Guidelines for medical care of children evaluated for suspected sexual abuse: an update for 2008 Joyce A. Adams

Guidelines for medical care of children evaluated for suspected sexual abuse: an update for 2008 Joyce A. Adams Department of Pediatrics, University of California-San Diego, San Diego, California, USA Correspondence to Joyce A. Adams, MD, Professor of Clinical Pediatrics, UCSD Pediatric Associates, 7910 Frost Street, Suite 350, San Diego, CA 92123, USA Tel: +1 858 496 4823; fax: +1 858 496 4851; e-mail: jadams@ucsd.edu Current Opinion in Obstetrics and Gynecology 2008, 20:435 441 Purpose of review Child sexual abuse is a common problem in our society and medical professionals who provide evaluations of children who may have been abused need to be updated as to recent research findings and recommendations for conducting examinations and interpreting results. Recent findings Research studies have provided important new information regarding the qualifications of examiners, the recovery of forensic evidence in children, the frequency of abnormal findings in children and adolescents, the healing of genital injuries, and the interpretation of medical findings and sexually transmissible infections with respect to abuse. Summary The recommendations for the timing and type of examinations for prepubertal children, in contrast to adolescent sexual assault victims, may need to be changed. Studies showing that partial tears of the hymen, as well as abrasions and contusions, may heal to leave very little or no sign of previous injury emphasize the importance of urgent evaluations. There is a need for standardization of the training of medical professionals who perform child sexual abuse evaluations to ensure continuing competence. Keywords child sexual abuse, genital injuries, interpretation of medical findings Curr Opin Obstet Gynecol 20:435 441 ß 2008 Wolters Kluwer Health Lippincott Williams & Wilkins 1040-872X Introduction Physicians with an interest and expertise in the field of child sexual abuse medical evaluation met at conferences and collaborated through the Internet, between 2003 and 2007, to develop and revise recommended guidelines for medical care for children with suspected sexual abuse. These guidelines were published in 2007 [1 ] and included a table listing an approach to the interpretation of medical and laboratory findings in children, which was based on research studies published before 2006 [2 20]. The interpretation table is included here as Table 1. The present article will review research studies and commentaries published in the past 2 years and discuss recommendations for changing the guidelines to reflect new knowledge. Healing of genital trauma Before 2007, there were a limited number of studies looking at the healing of genital and anal injuries in children. These studies [11 13] showed that injuries heal very rapidly, within days or weeks, and usually leave no signs of residual injury such as scars, unless the injuries were severe. McCann et al. [21 ] published the first of three articles reporting the results of a multicenter retrospective study of acute and healing genital trauma in children and adolescents in 2007. The cases for this study were solicited from colleagues by an electronic listserv. The final sample included photographs and case information for 113 prepubertal girls and 126 pubertal girls who had sustained a genital injury and had at least one followup examination. Because of the study design, it was not possible to have photographs taken at defined time periods after the first acute examination. The timing of the follow-up examinations, number and type of photographs, and examination techniques were variable. The photographs collected were reviewed by three team members together, and the authors report that agreement was reached before the findings were classified. There was no external review of the photographs, however, and the method of describing five levels of hymen lacerations (superficial, intermediate, deep, complete, transection, transection with extension) 1040-872X ß 2008 Wolters Kluwer Health Lippincott Williams & Wilkins DOI:10.1097/GCO.0b013e32830866f4

