Diagnosis : Sexual Abuse
The Normal Examination
Clinical findings in sexual abuse are rare. A normal examination does not exclude the possibility of sexual abuse. In most cases the most important aspect of the child sexual abuse evaluation is the child’s history.
There are several reasons for lack of physical findings and forensic evidence in sexually abused children and adolescents:
- Many types of sexual abuse do not include acts that would be expected to cause trauma to skin or body tissues.
- Delays in seeking medical care may result in healing of potential injuries and decrease the likelihood of identification of findings.
- Semen and other evidence of ejaculate is unlikely to be found if many hours have elapsed since the sexual abuse. In addition, vaginal penetration can occur without ejaculation or damage to tissues.
- Hymenal tissue is elastic and penetration by a body part or object may stretch the hymenal opening and not cause identifiable traumatic injuries.
- The rectal and anal areas are highly elastic and may not be damaged by penetration.
- Injuries, when they do occur, heal rapidly and often completely.
- With onset of puberty, evidence of healed injury may be obscured by changes in hymen tissue due to estrogen effect.
For recommendations related to how to document the normal examinations in cases of suspected sexual abuse, see DOCUMENTATION: Documenting the Diagnosis.
Interpretation of Genital Findings
Interpretation of genital findings are best left to experts in child abuse pediatrics.
Significant genital bleeding should be referred immediately for evaluation and treatment for potential life-threatening blood loss. For more information see: TRIAGE: Appropriate Level of Care.
An abnormal hymen or other genital finding is rarely, if ever, diagnostic of child sexual abuse and must be interpreted in the context of the history and complete physical examination. If possible, photographs of findings should be obtained to enable a second opinion and peer or expert review. For more information, see: DOCUMENTATION: Photographic Documentation.
For a comprehensive chart regarding the interpretation of genital findings, see: Kellogg ND, Farst KJ, Adams JA. Interpretation of medical findings in suspected child sexual abuse: An update for 2023. Child Abuse & Neglect. 2023; 145 (3) : 106283. https://cdn.icmec.org/wp-content/uploads/2023/10/Revised-Adams-Guidelines-2023.pdf (DOI) .
Genital Bleeding
Genital bleeding in a prepubertal girl may be a presenting complaint that leads to the suspicion of child sexual abuse. There are many medical possibilities for a history or finding of genital bleeding. The table Prepubertal Genital Bleeding: Diagnostic Possibilities, below, provides information regarding the differential diagnosis of genital bleeding.
The diagnosis of sexual abuse is generally based on clinical assessments and exhaustive evaluations for other diagnoses are generally not medically relevant.
May see other signs of “mini” puberty in a newborn, such as breast buds and occasionally breast milk production
inadequate hygiene
History of bubble baths or other irritants, tight fitting clothes (pants)
If persistent and foreign body is suspected but not identified, consider examination under anesthesia (EUA).
Vaginal foreign bodies have been reported in child sexual abuse
sexually transmitted infections (STIs); non-sexually transmitted infections; GI or respiratory pathogens
Peripheral: exposure to exogenous sex steroids
Central: history of headaches, visual changes, head trauma, or neurologic symptoms, history of brain tumor (radiation treatment), anosmia
Examine for an enlarged thyroid, cafe au lait spots, hirsutism, breast bud development, adnexal masses, estrogenized hymen
Epistaxis
Bleeding with circumcision or dental procedures
Family history of bleeding
Examine for bruises, other mucocutaneous bleeding
Examine for abdominal mass or between the labia at presentation, including possible polypoid mass protruding from vagina
Examine for hemangiomas (possibly) found elsewhere on body
Abdominal pain
Examine for palpable abdominal mass, palpable mass between vagina and rectum, polypoidal, nodular mass or flat ulcerated mass
With rhabdomyosarcoma may see “grape-like bunch" mass with vaginal introitus protrusion
With adrenal tumors may also see clitoromegaly, hirsutism
Abdominal pain
Abdominal pain/swelling
Difficulty with urination
Painless vaginal spotting
With infections or infestations, evaluate for urinary tract infection, consider pinworm testing (leeches have been reported)
Examine for suprapubic tenderness
Urate crystals
Urinary tract infection
Infestation
Scaly lesions, family history (autoimmune)
Autoimmune reactions may result in scaly lesions that occur elsewhere on body.
Table created by Aysha Malawaraarachchi, senior medical student (2025), as part of a research project at SUNY Upstate Medical University, Norton College of Medicine. Ann S. Botash, MD, mentor/advisor.
Adapted from Frasier, LF. Child abuse or mimic: Vaginal bleeding in an infant. Cliggot Publications. Consultant for Pediatricians. 2003; 2 (1) : 30-33.
Updated using Moore Y, Hopkinshaw B, Arrowsmith B, White C, Gabriel L. Genital bleeding in prepubertal girls: a systematic review. Archives of Disease in Childhood. 2025; 110 (5) : 358-362. (DOI)
Spermatozoa
A lack of spermatozoa is not conclusive evidence that an assault did not occur. Historically, medical and law enforcement personnel have placed significant emphasis on the presence of spermatozoa in or on the body or clothing of a sexual assault victim as the most positive indicator of sexual offense. This contributes to the misconception that the absence of spermatozoa means no sexual offense occurred.
Offenders may not have ejaculated during the offense, some may have had a vasectomy, used a prophylactic, have a low sperm count (common with heavy drug use or alcohol use), ejaculated somewhere other than in an orifice or on the victim's clothes or body, or fail to ejaculate if the assault is interrupted. Therefore, a lack of spermatozoa is not conclusive evidence that an assault did not occur. It only means that spermatozoa may have been destroyed after being deposited or that spermatozoa may never have been present.
If spermatozoa are identified on the body or clothes of a child, the information can be critical to the legal prosecution of the case. The finding of spermatozoa is useful for these reasons:
- It is an indication that ejaculation occurred and semen is present.
- When spermatozoa are motile, it can be an indicator of the length of time since ejaculation.
- DNA isolated from sperm can be used to identify the source.
Sexually Transmitted Infections
Some STIs are caused by microorganisms that live exclusively in or around the genitalia or rectum of an infected person. They are almost always transmitted through sexual contact. Other microorganisms, in addition to living in or around the genitalia or rectum, also live in non-sexual areas of the body. Infections by these microorganisms can be transmitted by sexual or non-sexual contact.
Some infections are caused by viruses. These may similarly be of concern when isolated to the genitalia or may be the result of non-sexual transmission. An example may be autoinoculation in a child of herpesvirus from a lip lesion to the genitalia. Certain STIs are transmitted to children in the perinatal period, during or before birth. The healthcare professional should always consider other ways of transmission, such as birth process, blood transfusion, consensual sexual activity and auto-inoculation.
Suspicions should be reported to the New York State Central Register or local hotline. The absence of a sexually transmitted disease does not rule out the possibility of sexual abuse.
Infections with a high likelihood of sexual transmission include Chlamydia trachomatis, Neisseria gonorrhoeae, Treponema pallidum (syphilis), and Human Immunodeficiency Virus (HIV). In the presence of other evidence of sexual abuse, the finding of a sexually transmitted disease may be diagnostic of child sexual abuse.
