Anogenital signs may be identified by healthcare professionals in their routine assessment of children for symptoms related to that anatomical area. A disclosure of sexual abuse should lead to a genital examination. The RCPCH document The Physical Signs of Child Sexual Abuse6 recommends that ‘In the case of suspected sexual abuse, most general paediatricians will not have the expertise to assess or manage the child/young person themselves but will refer to a clinician with more specialised child protection expertise and with training in forensic assessments.’
4.2.2. Genital and anal signs
The systematic reviews undertaken for the RCPCH document6 were categorised into genital signs of CSA in girls (analysed according to pubertal or prepubertal status where possible), anal signs of CSA and genital signs of CSA in boys. The topics covered were in girls: genital erythema/redness/inflammation, oedema, genital bruising, genital abrasions, genital lacerations/tears, healing/healed injuries, clefts/notches, hymenal bumps/mounds, size of hymenal orifice, hymenal width, friability, labial fusion, vaginal discharge in prepubertal girls, and vaginal foreign bodies; in girls and boys: anal/perianal erythema, perianal venous congestion, anal/perianal bruising, anal lacerations/tears, fissures, scars and tags, and reflex anal dilatation; and general genital injuries in boys. The findings from these systematic reviews are summarised below. [EL = 2++]
A general theme that recurs throughout the document is that the timing of the examination in relation to alleged incidents of abuse affects the ability to observe a sign. The evidence base itself poses problems because there are few comparative studies and few studies where abuse has been rigorously excluded from the comparison groups.
Genital signs in girls
Erythema: In prepubertal girls, genital erythema has been found in sexual abuse cases (7/20) and non-abused controls (2/195) (separate studies). Proportions of sexually abused pubertal girls with erythema ranged from 13% (n = 204) to 32% (n = 214) in two case series. In one comparison study combining data on prepubertal and pubertal girls, erythema was reported in 34% (n = 119) of the CSA group, in 68% (n = 59) of girls with genital complaints and in 13% (n = 127) of girls undergoing routine examination. Abuse was not rigorously excluded from the comparison groups. The timing of examination after the alleged incident and skin pigmentation influence the finding of erythema.
Oedema: No studies were identified that reported the prevalence of oedema in non-abused girls. Oedema was noted in 19% (n = 214) of pubertal sexually abused girls. The timing of examination after the alleged incident influences the finding of oedema.
Bruising: In one comparative study, bruising was noted in one of 192 girls with a history of vaginal penetration and in none of 200 girls who had not been abused. In the abuse cases, examination took place on average 42 days after the abusive event.
In a case series (n = 43) of prepubertal girls with a history of vaginal penetration, 13 haematomas were found but it was unclear how many girls this involved. No genital bruising was reported in one study of prepubertal girls selected for non-abuse.
In a case series (n = 204) of pubertal girls with a history of penile vaginal penetration, 4% had bruising.
A case series (n = 155) of sexually abused prepubertal and pubertal girls examined within 72 hours of the abusive event reported 3% with genital bruising.
Abrasions: Genital abrasions were reported in one study of healing in sexually abused girls with a history of penile and/or digital vaginal penetration. No genital abrasions were reported in a study of non-abused prepubertal girls (n = 195). Abrasions were reported in 17% (n = 214) of pubertal sexually abused girls. The majority of the cohort reported penile vaginal penetration and had been examined within 72 hours of the incident. In a comparative study of prepubertal and pubertal sexually abused girls, three of 119 girls had abrasions; no abrasions were reported in the genital complaints group (n = 59) or the routine health check group (n = 127). Abrasions have been reported in one study of prepubertal girls with straddle injury. Abuse was not rigorously excluded from this group.
Lacerations: There was inconsistency of definitions of genital lacerations and tears to the hymen across the studies identified by the authors. Hymenal lacerations were reported in 33% (n = 205) of prepubertal sexually abused girls in a case series. The authors reported difficulty in distinguishing small lacerations from notches. Partial hymenal tears were reported in two of 24 girls reporting penile vaginal penetration and four of 19 reporting digital vaginal penetration. In a study of non-abused prepubertal girls, no hymenal lacerations were reported. In two studies of pubertal girls, hymenal lacerations/tears were reported in 3% (n = 204) and 6% (n = 214) where more than 90% of study participants reported penetrative abuse.