436 Adolescent and pediatric gynecology Table 1 Approach to interpretation of medical findings in suspected child sexual abuse Findings documented in newborns or commonly seen in nonabused children (the presence of these findings generally neither confirms nor discounts a child s clear disclosure of sexual abuse) Normal variants 1. Periurethral or vestibular bands 2. Intravaginal ridges or columns 3. Hymenal bumps or mounds 4. Hymenal tags or septal remnants 5. Linea vestibularis (midline avascular area) 6. Hymenal notch/cleft in the anterior (superior) half of the hymenal rim (prepubertal girls), on or above the 3 o clock to 9 o clock line, patient supine 7. Shallow/superficial notch or cleft in inferior rim of hymen (below 3 o clock to 9 o clock line) 8. External hymenal ridge 9. Congenital variants in appearance of hymen, including: crescentic, annular, redundant, septate cribiform, microperforate, imperforate 10. Diastasis ani (smooth area) 11. Perianal skin tag 12. Hyperpigmentation of the skin of labia minora or perianal tissues in children of color, such as Mexican American and African American children 13. Dilation of the urethral opening with application of labial traction 14. Thickened hymen (may be due to estrogen effect, folded edge of hymen, swelling from infection, or swelling from trauma. The latter is difficult to assess unless follow-up examination is done) Findings commonly caused by other medical conditions 15. Erythema (redness) of the vestibule, penis, scrotum or perianal tissues (may be due to irritants, infection or trauma a ) 16. Increased vascularity ( dilatation of existing blood vessels ) of vestibule and hymen (may be due to local irritants, or normal pattern in the non estrogenized state) 17. Labial adhesion (may be due to irritation or rubbing) 18. Vaginal discharge (many infectious and noninfectious causes; cultures must be taken to confirm if it is caused by sexually transmitted organisms or other infections) 19. Friability of the posterior fourchette or commisure (may be due to irritation, infection, or may be caused by examiner s traction on the labia majora) 20. Excoriations/bleeding/vascular lesions (these findings can be due to conditions such as lichen sclerosus, eczema or seborrhea, vaginal/perianal Group A Streptococcus, urethral prolapse, hemangiomas) 21. Failure of midline fusion (also called perineal groove) 22. Anal fissures (usually due to constipation, perianal irritation) 23. Venous congestion, or venous pooling in the perianal area (usually due to positioning of child, also seen with constipation) 24. Flattened anal folds (may be due to relaxation of the external sphincter or to swelling of the perianal tissues due to infection or trauma a ) 25. Partial or complete anal dilatation to less than 2 cm (anterior posterior dimension), with or without stool visible. Indeterminate findings: insufficient or conflicting data from research studies (may require additional studies/evaluation to determine significance) (these physical/laboratory findings may support a child s clear disclosure of sexual abuse, if one is given, but should be interpreted with caution if the child gives no disclosure; report to Child Protective Services may be indicated in some cases) Physical examination findings 26. Deep notches or clefts in the posterior/inferior rim of hymen, between 4 and 8 o clock, in contrast to transections (see [41]). 27. Deep notches or complete clefts in the hymen at 3 or 9 o clock in adolescent girls 28. Smooth, noninterrupted rim of hymen between 4 and 8 o clock, which appears to be less than 1 mm wide, when examined in the prone knee chest position, or using water to float the edge of the hymen when the child is in the supine position. 29. Wart-like lesions in the genital or anal area (biopsy and viral typing may be indicated in some cases) 30. Vesicular lesions or ulcers in the genital or anal area (infectious and noninfectious causes; cultures, serology, and/or nucleic acid amplification tests should be done) 31. Marked, immediate anal dilation to an AP diameter of 2 cm or more, in the absence of other predisposing factors such as chronic constipation, sedation, anesthesia, neuromuscular conditions. Lesions with etiology confirmed: Indeterminate specificity for sexual transmission 32. Genital or anal Condyloma accuminata in a child, in the absence of other indicators of abuse b 33. Herpes type 1 or 2 in the genital or anal area in a child with no other indicators of sexual abuse b Findings diagnostic of trauma and/or sexual contact (the following findings support a disclosure of sexual abuse, if one is given, and are highly suggestive of abuse even in the absence of a disclosure, unless a clear, timely, plausible description of accidental injury is provided by the child and/or caretaker) Acute trauma to external genital/anal tissues 34. Acute lacerations or extensive bruising of labia, penis, scrotum, perianal tissues, or perineum (may be from unwitnessed accidental trauma, or from physical or sexual abuse) 35. Fresh laceration of the posterior fourchette, not involving the hymen (must be differentiated from dehisced labial adhesion or failure of midline fusion (see [21 ]); posterior fourchette lacerations may also be caused by accidental injury or consensual sexual intercourse in adolescents) Residual (healing) injuries (these findings are difficult to assess unless an acute injury was previously documented at the same location) 36. Perianal scar (rare, may be due to other medical conditions such as Crohn s disease, accidental injuries, or previous medical procedures) 37. Scar of posterior fourchette or fossa (pale areas in the midline may also be due to linea vestibularis or labial adhesions) Injuries indicative of blunt force penetrating trauma (or from abdominal/pelvic compression injury if such history is given) 38. Laceration (tear, partial or complete) of the hymen, acute 39. Ecchymosis (bruising) on the hymen (in the absence of a known infectious process or coagulopathy) 40. Perianal lacerations extending deep to the external anal sphincter (not to be confused with partial failure of midline fusion) (continued overleaf )

