Tackett KA, Williams LM, Finklehor D. Impact of sexual abuse on children: a review and synthesis of recent empirical studies. Psychol Bull, 1993; 113:164-80.
(5) Friedrich WN, Fisher J, Broughton D, Houston M, Shafran CR. Normative sexual behavior in children: a contemporary sample. Pediatrics, 1998; 101(4):E9.
(6) Cavanaugh Johnson T. Understanding the sexual behaviors of young children. Siecus Report, August/September.
Table Specific References:
(i) Berenson A, Heger A, Andrews S. Appearance of the hymen in newborns. Pediatrics, 1991; 87:458-465.
(ii) Berenson AB, Heger AH, et al. Appearance of the hymen in prepubertal girls. Pediatrics, 1992; 89:387-394.
(iii) McCann J, Wells R, Simon M, Voris J. Genital findings in prepubertal girls selected for non-abuse: A descriptive study. Pediatrics, 1990; 86:428-439.
(iv) Heger AH, Ticson L, Guerraq L, et al. Appearance of the genitalia in girls selected for nonabuse: Review of hymenal morphology and non-specific findings. J Pediatr Adolesc Gynecol 2002;15:27-35.
(v) 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 Obstet Gynecol, 2000;182:820-834.
(vi) McCann, J, Voris J, Simon M, Wells R. Perianal findings in prepubertal children selected for non-abuse: A descriptive study. Child Abuse & Neglect, 1989; 13:179-193.
(vii) Centers for Disease Control and Prevention (CDC) Guidelines, MMWR, Vol. 51, May 10, 2002. http://www.cdc.gov/std/treatment/rr5106.pdf
(viii) McCann J, Voris J, Simon M. Genital injuries resulting from sexual abuse, A longitudinal study. Pediatrics, 1992; 89:307-317.
(ix) McCann J, Voris J. Perianal injuries resulting from sexual abuse: A longitudinal study. Pediatrics, 1993; 91:390-397.
(x) Emans SJ, Woods ER, Allred EN, Grace E. Hymenal findings in adolescent women: Impact of tampon use and consensual sexual activity. J Pediatr,1994; 125:153-160.
(xi) Berenson AB, Grady JJ. A longitudinal study of hymenal development from 3 to 9 years of age. J Pediatr 2002;140:600-607.
June 27, 2003