Posterior fourchette/fossa tears were reported in 14 of 24 prepubertal sexually abused girls. No genital lacerations were reported in the study of prepubertal non-abused girls (n = 195). Posterior fourchette/fossa tears were reported in 40% of pubertal sexually abused girls examined less than 72 hours after the incident and in 2% of those examined more than 72 hours after the incident (n = 204). In a study of prepubertal and pubertal sexually abused girls, one of 155 girls had a vaginal laceration (poor definitions used in this study).
Healing/healed injuries: Hymenal transection was inconsistently defined in the studies. Hymenal transections were found in some prepubertal girls with a history of penetrative abuse; none were found in non-abused girls. The evidence on the importance of scars in prepubertal girls is inconclusive.
Hymenal bumps/mounds: There was inconsistency of definitions in the identified studies but, overall, hymenal bumps/mounds were found to be a normal variant.
Hymenal width and diameter: No conclusions could be drawn about the importance of hymenal width or diameter as signs of sexual abuse.
Friability of the genital tissues is not specific for sexual abuse in prepubertal girls and there is insufficient literature in pubertal girls.
Labial fusion has been found in both abused and non-abused prepubertal girls. There is insufficient evidence to determine the importance of labial fusion in sexual abuse of pubertal girls.
Vaginal discharge in prepubertal girls was observed more often in girls reporting penile vaginal penetration than those reporting digital penetration or no abuse in a case–control study where presence of a sexually transmitted infection (STI) was used to define abuse. Vaginal discharge was found in 1% to 2% of non-abused prepubertal girls.
Vaginal foreign bodies: No suitable comparative studies were identified that investigated vaginal foreign bodies. No studies of foreign bodies in pubertal or non-abused girls were identified. In prepubertal girls, three studies representing data on 47 girls (age range 2–10 years) with vaginal foreign bodies. Nine girls were defined as victims of CSA according to differing criteria.
Anal signs in girls and boys
No comparative studies of suitable quality were identified that reported on anal/perianal erythema, perianal venous congestion, anal/perianal bruising, anal fissures, lacerations, scars and tags, or reflex anal dilatation.
Anal or perianal erythema was observed in 1% (n = 310) to 10% (n = 189) of CSA cases. The timing of examination in relation to the incident was not stated. In non-abused children, redness was reported in 7% (n = 89) of infants and 11% (n = 276) of 5- to 6-year-olds.
Perianal venous congestion was observed in 8% (n = 50) and 36% (n = 50) of anally abused children; the timing of the examination after the incident ranged from 4 weeks to 6 years. In non-abused children, perianal venous congestion was reported in 1% of infants (n = 89) and 20% of 5- to 6-year-olds (n = 276).
Bruising: In a case series of anally abused children, bruising was observed in 10% (n = 50); the timing of examination after the incident was not reported. In another study, 1% of sexually abused children (n = 190) examined within 72 hours had anal/perianal bruising. There were no reports of bruising in non-abused children (n = 305).
Anal lacerations/tears defined as acute tears in the anus and tissues immediately surrounding it were not found in a study (n = 305) where abuse was excluded. Lacerations/tears were found in between 1% and 18% of sexually abused children (based on six case series).
Anal fissures were found in one child in a study of non-abused children (n = 89). In a study of abused children, 25 of 50 anally abused children had anal fissures, fissures were present in 7% of sexually abused children who denied anal abuse (n = 83) and 3% of children with no allegation of sexual abuse (n = 81).
Anal scars were not found in children selected for non-abuse (n = 305). In anally abused children, scars were found in 38% and 84% of children (n = 50) in two studies. In sexually abused children, anal scars were found in between 1% and 4%.
