The simple statement “I can tell you because you're a doctor” is a testament to the trust that patients have in their doctors. It is this special relationship that provides an opportunity for patients to share sensitive, personal information in a way that they are unlikely to share with anyone else. As Carl Jung so eloquently said, “The patient who comes to us has a story that is not told, and which as a rule no one knows of… . It is the patient's secret, the rock against which he is shattered. If I knew his secret story, I have the key to the treatment. The doctor's task is to find out how to gain that knowledge.”1 Jung's observation could not ring truer than when trying to understand what a child suspected of being sexually abused has experienced. After sexual abuse, children have worries and concerns about their bodies. Pediatricians are uniquely positioned to understand and address those concerns in the context of the medical history. Once again, the least high-tech aspect of modern medicine and the foundation of any diagnosis is the medical history. No doubt, talking to children about inappropriate sexual experiences is not intuitive and requires specials skills, but it is these skills that are critical for diagnosing child sexual abuse.
Over the last 30 years we have learned much about the clinical expression of the sexually abused child, normal anogenital anatomy, healing of anogenital trauma, and the pediatrician's role in recognition, reporting, and treatment.2–7 We know through large case studies that <5% of sexually abused children have physical examination findings that, on their own, are diagnostic.8
The article by DeLago et al9 in this month's issue of Pediatrics Electronic Pages, “Girls Who Disclose Sexual Abuse: Urogenital Symptoms and Signs After Genital Contact,” refocuses the diagnosis of child sexual abuse on medical history–taking skills to obtain the most available form of evidence in cases of sexual abuse: the spoken word. When children have opportunities to express their worries about symptoms they experienced related to inappropriate contact, their worries can be alleviated.
The significant prevalence of signs and symptoms that children disclose temporally related to inappropriate sexual contact, as elucidated in this article, provides an opportunity to enhance diagnostic certainty. The signs and symptoms of dysuria, pain, and/or bleeding as a result of a specific form of contact without preexisting conditions are more significant than the infrequent finding of acute or healed genital trauma. It is precisely these historical details, as well as the idiosyncratic statements of children, that provide the greatest insight into a child's experience. These details are unlikely to be shared by children with anyone other than a doctor, which makes a qualitative difference in the type of information that can be obtained by simply taking a detailed medical history. Physicians, not forensic interviewers, are uniquely qualified to obtain and interpret examination findings and associated signs and symptoms to formulate a sound and defensible medical opinion.
No doubt it is the collective insight of law enforcement, child protection, mental health, and medical professionals that results in the most complete understanding of a sexually abused child's experience, but now, by the mere act of enhancing medical history–taking skills, medical professionals can bring much more to the table.
- Accepted May 22, 2008.
- Address correspondence to Martin A. Finkel, DO, FACOP, FAAP, CARES Institute, Department of Pediatrics, UDP Suite 1100, School of Osteopathic Medicine, 42 E Laurel Rd, Stratford, NJ 08084-7036. E-mail:
The author has indicated he has no financial relationships relevant to this article to disclose.
- ↵Jung CG. Memories, Dreams, Reflections. New York, NY: Random House; 1965:117
- ↵Berenson AB, Heger AH, Hayes JM, Bailey RK, Emans SJ. Appearance of the hymen in prepubertal girls. Pediatrics. 1992;89 (3):387– 394
- Finkel MA. Anogenital trauma in sexually abused children. Pediatrics. 1989;84 (2):317– 322
- McCann J, Miyamoto S, Boyle C, Rogers K. Healing of hymenal injuries in prepubertal and adolescent girls: a descriptive study. Pediatrics. 2007;119 (5). Available at: www.pediatrics.org/cgi/content/full/119/5/e1094
- Dubowitz H. Healing of hymenal injuries: implications for child health care professionals. Pediatrics. 2007;119 (5):997– 999
- Christian CW, Lavelle JM, De Jong AR, Loiselle J, Brenner L, Joffe M. Forensic evidence findings in prepubertal victims of sexual assault. Pediatrics. 2000;106 (1 pt 1):100– 104
- ↵Heppenstall-Heger A, McConnell G, Ticson L, Guerra L, Lister J, Zaragoza T. 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 (4):829– 837
- ↵DeLago C, Deblinger E, Schroeder C, Finkel MA. Girls who disclose sexual abuse: urogenital symptoms and signs after genital contact. Pediatrics. 2008;122 (2). Available at: www.pediatrics.org/cgi/content/full/122/2/e281
- Copyright © 2008 by the American Academy of Pediatrics