Guidelines for medical care of sexually abused children Adams 437 Table 1 (continued ) 41. Hymenal transection (healed). An area between 4 and 8 o clock on the rim of the hymen where it appears to have been torn through, to or nearly to the base, so there appears to be virtually no hymenal tissue remaining at that location. This finding has also been referred to as a complete cleft in sexually active adolescents and young adult women. 42. Missing segment of hymenal tissue. Area in the posterior (inferior) half of the hymen, wider than a transection, with an absence of hymenal tissue extending to the base of the hymen, which is confirmed using additional positions/methods Presence of infection confirms mucosal contact with infected and infective bodily secretions, contact most likely to have been sexual in nature 43. Positive confirmed culture for gonorrhea, from genital area, anus, and throat, in a child outside the neonatal period 44. Confirmed diagnosis of syphilis, if perinatal transmission is ruled out 45. Trichomonas vaginalis infection in a child older than 1 year of age, with organisms identified by culture or in vaginal secretions by wet-mount examination 46. Positive culture from genital or anal tissues for Chlamydia, if child is older than 3 years at time of diagnosis, and specimen was tested using cell culture or comparable method approved by the Centers for Disease Control. 47. Positive serology for HIV, if perinatal transmission, transmission from blood products, and needle contamination has been ruled out Diagnostic of sexual contact 48. Pregnancy 49. Sperm identified in specimens taken directly from a child s body AP, anterior-posterior. a Follow-up examination is necessary before attributing these findings to trauma. b Changes made since the publication of the table in 2007. Adapted from Adams et al. [1 ]. had not been previously described or validated. In spite of these limitations, the study is important because it was the first to review such a large number of cases and document how rapidly acute injuries can heal. In prepubertal girls, findings of hymenal abrasions, petechiae, mild submucosal hemorrhages, and hematomas at the first acute examination appeared to have healed completely by 2 3 days in most of the cases reviewed. When the submucosal hemorrhages were rated by the reviewers as being moderate or marked, some were still identified at follow-up visits up to 15 days later. The authors identified and classified 40 lacerations of the hymen among the prepubertal girls. Of the 19 hymen lacerations that were classified as less than complete, four healed with no evidence of injury. Among pubertal girls, there were more cases in which the hymen defect at the site of the initial laceration appeared to be deeper at the follow-up examination; for example, a deep laceration initially would be revealed as a transection at follow-up, due to the decrease in swelling of the tissues. An interesting difference was found between the location of the hymen lacerations between prepubertal and pubertal girls. In the prepubertal girls, 35/40 lacerations (88%) were in the posterior location, below the 3 o clock 9 o clock line, whereas in adolescents, 50/80 (60%) were posterior and 18/80 (23%) were lateral, at either the 3 o clock or 9 o clock location. In another article, the authors describe nonhymenal findings in the same group of prepubertal and pubertal girls whose photographs they reviewed [22 ]. Similar to the findings on the hymen, abrasions resolved within 3 days, petechiae within 24 h, and submucosal hemorrhage and hematomas within 7 14 days, depending on the severity. Deep lacerations of the posterior fourchette or perineum took 2 3 weeks to heal in prepubertal girls. Examination techniques The study including a subset of the cases reviewed for the healing of injuries was analyzed by Boyle et al. [23 ]to compare the effectiveness of three examination methods used by the participating centers to detect the acute and healing genital injuries. The authors found that the prone knee chest position was the most successful method for detecting hymen lacerations in both prepubertal and pubertal girls. Of 10 hymen lacerations identified in nine prepubertal