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Primary care providers are often the first point of contact when there are concerns of child sexual abuse. The history is the key factor in making the diagnosis as most children who have experienced child sexual abuse do not have an abnormal anogenital examination. When anogenital symptoms precipitate concerns for sexual abuse, especially in the absence of a history of sexual abuse, it is important to be aware of conditions that mimic sexual abuse. Being familiar with such conditions allows the provider to determine appropriate management, differentiate an anatomical variant or medical condition from abuse, and provide reassurance to the patient and family. Unnecessarily reporting these cases can have detrimental effects on the patient and family. If any doubt arises, patients can be referred for further evaluation by an expert in child abuse. This article presents many common medical conditions that can mimic sexual abuse, with a focus on history, examination findings, and management. [Pediatr Ann. 2020;49(8):e334-e340.]., (Copyright 2020, SLACK Incorporated.)

Objectives: to identify characteristics of victims of sexual assault or domestic violence who consulted in a Department of Forensic Medicine without a formal complaint to the police., Methods: observational study (03/01/2014-08/31/2015) of individuals (age>15years) consulting in a Department of Forensic Medicine near Paris, France, after a sexual assault or domestic violence. Among the individuals who were examined in the department of Forensic Medicine, we compared the individuals who had not complained to the police to those who had complained to the police., Results: A hundred and nine individuals have consulted without a prior complaint to the police, including 73 persons after domestic violence (i.e. 4% of all persons examined with or without a complaint to the police) and 36 persons after a sexual assault (i.e. 8% of all persons examined). Regarding domestic violence, the proportion of persons presenting recent traumatic injuries was lower among those who did not complain to the police than among those who did (64% vs. 78%, P=0.008). Regarding sexual violence, the persons who did not complain to the police were more frequently uncertain about the assault (42% vs. 13%, P<0.001), reported more frequently a recent alcohol or drug intake (42% vs. 26%, P=0.039) and less frequently showed extragenital traumatic injuries than the persons who did complain to the police (22% vs. 43%, P=0.016)., Conclusion: the persons examined who had not complained to the police accounted for less than one in 20. The extension of the activity of a Department of Forensic Medicine to persons who do not want to be involved in a judicial process is not sufficient for the majority of victims to consult a forensic physician., (Copyright © 2017 Elsevier Masson SAS. All rights reserved.)

The available research evidence pertaining to anogenital injury in victims of sexual violence presents a very wide range of injury prevalence data. As such, it is extraordinarily challenging for health care practitioners involved in clinical forensic examination of victims of sexual violence to place their examination findings in to context. It is generally accepted that the broad range of existing injury prevalence data is reflective of heterogeneous research study methodologies and clinical practice techniques. Thus, health care practitioners should be encouraged to present their evidence in the context of the prevalence data that are most representative of their clinical practice. Presented herein is a simple categorization of existing prevalence data in accordance with national clinical practice guidelines. The range of anogenital injury prevalence is narrower when presented in this manner than when taken as a whole. This will facilitate health care practitioners in presenting their examination findings in the context of research literature that is most representative of their clinical practice.

Sexual violence is a pervasive problem worldwide. Anogenital injuries are one type of injury that may be present because of sexual violence. A review of the forensic literature yielded 13 published studies from 6 countries between 1987 and 2011 that met the inclusion/exclusion criteria, illustrating that anogenital (anal and/or genital) trauma is observed in 16% to 77% of sexual assault victims. Establishing the reliability of the conclusions of these studies is difficult due to a lack of uniformity in methodology to include detection of injury, injury definition, victim age, time window for examination, injury from consensual sex, and training of examiners. Each one of these factors can change the rate of injury observed. The evaluated studies show a disparity due to a lack of uniformity in examination protocols, injury classification, and examiner qualifications. A current, state of the science, evidence-based standardized protocol should be constructed that promotes objective and accurate parameters including the use of colposcopy, staining techniques, digital photography, and adequate training for examiners of sexual assault victims who present with anogenital injury.

This paper examines the problems faced by forensic physicians assessing overweight victim/survivors of sexual assault, using sample cases and reviewing the literature. This under-researched area is a minefield of practical difficulties and unanswered questions, with the need for solutions becoming more pressing as overweight becomes more common. Overweight has the potential to alter injury patterns; the way forensic medical examinations are conducted; and injury and specimen interpretation. Pertinent questions include whether the "cushion effect" noted in motor vehicle accidents is relevant to sexual assault and how obesity-related comorbidities affect our ability to age injuries. Practical problems include positioning the client safely, obtaining clear views of areas of interest, and taking high-quality specimens. Although overweight victims appear to be uncommon in sexual assault services, as the obesity epidemic progresses clinicians will need to address these issues., (Copyright © 2012 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.)

Since 2001, the Los Angeles County Department of Coroner has collaborated with Los Angeles County-University of Southern California Medical Center Violence Intervention Program and their Sexual Assault Center. The partnership was established at the suggestion of the district attorney's office to enhance the clinical recognition of sexual assault in the medical examiner's office using the extensive experience of experts in the field of sexual assault. As of December 2008, over 5 dozen victims of sexual assault have been evaluated with this collaboration. The partnership relied on the expertise of 2 pediatricians who are established clinical experts in the field of sexual abuse and assault, in collaboration with the staff of the medical examiner's office. In cases of suspected sexual assault, a joint evaluation by the clinical experts and the medical examiner was made. The goal of the project was for the medical examiners to become more confident in their observations and documentation of crimes of sexual abuse. Even though they are still available upon request, consultations with the sexual assault experts have decreased as the skills of the medical examiner to evaluate sexual assault cases have increased.

Introduction: Sexual abuse includes obscenity, rape and sodomy. Forensic medical examinations routinely include the genital area, anus and the body of the victims for signs of recent or old injury., Objectives: To evaluate the incidence of physical evidence in forensic sexual abuse cases and to compare the Israeli findings to data from other countries, including the USA., Methods: The study was conducted during one calendar year in Israel and included 95 children from infancy to 16 years of age, of whom 83% were females. Examination results were defined by the presence of physical injury or its absence. These findings were classified by their location in the anogenital area or other body areas and findings in the anogenital area were further classified by their likelihood to have been caused by a sexual assault. The results of the examination were related to parameters such as age and sex of the participants, length of time since the last assault, and the degree of proximity between the suspected assailant and the victim., Results: Evidence of physical abuse was found in 41 patients, in 37 (39%) of these cases physical abuse was detected in the anogenital area. In all these cases of anogenital abuse, 11 (12%) showed clear evidence of sexual assault and five of them had recent signs of injury; 80% of the recent injuries in the anogenital area were identified in patients within the first 24 hours after the assault., Conclusions: The prevalence of clear evidence of sexual assault in the U.S. ranges from 3-23%, in Italy 9.5%, in Thailand 32% and in Denmark 40%. In Israel, as elsewhere in the world, few cases of sexual assault in children will have clear evidence of a sexual nature. A lack of physical evidence does not rule out sexual assault, therefore, finding physical evidence during an examination is the exception rather than rule. Questioning the victim and investigating the circumstances of the case are crucial elements in all instances of presumed sexual assault on children.

Straddle injuries are common in children. At the end of this case presentation, you should be able to describe the approach to the evaluation and treatment of a straddle injury, list indications for gynecologic consultation and/or sedation, plan disposition, and discuss pitfalls to avoid in evaluating patients with straddle injuries.