Sexual Abuse in Children: What the General Practice Ob/Gyn N
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Physicians in many fields of practice may be called to evaluate a young child for possible abuse. A child and family may present to the physician due to a concern for abuse raised by the parent, a report of the child’s disclosure of abuse, an unusual examination finding, or an unexpected laboratory result. It is important for any physician who examines children to understand how to approach the medical examination, how to recognize normal variations in genital anatomy, and how to interpret any findings that are revealed during the evaluation.
In cases where the child has not disclosed abuse, the concern may be raised due to the girl’s complaints of genital pain or itching, or if the mother notices vaginal discharge, genital sores or warts or thinks the child’s vaginal opening looks “too big.” There are several conditions that the general practice gynecologist needs to be aware of and recognize when evaluating a young girl for these genital complaints.

In addition to common nonspecific vulvovaginitis, conditions such as lichen sclerosus, aphthous ulcers, bacterial vaginitis, common warts, molluscum contagiosum, genital warts, and genital herpes can also cause symptoms of itching, pain, redness, or bleeding. A close inspection of the external genitalia is important to sort out possible causes of these signs and symptoms.

To visualize the labia majora, labia minora, and contents of the vestibule, 2 techniques can be used with the child in the supine position. First, the examiner gently spreads the labia majora apart, explaining that the doctor needs to take a close look. If the child is very reticent to have her genitalia touched, the child can be asked to use her own hands to spread the labia, with the doctor’s hands on top of her hands to guide the separation. If the vestibule and hymen are not clearly visualized, the examiner may use the labial traction technique. The labia majora are gently grasped with thumb and forefinger and spread slightly apart and pulled toward the examiner. Unless she has bruising or abrasions on the labia, this is not painful for the child.

The prone knee-chest position is very helpful when trying to get a clear look at the hymen or to look inside the vagina without the use of any instrumentation. Asking the child, in the prone position, to lift her bottom up in the air, with tummy towards the table “like a kitty cat” can facilitate positioning for this examination method. The examiner then uses her/his thumbs to lift up the lower portion of the labia majora, allowing a clear view of the hymen and into the vagina. Recognizing the prevalence of sexual abuse, being alert to signs and symptoms that can be associated with abuse, and understanding how to best evaluate young children are important for all health care professionals who care for children and adolescents, even those who do not regularly do so, such as general obstetricians and gynecologists.

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