girls, 6/10 were identified when labial traction was used and 10/10 with the use of the prone knee chest position. In pubertal girls, 35/49 hymen lacerations were identified using labial traction and 44/49 with the prone knee chest position. This is useful information for medical providers who examine children and adolescents following genital injury or acute sexual assault, though techniques other than the prone knee chest position can be used with adolescent girls. Cotton swabs and Foley catheters can also be used to stretch out the edge of the redundant hymen in order to look for acute or healing injuries in pubertal girls. Cross-sectional studies of injuries and forensic evidence Table 2 summarizes the results of nine studies [24,25,26 31,32 ] conducted at various centers with a large number of child or adolescent sexual assault cases, analyzing the prevalence of abnormal physical findings, positive test results for sexually transmitted diseases, and/or rates of recovery of forensic material. In general, these studies showed that abnormal physical examination

438 Adolescent and pediatric gynecology Table 2 Summary of findings from cross-sectional studies of sexually abused children and adolescent girls N Age range Timing of examination Abnormal medical examinations (% ) Positive STIs (% ) Positive forensic results (%) Special characteristics or findings Drocton et al. [24 ] 1674 women 12 20 years <72 h 53 overall, 63 positive anal finding if anal abuse described Hobbs and Osman [25 ] 86 men 1 month to 15 years, mean 5 years Palusci et al. [26] 190 <13 years, mean age 6.5 years Palusci et al. [26] 586 <13 years, mean age 7.0 years Variable All (sample selected for injury) NA NA Adolescents, virgins, history of penetration, alcohol use had more injuries NA NA Boys with genital injuries referred for suspected abuse. Lacerations, bruises, abrasions most common finding <72 h 13 5% 9 (17/93 tested) Positive forensics from body swabs only recovered from girls aged 10 13 who had not bathed. >72 h 4 NA NA Positive examinations more common in women, after puberty, and with h/o genital contact Young et al. [27] 48 4 months to 11 years <72 h NA NA 6 No swabs from child s body were positive, only clothing, bedding in three children Young et al. [27] 31 12 16 years <72 h NA NA 42 All positive swabs collected within 24 h of assault Christian et al. [28] 273 <10 years Most cases <72 h Edinburgh et al. [29] 226 women (32 of Hmong ethnicity) 23 (only cases reviewed were those with forensic swabs taken and analyzed) 10 14 years <72 h Hmong: 63 other: 21 Hmong: 36 positive Chlamydia; other: 4 NA 25 No body swabs positive after 18 h NA Hmong girls were significantly more likely to be victims of multiple assailants, be runaways, depressed and suicidal Kelly et al. [30] 2134 1 month to 17 years Variable 6 3 NA Abnormal findings more common in adolescents Kelly and Koh [31] 1392 <10 years Variable NA 1 NA No STI was found in prepubertal child without symptoms Kohlberger and Bancher-Todesca [32 ] 770 10 17 years Variable NA 6 180 girls 1 16 years Variable 24 ( hymen vaginal tear ) 0 (HIV, syphilis) to 2 (gonorrhea) NA Gardnerella vaginalis found in 25%, no correlation with hymen vaginal tear NA, not available; STI, sexually transmitted infection.

Guidelines for medical care of sexually abused children Adams 439 findings, positive tests for sexually transmitted diseases, and positive forensic specimen results were more common in adolescent than prepubertal children. Importantly, both Palusci et al. [26] in reviewing 190 cases and Young et al. [27] reviewing 80 cases found that no forensic evidence was recovered from a prepubertal child s body, even if they had been brought for examination within 6 h of the last episode of abuse. These two studies support the findings of Christian et al. [28]. Change the 72-hour rule? As Palusci et al. [26] and Christian et al. [28] describe, this rule evolved as a result of data from a few studies showing that sperm could be recovered from the adult female genital tract up to 72 h following penile vaginal intercourse. If the goal of performing an urgent examination is to collect swabs for forensic evidence, this author would argue that the 72-hour rule should be changed to the 24-hour rule for prepubertal children. Prepubertal children who are brought in within 24 h of an alleged episode of abuse, have not been bathed, and have a history or possibility of having been exposed to the alleged perpetrator s semen or saliva should have samples taken for forensic evidence. Those who have been bathed, or in whom the last contact was more than 24 h prior to the request for an examination, and have no symptoms or signs of injury or infection would most likely be better served, if the examination could be scheduled, during the day, at the facility with the most experienced