Forensic Science International 217 (2012) 14

Contents lists available at ScienceDirect

Forensic Science International

journal homepage: www.elsevier.com/locate/forsciint

Review article

Child sexual abuse

Manoel E.S. Modelli a,*, Malthus Fonseca Galvao a, Riccardo Pratesi b
a
b

Institute of Legal Medicine, University of Brazilia, Brazilia, Brazil

University of Brazilia, Brazil

A R T I C L E I N F O

A B S T R A C T

Article history:
Received 30 August 2010
Received in revised form 2 July 2011
Accepted 5 August 2011
Available online 30 August 2011

Objective: To evaluate the prevalence of sexual abuse in the pediatric population of the Federal District
and discuss the difculties in interpreting the examination of the genitalia in this age group, both by
general practitioners as medical expert forensic ofcers.
Methodology: This is a retrospective, transversal, and epidemiological study on children younger than 12
years, who attended the Institute of Forensic Medicine of DF (IML-DF), Brasilia, Brazil, with suspicion of
sexual abuse between 2008 and 2009.
Results: During this period, 3607 persons with suspected sexual abuse and 1762 (48.8%) children
younger than 12 years were treated in IML-DF. Of this total, 238 (13.5%) were boys, and 1524 (86.5%)
were girls. Among the boys, the average age was 6.5 years, and 9.6% were found to have injuries
consistent with sexual abuse. In 43.4% of these cases, the perpetrator was known. The main lesions found
were anal ssures and lacerations, bruises, and anal dilatation. In 20 cases (8.4%), the time interval
between fact and examination precluded any conclusion. The girls (1524 cases) referred to the IML-DF
were subjected to two types of tests: libidinous acts (773 to 50.7%) and rape (751 to 49.3%). In tests of
libidinous acts, 5.3% had signs of sexual abuse perpetrated by acquaintances (68.2%), and 3.0% were
inconclusive because of the long time lag between the examination and fact. In survey of rape cases, only
2.1% of subjects examined had lesions consistent with abuse. In 57 of 1524 cases, specimens were
sampled for sperm test, and ve cases (8.7%) showed positive results. The average age of girls being
sexually abused (10.7 years) was higher than that for boys (6.5 years).
Discussion: Our ndings conrm the discrepancy between the expectations of parents and the general
practitioner, and the reality of the ndings in specialized centers. Approximately 90% of child victims of
abuse do not show evidence of physical damage. These were found in less than 10% of abused children.
Physical signs of abuse often are difcult to recognize and should not be the only indicators.
Published by Elsevier Ireland Ltd.

Keywords:
Sexual abuse
Child violence
Rape

Contents
1.
2.
3.
4.
5.

Introduction .
Methodology
Results . . . . .
Discussion . .
Conclusion . .
References . .

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1
2
2
2
4
4

1. Introduction

* Corresponding author. Tel.: +55 61 34435548; fax: +55 61 34435548.

E-mail addresses: manoelmodelli@gmail.com (Manoel E.S. Modelli),
malthus@malthus.com.br (M.F. Galvao), pratesir@unb.br (R. Pratesi).
0379-0738/$ see front matter . Published by Elsevier Ireland Ltd.
doi:10.1016/j.forsciint.2011.08.006

Sexual abuse in children is a problem of epidemic proportions,

affecting children of all ages, socioeconomic levels, and cultural
backgrounds. Approximately 1% of children experience some form
of sexual abuse each year, resulting in victimization of girls of 12
25% and 810% of children younger than 18 years. Of the 3 million
cases of maltreatment of children, approximately 20% are reported

