Sexual Abuse, Exploitation, and Anogenital Findings
Disclosure and grooming
Most sexually abused children never disclose in childhood, and disclosure is often delayed, partial, or recanted. Grooming - special attention, boundary erosion, secrecy - is a key concept. Abuse includes noncontact acts (exposure, photography, online solicitation), contact acts, and exploitation such as child sexual abuse material, sextortion, and trafficking.
Anogenital examination
Most children with confirmed abuse have normal or nonspecific examinations. Findings diagnostic of trauma include acute lacerations, bruising, and hymenal transection or a deep notch in the posterior hymen. Normal variants - hymenal bumps, tags, septa, and notches in the anterior hymen - are common. Reflex anal dilation, anal tone, and 'gaping' are not diagnostic. The estrogenized adolescent hymen differs from the prepubertal hymen. 'Virginity' testing is invalid and unethical.
Evidence and testing
Acute assault: collect forensic evidence within 72 hours (sooner for DNA), document with photographs and diagrams, and offer emergency contraception and STI prophylaxis. Test for gonorrhea, chlamydia, trichomonas, HIV, and syphilis based on risk; perinatally acquired chlamydia and gonorrhea can persist, but gonorrhea beyond the neonatal period strongly suggests abuse. HPV and HSV are not reliable markers.
Traps and rule of thumb
Traps: equating a normal exam with no abuse; interpreting 'absent hymen' as proof; performing repeated exams; or missing exploitation in a child with behavioral change. Use a child advocacy center for forensic interviews.
Rule of thumb: a normal examination never excludes sexual abuse; the history and multidisciplinary assessment carry the diagnosis.