medical providers. These examinations should be expedited and performed as soon as possible by medical providers with specific training in order to increase the chances of finding signs of minor injury that tend to heal within a few days. Commenting on the need for urgent examinations when children have been sexually abused, Dubowitz ([33 ], p. 998) states: Too often, the perceived need for an immediate evaluation leads to an emergency department, in the middle of the night, with staff not trained to evaluate these children and in a setting that may exacerbate their stress. If there is little or no likelihood of recovering forensic evidence from the child s body, the examination could just as easily be scheduled within the next day or two and still accomplish the most important goal: reassurance of the child and family that the child is not damaged. Expertise in interpreting genital findings with respect to abuse Physicians in several specialties may have difficulty in interpreting genital examination findings in children. Muram and Simmons [34 ] showed color photographs of normal anatomy and common pediatric gynecologic conditions to 20 faculty members and 40 residents in pediatrics, family medicine, and obstetrics and gynecology at one large medical school. The mean correct response rate ranged from 42% for residents to 58% for faculty, in spite of the fact that regular seminars and lectures in pediatric gynecology were provided at the teaching hospital. The authors also report that many of the residents and faculty members had a tendency to label examinations, both normal and abnormal, as indicative of sexual abuse. Botash et al. [35] found that even after participating in a comprehensive educational intervention for generalist pediatric providers on evaluating suspected child sexual abuse, 59% of the participants could not correctly identify the medical findings on presented case photographs. The conclusion of the consensus group who developed the guidelines for child sexual abuse medical evaluation [1 ] is that medical providers should have formal medical education in the field, including didactic education, practical experience in performing medical evaluations, and mentoring by an established expert; be familiar and keep up to date with published research and recommendations from relevant professional organizations; be able to demonstrate substantial experience and proficiency in performing medical evaluations of children and understand the process of differential diagnosis of physical findings that could be mistaken for abuse; and have a system in place to consult with established experts when a second opinion is needed regarding the interpretation of a medical finding. Rethinking herpes, vulvar ulcers, and gonorrhea Ongoing education of medical providers is particularly important when considering the diagnosis of sexually transmissible infections. Shapiro and Makoroff [36] reviewed the topic of sexually transmitted diseases in children and adolescents who are evaluated for suspected sexual abuse, focusing on research related to human papilloma virus transmission and indications for HIV prophylaxis following sexual assault. Herpes simplex virus type 1 and 2 Studies of the prevalence of antibodies to herpes type 1 and 2 (HSV-1, HSV-2), among children and young adolescents have been published in the last year. Xu et al. [37 ] analyzed sera from 2989 children between age 6 and 13 who participated in the National Health And Nutrition Examination Surveys (NHANES) between 1999 and 2002. They found seroprevalence rate for HSV-1 of 31% for the overall sample, with significantly higher rates among older compared with younger children and among those living below the poverty line compared with those above the poverty line.

440 Adolescent and pediatric gynecology In another study from Sweden [38 ], sera from mothers and infants was analyzed for antibodies to HSV-1 and HSV-2. The seroprevalence of HSV-1 among mothers was higher than HSV-2 (65 versus 19%), and at 30 months of age, 30% of infants had seroconverted for HSV-1 after being negative at an earlier testing. The peak time of acquisition of antibodies to HSV-1 among infants was found to be within the first 13 months of life. None of the infants became positive for HSV-2 antibodies. As both types of herpes virus infections can be, and are usually, transmitted by individuals who do not know they are infected [39 ], it is often not possible to know how and from whom a child might have acquired HSV lesions or antibodies. If the child is young enough that parents or other caretakers are still assisting with hygiene or toileting activities (generally under the age 5 or 6 years), it is not unreasonable to postulate that a young child with genital ulcers found to be caused by HSV-1 or HSV-2 may have been exposed through nonsexual contact. How