Anal tags were reported in between 3% and 7% of children selected for non-abuse (two studies) and between 4% and 32% of anally abused children (two studies) where the majority of tags were found away from the midline. In sexually abused children, tags were found in between 3% and 7%.
Reflex anal dilatation: In children selected for non-abuse, reflex anal dilatation has been reported in less than 1% of children examined in the left lateral position and in 5% of those examined in the knee-chest position. It was observed in 10% and 34% (two studies, each n = 50) of anally abused children and in 5% of sexually abused children.
Genital signs in boys
Genital injuries in boys following sexual abuse have not been well reported. Four case series of sexual abuse in boys have reported injury to the external male genitalia as a result of sexual abuse in between 0% and 7% of abuse cases. Genital injuries due to sexual abuse occur mostly to the penis. Testicular or scrotal injuries are more commonly due to accidents than abuse (based on one study where confirmation of abuse was unclear).
Evidence statement
The thorough review of the literature on physical signs of sexual abuse6 highlights important issues for the use of physical signs in suspecting abuse. The evidence base is lacking in both quality and quantity, in part due to difficulties in conducting research in this area. Observable signs are relatively uncommon and this could be because of the timing of the examination relative to the abuse.
GDG considerations
Among the various signs presented in the systematic review, few are commonly observed and, of those, many will only be seen on examination following a disclosure or report. In the context of this guidance and its intended audience, the GDG believes that the history that the child or parent/carer provides will be of the utmost importance. Therefore the GDG believes that genital or anal symptoms and their context are more likely to become apparent as features of maltreatment in a routine clinical situation than genital or anal signs. The GDG has considered signs and symptoms outside of the remit of the RCPCH guidance, as the RCPCH did not consider an exhaustive list.
The GDG acknowledges that it is common for newborns to have vaginal discharge and sometimes bleeding, especially if they are breastfed.
There are no studies reporting the prevalence of anal fissures in constipation or the passing of hard stools but the GDG's clinical experience suggests that these, together with Crohn's disease, should be excluded before suspecting anal abuse.
After discussion, the GDG decided that reflex anal dilatation is a sign that would be sought during the full assessment of a child where child abuse was suspected. Such an assessment would be conducted by a professional with expertise in the field and the GDG therefore concluded that reflex anal dilatation is not a sign that a frontline healthcare professional would be expected to recognise. However, a healthcare professional may come across a child with a gaping or dilated anus. In the absence of an obvious medical condition to explain this finding, such as a neurological disorder or severe constipation, the GDG believes that they should consider child maltreatment and seek advice from a more experienced colleague.
The GDG sought the opinions of the Delphi panel on statements about genital and anal symptoms (see above and Section C.2.6). 5a–14a, 15b, 19a and 20a were adopted for use in the recommendations. There was consensus within the GDG about the recommendations on genital and anal signs and thus the views of the Delphi panel were not sought.
Recommendations on anogenital symptoms and signs
Suspect* sexual abuse if a girl or boy has a genital, anal or perianal injury (as evidenced by bruising, laceration, swelling or abrasion) and the explanation is absent or unsuitable.*
Suspect* sexual abuse if a girl or boy has a persistent or recurrent genital or anal symptom (for example, bleeding or discharge) that is associated with behavioural or emotional change and that has no medical explanation.
Suspect* sexual abuse if a girl or boy has an anal fissure, and constipation, Crohn's disease and passing hard stools have been excluded as the cause.
Consider* sexual abuse if a gaping anus in a girl or boy is observed during an examination and there is no medical explanation (for example, a neurological disorder or severe constipation).
Consider* sexual abuse if a girl or boy has a genital or anal symptom (for example, bleeding or discharge) without a medical explanation.
Consider* sexual abuse if a girl or boy has dysuria (discomfort on passing urine) or anogenital discomfort that is persistent or recurrent and does not have a medical explanation (for example, worms, urinary infection, skin conditions, poor hygiene or known allergies).
