An urgent call to help patients who have been abused sexually

Pediatricians can help young victims deal with the trauma of child abuse, but they can also exacerbate problems associated with abuse.

"The medical exam is a critical part of the process of investigating and dealing with child abuse," said James Crawford, MD, FAAP, medical director of the Center for Child Protection at Children's Hospital Oakland in Oakland, Calif. "The way you handle the exam, the patient, and the patient's caregiver can make a tremendous difference."

Sexual abuse of children is not an extraordinary event, Dr. Crawford told an audience of physicians Saturday at the AAP National Conference and Exhibition. Studies suggest that as many as one girl in four and one boy in seven are victims of sexual abuse. Many are abused by either a family member, family acquaintance, neighbor, teacher, coach, youth group leader, or religious staff. Random assaults by strangers are less common.

In some cases, the child discloses abuse directly. In other cases, abuse is discovered indirectly, through a diary, images produced by the child, or secrets repeated by a sibling or friend. Abuse can also come to light by way of injury, infection, pregnancy, or other physical signs. Whether abuse is real or only suspected, a physical exam is almost always required.

But in most cases, Dr. Crawford said, the physical exam will be entirely normal. Even if physical abuse has occurred, there may be little to no physical evidence of trauma. Children heal far more quickly than even most pediatricians realize, he continued. And even an abnormal exam does not necessarily indicate abuse. Straddle injuries and in-line skating are just two of the many common childhood injuries that can produce trauma mimicking sexual abuse and assault.

Whether the child has been abused or not, the examination process itself can be traumatic. The most important step, Dr. Crawford said, is to include genital exams as part of regular well-child care for both boys and girls. If an exam is required because of possible abuse, the genital examination will be a familiar process, not an occasion for additional worry or psychological trauma.

Dr. Crawford noted that a pediatric genital exam is not a "baby GYN" with stirrups and speculum. Instead, he recommended examination in the frog position, with the child on his or her back and the knees drawn up. When the legs are relaxed, they naturally splay outward, allowing easy access to the genital area.

One of the most important steps, Dr. Crawford said, is to reassure the caregiver.

"You may be examining the child, but the caregiver is an integral part of the examination. If Mom is less anxious, the child will be less anxious. You will have a less stressful, more successful exam."