likely is it that a child with genital ulcers caused by HSV-1 or HSV-2 acquired the infection as a result of sexual versus nonsexual contact? There is little data from research studies in this area to help answer that question. Reading and Rannan-Eliya [40 ] found in a literature review that investigators reported sexual transmission more commonly in children who were 5 years of age or older, who had genital lesions only, and in whom HSV-2 was isolated from the lesions. However, there are no large studies comparing the seroprevalence of HSV-1 or HSV-2 among children with and without a suspicion of sexual abuse. Consequently, genital herpes infections in children should probably remain in the indeterminate category with respect to sexual transmission. Vulvar ulcers Vulvar ulcers in children and adolescents can have many causes other than herpes infection. Huppert et al. [41] reviewed 20 cases of adolescent girls aged 10 19 years who presented with vulvar ulcers and were negative for herpes virus. Laboratory findings were nonspecific, including testing for Epstein Barr virus and cytomegalovirus, and the appearance and clinical course for these young women was most consistent with apthosis. This study emphasizes the importance of testing for herpes virus and waiting for the result before concluding that a young woman with vulvar ulcers might have been sexually abused. Is gonorrhea always sexually transmitted? Sexually transmissible infections are not always sexually transmitted. A review of studies of gonococcal infections [42 ], dating back to 1904, describes over 40 epidemics of gonococcal vulvovaginitis or conjunctivitis, involving over 2000 children in Europe and the United States. The article also reviews research studies that demonstrated the viability of gonococcus organisms on various surfaces for 2 72 h. Although some expert clinicians disagree, the wording as mentioned in Table 1 regarding infections with Neisseria gonorrhea, Chlamydia trachomatis, syphilis, and HIV is as follows: Infection confirms mucosal contact with infected and infective genital secretions: contact most likely to have been sexual, not Definite evidence of sexual contact. Conclusion Most genital injuries in sexually abused children heal with little residua, unless the injuries are severe. More information is needed on the prevalence of infections with HSV-1 and HSV-2 in children with and without a history of sexual abuse to help with the interpretation of an infection in a child. Recommendations regarding the timing of urgent forensic examinations for prepubertal children should be revised, based on the low yield of forensic evidence from the child s body more than 24 h after the last sexual contact. References and recommended reading Papers of particular interest, published within the annual period of review, have been highlighted as: of special interest of outstanding interest Additional references related to this topic can also be found in the Current World Literature section in this issue (p. 507). 1 Adams JA, Kaplan RA, Starling SP, et al. Guidelines for medical care of children who may have been sexually abused. J Pediatr Adolesc Gynecol 2007; 20:163 172. This article presents guidelines for how, when, and by whom children should be examined and suggests an approach to the interpretation of physical and laboratory findings in children with suspected sexual abuse. Groups of experts used a process of consensus development to arrive at the guidelines presented. 2 Berenson A, Heger A, Andrews S. Appearance of the hymen in newborns. Pediatrics 1991; 87:458 465. 3 McCann J, Voris J, Simon M, Wells R. Perianal findings in prepubertal children selected for nonabuse: a descriptive study. Child Abuse Negl 1989; 13:179 193. 4 McCann J, Wells R, Simon M, Voris J. Genital findings in prepubertal girls selected for nonabuse: a descriptive study. Pediatrics 1990; 86:428 439. 5 Berenson AB, Heger AH, Hayes JM, et al. Appearance of the hymen in prepubertal girls. Pediatrics 1992; 89:387 394. 6 Myhre AK, Berntzen K, Bratlid D. Genital anatomy in nonabused preschool girls. Acta Paediatr 2003; 92:1453 1462. 7 Heger AH, Ticson L, Guerra L, et al. Appearance of the genitalia in girls selected for nonabuse: review of hymenal morphology and nonspecific findings. J Pediatr Adolesc Gynecol 2002; 15:27 35. 8 Myhre AK, Berntzen K, Bratlid D. Perianal anatomy in nonabused preschool children. Acta Paediatr 2001; 90:1321 1328. 9 Berenson AB, Grady JJ. A longitudinal study of hymenal development from 3 to 9 years of age. J Pediatr 2002; 140:600 607. 10 Berenson AB, Chacko MR, Wiemann CM, et al. A case-control study of anatomic changes resulting from sexual abuse. Am J Obstet Gynecol 2000; 182:820 834. 11 McCann J, Voris J, Simon M. Genital injuries resulting from sexual abuse. A longitudinal study. Pediatrics 1992; 89:307 317.