Consider* sexual abuse if there is evidence of one or more foreign bodies in the vagina or anus. Foreign bodies in the vagina may be indicated by offensive vaginal discharge.
- *
Refer to Chapter 3 for the definitions of ‘unsuitable explanation’, ‘consider’ and ‘suspect’, and for their associated actions.
Research recommendation on anogenital symptoms and signs
What are the anogenital signs, symptoms and presenting features (including emotional and behavioural features) that distinguish sexually abused from non-abused children?
Why this is important
A well-conducted prospective study is needed in this area to address problems of reporting bias in the existing literature, particularly in relation to non-abused children.
4.2.3. Sexually transmitted infections
In this review we sought to establish whether the most common STIs occur more often in children who were sexually abused than in those who were not.
Overview of available evidence
A systematic review for physical signs of CSA builds the evidence base for STIs.6 The chapter on STIs is treated as one systematic review for the purposes of this document.
Narrative summary
In a systematic review of some of the most frequent STIs that have been noted in CSA cases, 84 studies were reviewed.6 Conclusions were drawn from prevalence figures of:
sexual abuse in children with the STI, and
prevalence figures of the STI in sexually abused children. [EL = 2+]
None of the literature was able to establish the age at which mother-to-child (vertical) transmission can be excluded.
Bacterial STIs
Neisseria gonorrhoeae (17 studies included)
Gonorrhoea is not often seen in sexually abused prepubertal and pubertal children. Nevertheless, a significant number of children with gonorrhoea who have been evaluated for sexual abuse were found to have been abused. This suggests that sexual contact was the mode of transmission. Sexual abuse is the most likely mode of transmission in pubertal and prepubertal children.
Chlamydia trachomatis (ten studies included)
Chlamydia infection is rarely seen in sexually abused children. The majority of children with chlamydia who have been evaluated for sexual abuse were found to have been abused. This suggests that sexual contact was the mode of transmission.
Chlamydia is more frequent in pubertal than prepubertal sexually abused girls. This result may be biased because of consensual sexual activity or younger children being less likely to disclose abuse.
Bacterial vaginosis (six studies included)
The authors concluded that there were insufficient data in children to determine the significance of bacterial vaginosis in relation to CSA.
Genital mycoplasmas (six studies included)
The available literature does not help to establish whether or not genital mycoplasmas are sexually transmitted in children.
Syphilis (nine studies included)
No literature was identified that distinguished sexually acquired syphilis from congenitally acquired syphilis in children.
Viral STIs
Anogenital warts (ten studies included)
A significant proportion of children with anogenital warts have been sexually abused. In six studies, sexual transmission was reported to be the cause of infection in 31% to 58% of children with anogenital warts. The evidence does not help to establish the age at which the possibility of mother-to-child transmission during birth can be excluded.
Oral warts (one study included)
The authors' conclusion was that there is currently insufficient evidence to determine the significance of oral warts in relation to CSA.
Genital herpes simplex (five studies included)
There are very few published studies to inform whether sexual abuse is likely to be the mode of transmission. Where infected children had been evaluated, one of two and six of eight children were found to have been abused.
Hepatitis B (four studies included)
There is insufficient evidence to determine the significance of hepatitis B in relation to sexual abuse in children.
Hepatitis C (two studies included)
There is insufficient evidence to determine the significance of hepatitis C in relation to sexual abuse in children.
Human immunodeficiency virus (HIV) (four studies included)
Published studies suggest that sexual abuse is a likely source of infection in children with HIV in whom the possibility of mother-to-child transmission or blood contamination has been excluded.
Trichomonas vaginalis (ten studies included)
Published studies suggest that sexual abuse is a likely source of infection in girls. The evidence does not help to establish the age at which the possibility of mother-to-child transmission can be excluded. Consensual sexual activity should be considered.
Limitations
The limitations of the study are discussed in detail by the authors. For STIs the limitations were that the majority of studies came from outside the UK and need to be interpreted in the context of different population prevalence of STIs and different healthcare and child protection systems. The studies included were of variable quality. They often failed to screen all participants for a particular infection and almost no study rigorously explored other methods of transmission in children with confirmed infection.