M.E.S. Modelli et al. / Forensic Science International 217 (2012) 14

as abuse sexual [1]. In Milan, in 2002, with approximately 1.3

million inhabitants, 634 cases were reported, including 110 in
children up to 14 years [2].
The Federal District, with approximately 2.6 million inhabitants, has a high rate of sexual crimes. For the years 2008 and 2009,
approximately 3607 examinations related to crimes of sexual
abuse were carried out in IML-DF, of which, 1762 involve children
younger than 12 years. Most cases of sexual abuse against children
are committed by men (90%), and in 7090% of these, the
perpetrator is known to the child. Sexual abuse affects approximately 12% of girls younger than 14 years, and in 3050% of these
cases, the perpetrators are family members [1,3].
Diagnosing sexual abuse is a challenge because many children
do not report the abuse, and the physical ndings tend to be absent
or nonspecic. The prevalence of child victims of sexual abuse has
been little described in developing countries. Bassani et al. [4],
through a condential questionnaire, found that the prevalence
among girls and boys was 5.6% and 1.6%, respectively, in Canoas, a
city in southern Brazil. Aded et al. [5], in the city of Rio de Janeiro,
found a higher rate of sexual abuse (22.73%) in boys aged 014
years. Machado et al. [6], in Florianopolis, found that the majority
of cases occurred in females, and in 39.4% of these cases, the father
was responsible, showing the prevailing practice of continuous
libidinous acts involving children aged 710 years. In 1977, Kempe
[7] called sexual abuse in children as a hidden pediatric problem.
Currently, it has been more reported, questioned, and investigated.
In 2002, more than 88,000 children were sexually abused in the
U.S., constituting 1225% of girls and 8010% of boys aged 18 years
or younger [8]. Worldwide, the abuse has been identied in
percentages ranging from 736% in girls and 329% in boys [9].
Sexual abuse is dened as any sexual activity that the child
cannot understand or give consent or that violates the law. Sexual
activity may include fondling, oral-genital contact, rape, penetration genital or anal, exhibitionism, voyeurism, and exposure to
pornography [10,11]. It is considered that any sexual contact
between an adult and a child is considered abuse because children
aged 12 years should not be involved in any sexual activity.
2. Methodology
The work consisted of a retrospective analysis of cases of sexual abuse in children
younger than 12 years examined at the Institute of Forensic Medicine of the Federal
District (IML-DF), Brasilia, Brazil, during the years 20082009. We investigated
gender, type of sexual aggression, degree of acquaintance between the victim and
the offending agent, and the lesions found.

3. Results
During the two years, 3607 people suspected of sexual abuse
and 1762 (48.8%) children younger than 12 years were treated in
IML-DF. Of this total, 238 (13.5%) were boys, and 1524 (86.5%) were
girls. The average age of boys was 6.5 years, and injuries consistent
with sexual abuse were found in 9.6%. Among the positive cases
(with injuries), the offending agent was known to the victim in 10
cases (43.4%). In 11 cases, the agent was unknown, and in one case,
anal ssures were detected by general practitioners. In other
isolated cases, there was no reference about the author. The main
lesions found in boys were ssures, lacerations, bruises, and anal
dilatation. In 20 boys (8.4%), the time interval between fact and
examination precluded any conclusion. The physical examination
Table 1
Distribution by age and sex.
Age (years)
Male (23 cases)
Female (57 cases)

2
1
1

3
2
6

4
2
6

5
4
5

6
2
2

7
5

9
4
5

10
1
1

11
2
6

12

15

Table 2
Positive ndings, mean age and known offenders.
Libidinous act

Rape

Mean age (years)

Known offenders

2.1%

6.54
10.7

43.4%
68.2%

Positive ndings
Male
Female

9.6%
5.3%

in 82% of boys was normal. The distribution of children with

positive ndings on physical examination is shown in Table 1.
The 1524 girls referred to the IML-DF were subjected to two
types of tests: libidinous acts, such as fondling and bites (773 or
50.7%) and rape (751 or 49.3%). In surveys of indecent assault, 5.3%
of girls showed signs of sexual abuse perpetrated by acquaintances
(68.2%), and 3.0% were inconclusive because of the long time
interval between the examination and fact. In six cases, the
perpetrator was unknown, two children had a fall, a child was
referred for suspicion of the mother, one complained of pain in the
genitals, and two had no history of abuse. Lesions were foundanal
and labial ssures and bruises in anal, vaginal, breast, thigh, and
neck areas. In surveys of carnal intercourse (rape) (751 cases), only
16 (2.1%) presented lesions. In 57 cases (7.5%), specimens were
collected, which were positive for sperms in ve cases (8.7%). The
average age of girls who are victims of rape was higher (10.7 years)
than that in cases of libidinous acts (7.0 years) (Table 2).
Associated injuries were rare outside of the genitalia, some
cases had bruises on her thighs and one case had bruises on the
neck. None had a history of using alcohol or drugs before the
assault.
4. Discussion
Among the 1762 cases of children younger than 12 years, who
were suspected to be sexually abused and examined in the IML-DF
in the two-year period, approximately 4.5% presented themselves
with lesions at physical examination. Low percentages of positive
ndings are common in the literature. Edgardh et al. [12] reported
no injuries in 2673% of girls and 7594% of boys at physical
examination. Smith et al. [13] drew attention to the discrepancy
between the expectations of parents and general practitioners, and
the ndings in specialized centers.
The general practitioner has a key role in the evaluation of
suspected child sexual abuse. The knowledge of the results is
important to understand where and how to refer suspected cases.
The referral to a judicial authority must be done in the presence of a
reliable history or the presence of physical ndings [2].
The diagnosis of sexual abuse is of unquestionable importance,
but the wrong diagnosis can lead to irreparable damage to the
child, family, and suspects; therefore, referrals to forensic services
should be well founded and made by people with knowledge on
the normal anatomy of the child and pathological conditions that
simulate injuries caused by sexual abuse. Many abnormal
anatomical changes are now considered nonspecic variations,
such as increased hymen diameter, partial notches, changes in
tone, or anal dilatation [3,14].
The story is the main point in the investigation of sexual abuse
and should be obtained from parents, caregivers, and children
themselves. The physician should have an understanding of
interview techniques and abnormal behaviors of children because
psychological and interpersonal problems are more common
among those who suffered sexual abuse. The evaluation of sexual
abuse requires a multidisciplinary approach [1,15].
Guidelines for evaluation of abused children has been published
regularly, such as those by Adams et al. [11,1619]. The APSAC (The
American Professional Society on the Abuse of Children) is the
most popular interdisciplinary society and has developed practical