Guidelines for medical care of sexually abused children Adams 441 12 McCann J, Voris J. Perianal injuries resulting from sexual abuse: a longitudinal study. Pediatrics 1993; 91:390 397. 13 Heppenstall-Heger A, McConnell G, Ticson L, et al. Healing patterns in anogenital injuries: a longitudinal study of injuries associated with sexual abuse, accidental injuries, or genital surgery in the preadolescent child. Pediatrics 2003; 112:829 837. 14 Boos SC. Accidental hymenal injury mimicking sexual trauma. Pediatrics 1999; 103:1287 1289. 15 Herrmann B, Crawford J. Genital injuries in prepubertal girls from inline skating accidents. Pediatrics 2002; 110:e16; http://www.pediatrics.org/cgi/content/ full/110/2/e16. 16 Boos SC, Rosas AJ, Boyle C, McCann J. Anogenital injuries in child pedestrians run over by low-speed motor vehicles: four cases with findings that mimic child sexual abuse. Pediatrics 2003; 112:e77; http://www.pediatrics. org/cgi/content/full/112/1/e77. 17 Heger A, Ticson L, Velasquez O, Bernier R. Children referred for possible sexual abuse: medical findings in 2384 children. Child Abuse Negl 2002; 26:645 659. 18 Adams JA, Botash AS, Kellogg N. Differences in hymenal morphology between adolescent girls with and without a history of consensual sexual intercourse. Arch Pediatr Adolesc Med 2004; 158:280 285. 19 Kellogg ND, Menard SW, Santos A. Genital anatomy in pregnant adolescents: normal doesn t mean nothing happened. Pediatr 2004; 223:e67 e69; http://www.pediatrics.org/cgi/content/full/113/1/e67. 20 Jones JS, Rossman L, Hartman M, Alexander CC. Anogenital injuries in adolescents after consensual sexual intercourse. Acad Emerg Med 2003; 10:1378 1383. 21 McCann J, Miyamoto S, Boyle C, Rogers K. Healing of hymenal injuries in prepubertal and adolescent girls: a descriptive study. Pediatrics 2007; 119: e1094 e1106; http://www.pediatrics.org/cgi/content/full/119/5/e1094. Downloaded May 16, 2007. The authors report the findings of a retrospective study reviewing photographs and cases of genital trauma and healing in 113 prepubertal girls and 126 adolescent girls. The presentation of the findings is somewhat difficult to understand, but the study is important because of the large number of cases reviewed and the finding that most minor injuries healed completely. 22 McCann J, Miyamoto S, Boyle C, Rogers K. Healing of nonhymenal genital injuries in prepubertal and adolescent girls: a descriptive study. J Pediatr 2007; 120:1000 1011. This is the second article from the retrospective study reviewing photographs of injuries. The main findings were that petechiae resolved within 24 h, blood blisters persisted up to 24 days, and deep perineal lacerations took up to 20 days to heal, following the initial injury. 23 Boyle C, McCann J, Miyamoto S, Rogers K. Comparison of examination methods used in the evaluation of prepubertal and pubertal female genitalia: a descriptive study. Child Abuse Negl 2008; 32:229 243. The authors reviewed a subset of cases in which photographs were taken using labial separation, labial traction, and the prone knee chest position. The latter position was found to be the most effective in showing hymen lacerations. 24 Drocton P, Sachs C, Chu L, Wheeler M. Validation set correlates of anogenital injury after sexual assault. Acad Emerg Med 2008; 15:1 8. The authors of this article used an electronic database to summarize demographic data and medical findings in 2879 cases of acute sexual assault. Half of the cases were of girls/women between age 12 and 20 years, and this group had the highest rates of injury. Although limited in not being able to separate out the youngest victims, this study is important because of the ability to correlate findings with specific factors related to the assault. 25 Hobbs CJ, Osman J. Genital injuries in boys and abuse. Arch Dis Child 2007; 92:328 331. This article reports on the types of genital injuries in a population of boys in Leeds, UK, who were referred for sexual abuse evaluations because of genital injuries. The author s listing of anal findings such as venous pooling and anal gaping as signs of injury does not reflect current opinion in the United States regarding the nonspecific nature of these findings. 26 Palusci VJ, Cox EO, Shatz EM, Schultze JM. Urgent medical assessment after child sexual abuse. Child Abuse Negl 2006; 30:367 380. 27 Young KL, Jones JG, Worthington T, et al. Forensic laboratory evidence in sexually abused children and adolescents. Arch Pediatr Adolesc Med 2006; 160:585 588. 28 Christian CW, Lavelle JM, De Jong AR, et al. Forensic findings in prepubertal victims of sexual assault. Pediatrics 2000; 106:100 104. 