Delphi consensus (see also Appendix C)
The GDG sought the opinions of the Delphi panel on the circumstances under which an STI in a young person aged 13 years or over is a reason to suspect sexual abuse. They did not seek validation on the list of STIs that should prompt a concern. The following statements were drafted:
Round 1
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Statement number | Round 1 | % agreed | n | Outcome |
---|
21a | Healthcare professionals should consider sexual abuse when a young person aged 13 to 15 years presents with any sexually transmitted infection unless there is clear evidence of blood contamination or that the STI was acquired from consensual sexual activity with a peer. | 93 | 91 | Statement accepted. |
22a | Healthcare professionals should consider sexual abuse when a young person aged 16 or 17 years presents with any sexually transmitted infection unless there is clear evidence of blood contamination or that the STI was acquired from consensual sexual activity. | 60 | 91 | See below. |
23a | Healthcare professionals should consider sexual abuse when a young person aged 16 or 17 years presents with any sexually transmitted infection when there is no clear evidence of blood contamination or that the STI was acquired from consensual sexual activity, and when there is a clear discrepancy in power, emotional maturity or mental capacity between the young person and their sexual partner. | 91 | 92 | Statement accepted but incorporated into an expanded Statement 22b in Round 2. |
24a | Healthcare professionals should consider sexual abuse when a young person aged 16 or 17 years presents with any sexually transmitted infection when there is no clear evidence of blood contamination or that the STI was acquired from consensual sexual activity, and when there is concern that the young person is being exploited. | 90 | 92 | Statement accepted but incorporated into an expanded Statement 22b in Round 2. |
Statement 21a
This statement was agreed in Round 1 and incorporated into recommendations.
Statement 22a
40% of respondents did not agree with Statement 22a as a stand-alone statement.
Statements 23a and 24a
Over 90% of respondents agreed with these statements about STIs in 16- and 17-year-olds. Combining Statements 22a, 23a and 24a led to Statement 22b in Round 2:
Round 2
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Statement number | Round 1 | % agreed | n | Outcome |
---|
22b | Healthcare professionals should consider sexual abuse when a young person aged 16 or 17 years of age presents with any sexually transmitted infection when there is no clear evidence of blood contamination or that the STI was acquired from consensual sexual activity with a peer, and one or more of the following is present:
a clear discrepancy in power, emotional maturity or mental capacity between the young person and their sexual partner concern that the young person is being exploited.
| 92 | 79 | Round 2 statement accepted. |
GDG considerations
It is the GDG's opinion that an STI in children as a direct result of sexual abuse falls within the legal framework outlined in the Sexual Offences Act 2003 (see below). Therefore, an STI in a child younger than 13 years should raise the suspicion of sexual abuse. The GDG was unable to make specific recommendations about the age at which mother-to-child transmission of infections can be ruled out as the evidence in this area is scarce. If vertical transmission is suspected, it is good clinical practice to trace the family member concerned. The GDG believes that hepatitis B can be transmitted non-sexually within households so this should be ruled out as a cause before sexual abuse is considered.
There is a high prevalence of sexual abuse among children with anogenital warts. However, it is not known at what age vertical transmission can be excluded. The GDG were also concerned that it can be difficult for healthcare professionals to tell the difference between cutaneous warts or molluscum contagiosum and anogenital warts in the perineal region. The GDG concluded that healthcare professionals should consider sexual abuse in all children where they are concerned about anogenital warts and seek advice from a more experienced professional.
There is insufficient information about bacterial vaginosis, genital mycoplasma and oral warts in the context of sexual abuse to warrant inclusion in a list of possible STIs due to sexual abuse.
The GDG believes that the issues around consensual experimentation among 13- to 15-year-olds outlined in Crown Prosecution Service guidance40 should be taken into account when a young person of this age presents with an STI: that guidance indicates that an STI in this age group is not an immediate reason to suspect sexual abuse.