29 Edinburgh L, Saewyc E, Thao T, Levitt C. Sexual exploitation of very young Hmong girls. J Adolesc Health 2006; 39:111 118. 30 Kelly P, Koh J, Thompson JM. Diagnostic findings in alleged sexual abuse: symptoms have no predictive value. J Paediatr Child Health 2006; 42:112 117. 31 Kelly P, Koh J. Sexually transmitted infections in alleged sexual abuse of children and adolescents. J Paediatr Child Health 2006; 42:434 440. 32 Kohlberger P, Bancher-Todesca D. Bacterial colonization in suspected sexually abused children. J Pediatr Adolesc Gynecol 2007; 20:289 292. This study from Vienna, Austria, reports on findings in 180 girls examined between 1996 and 2006 for suspected sexual abuse. Routine vaginal cultures were taken from all girls and both Gardnerella vaginalis and Ureaplasma were recovered significantly more often in adolescent compared with prepubertal girls. 33 Dubowitz H. Healing of hymenal injuries: implications for child healthcare professionals. Pediatrics 2007; 119:997 999. This commentary to the article by McCann et al. [21 ] reviews the findings reported in the article and also discusses larger issues related to the evaluation of children who may have been sexually abused. 34 Muram D, Simmons KJ. Pattern recognition in pediatric and adolescent gynecology: a case for formal education. J Pediatr Adolesc Gynecol 2008; 21:103 108. This is a report of a small but sobering study in which physicians reviewed color photographs of common pediatric gynecologic conditions. The overall percentage of correct interpretations ranged from 42% for residents to 58% for faculty. The authors propose that there is a need for an easily accessible library of images to assist physicians with accurate diagnosis of normal and abnormal gynecologic conditions in children. 35 Botash AS, Galloway AE, Booth T, et al. Continuing medical education in child sexual abuse: cognitive gain but not expertise. Arch Pediatr Adolesc Med 2005; 159:561 566. 36 Shapiro RA, Makoroff KL. Sexually transmitted diseases in sexually abused girls and adolescents. Curr Opin Obstet Gynecol 2006; 18: 492 497. 37 Xu F, Lee FK, Morrow RA, et al. Seroprevalence of herpes simplex virus type 1 in children in the United States. J Pediatr 2007; 151:374 377. This important article reports the increasing rates of antibodies to HSV-1 among children from 6 to 12 years of age and the high rates of positive antibodies among children living below the poverty line (52%). The implication is that HSV-1 is commonly spread by household contact rather than sexual contact, though this is not specifically stated. 38 Tunback P, Bergstrom T, Claesson BA, et al. Early acquisition of herpes simplex virus type 1 antibodies in children: a longitudinal serological study. J Clin Virol 2007; 40:26 30. In this article from Sweden, the authors show that antibodies to HSV-1 and HSV-2 are common in mothers and decrease in the children up to the age of 1 year. None of the infants had antibodies to HSV-2 after maternal antibodies disappeared, but 30% acquired antibodies to HSV-1, most between 12 and 30 months of age. This study implies that HSV-2 infections in children may be more concerning for sexual transmission and HSV-1 infections less concerning. 39 Gupta R, Warren T, Wald A. Genital herpes. Lancet 2007; 370:2127 2137. The authors present a comprehensive and scholarly review of the epidemiology, diagnosis, and treatment of genital herpes in adults. 40 Reading R, Rannan-Eilya Y. Evidence for sexual transmission of genital herpes in children. Arch Dis Child 2007; 92:608 618. An attempt was made by the authors to systematically review published research concerning the transmission of HSV in children. None of the studies had sufficient details regarding the cases of genital herpes and the possible modes of transmission, so the authors concluded that the evidence concerning the likelihood of sexual transmission of HSV in children is weak. 41 Huppert JS, Gerber MA, Deitch HR, et al. Vulvar ulcers in young females: a manifestation of apthosis. J Pediatr Adolesc Gynecol 2006; 19:195 204. 42 Goodyear-Smith F. What is the evidence for nonsexual transmission of gonorrhea in children after the neonatal period? A systematic review. J Forensic Legal Med 2007; 14:489 502. The author asks a legitimate question and this review with 116 references makes very interesting reading. Although a vast majority of cases of genital gonorrhea in children are due to sexual abuse, a careful reading of this article may convince medical providers that transmission by mucosal contact with infected and infective secretions can also spread gonorrhea.