The GDG believes that to consider an STI in young people aged 16 or 17 years to be a direct result of sexual abuse will depend on the context and nature of the sexual act. Therefore, the presence of an STI in this age group needs to be evaluated in the context of consensual sexual activity.
The GDG sought the opinions of the Delphi panel on recommendations about young people between the ages of 13 and 18 years (see above and Section C.2.5). The GDG accepted statements 21a and 22b from the Delphi survey. Although agreement was reached on Statement 22b, the GDG amended the definition of a ‘discrepancy in power, emotional maturity or mental capacity’ to provide examples that are meaningful for healthcare professionals.
Recommendations on sexually transmitted infections
Consider* sexual abuse if a child younger than 13 years has hepatitis B unless there is clear evidence of mother-to-child transmission during birth, non-sexual transmission from a member of the household or blood contamination.
Consider* sexual abuse if a child younger than 13 years has anogenital warts unless there is clear evidence of mother-to-child transmission during birth or non-sexual transmission from a member of the household.
Suspect* sexual abuse if a child younger than 13 years has gonorrhoea, chlamydia, syphilis, genital herpes, hepatitis C, HIV or trichomonas infection unless there is clear evidence of mother-to-child transmission during birth or blood contamination.
Consider* sexual abuse if a young person aged 13 to 15 years has hepatitis B unless there is clear evidence of mother-to-child transmission during birth, non-sexual transmission from a member of the household, blood contamination or that the infection was acquired from consensual sexual activity with a peer.
Consider* sexual abuse if a young person aged 13 to 15 years has anogenital warts unless there is clear evidence of mother-to-child transmission during birth, non-sexual transmission from a member of the household, or that the infection was acquired from consensual sexual activity with a peer.
Consider* sexual abuse if a young person aged 13 to 15 years has gonorrhoea, chlamydia, syphilis, genital herpes, hepatitis C, HIV or trichomonas infection unless there is clear evidence of mother-to-child transmission during birth, blood contamination, or that the sexually transmitted infection (STI) was acquired from consensual sexual activity with a peer.†
Consider* sexual abuse if a young person aged 16 or 17 years has hepatitis B and there is:
no clear evidence of mother-to-child transmission during birth, non-sexual transmission from a member of the household, blood contamination or that the infection was acquired from consensual sexual activity and
a clear difference in power or mental capacity between the young person and their sexual partner, in particular when the relationship is incestuous or is with a person in a position of trust (for example, teacher, sports coach, minister of religion) or
concern that the young person is being exploited.
Consider* sexual abuse if a young person aged 16 or 17 years has anogenital warts and there is:
no clear evidence of non-sexual transmission from a member of the household or that the infection was acquired from consensual sexual activity and
a clear difference in power or mental capacity between the young person and their sexual partner, in particular when the relationship is incestuous or is with a person in a position of trust (for example, teacher, sports coach, minister of religion) or
concern that the young person is being exploited.
Consider* sexual abuse if a young person aged 16 or 17 years has gonorrhoea, chlamydia, syphilis, genital herpes, hepatitis C, HIV or trichomonas infection and there is:
no clear evidence of blood contamination or that the STI was acquired from consensual sexual activity and
a clear difference in power or mental capacity between the young person and their sexual partner, in particular when the relationship is incestuous or is with a person in a position of trust (for example, teacher, sports coach, minister of religion) or
concern that the young person is being exploited.
- *
Refer to Chapter 3 for the definitions of ‘unsuitable explanation’, ‘consider’ and ‘suspect’, and for their associated actions.
- †
In these circumstances, consider should include discussion of your concerns with a named or designated professional for safeguarding children.
Research recommendation on sexually transmitted infections
What is the association between anogenital warts and sexual abuse in children of different ages?
Why this is important
Anogenital warts can be acquired by vertical transmission, sexual contact and by non-sexual transmission within households. A thorough prospective study is needed to investigate the differential causes of anogenital warts in children. Such a study should include full viral typing of the warts in the index case and contacts where possible.