M.E.S. Modelli et al. / Forensic Science International 217 (2012) 14

guidelines for investigation of child victims of abuse [20,21].

Laraque et al. [22], on a review of assessment of child sexual abuse,
discuss the psychological and forensic aspects of these children
and emphasize the need to assess the child as a whole and to
minimize trauma during the investigation process.
The Committee on Child Abuse and Neglect of the American
Academy of Pediatrics also has published guidelines for adequate
assessment [8]. In all children suspected of sexual abuse, a medical
evaluation should be offered, with the following objectives: to
obtain a history of child or guardian; to consider alternative
explanations for signs and symptoms; to identify and document
evidence of trauma or infection; to diagnose and treat medical
conditions resulting from abuse, to identify and treat medical
conditions unrelated to abuse; to consider the possibility of
developmental, emotional, or behavioral problems that may arise;
to evaluate the childs safety and make a report to protective
services, if necessary to reassure the child and family appropriately; to document the ndings for future decisions; and to help
ensure the well-being of children [19,23,24].
In our study, 1524 girls younger than 12 years were examined
50.7% for examinations of libidinous acts and 49.3% for examinations of rape. The rate of abnormal ndings was between 2.1% and
5.3%, depending on the type of examination. These abuses were
caused by acquaintances in 68.2% and consisted of perineal
bruising, lacerations of the genitalia, and transections of the
hymen.
Children should generally be examined in the supine position,
using labial separation or traction. Where it is not possible to
visualize the posterior aspect of the hymen, the prone position
(kneechest) can be used. In cases of redundant hymens, some
techniques can be used to allow better visualization of its edges
and provide a correct diagnosis of the lesions: use of a wet swab;
use of Foley catheter; making a slight traction of the balloon,
partially inated; or introduction of serum in the vaginal cavity.
The use of colposcope [25], a medical instrument, interposes a
distance of 30 cm between the examiner and the childs body and
provides a magnied image of the genital, perineal, and edges of
the hymen. The examination provides a good lift and light source
and clear photos and is considered the best method of
documentation and review.
The rst step is to understand the physical examination and
their pediatric genital variations [26]. Some similar changes may
be seen in children abused and not abused, such as labial
adhesions, increased vascularity, vestibular lines, hymen friability,
depression perianal, hymeneal appendices, surface elevations, and
indentations. Evaluation of the hymen is challenging because its
appearance changes with age, according to hormonal inuences.
Maternal estrogens cause the hymen in the newborn to have a
thick appearance and become pale, elastic, and redundanteffects
that last up to 23 years of age and may reappear at puberty [1].
There is no scientic report of congenital absence of the hymen.
The mucosa of the newborn hymen is eshy and redundant, and
anatomical characteristics, such as appendices and ridges, can be
seen. Hymeneal appendages are elongated projections that
originate from anywhere on the rim hymen and usually involutes
up to 3 years of age. Notches in the upper portion of the hymen are
normal and should not be construed as evidence of trauma healing.
No congenital notch depth has been reported in the posterior
hymen in normal children. Most hymeneal measures lack
sensitivity or specicity to be used as evidence of previous
penetration [27].
In boys who are victims of sexual abuse (238 cases), the
incidence of injuries at initial examination was higher (9.6%) than
that in girls, and the most frequently found injuries were cracks,
lacerations, bruises, and anal dilatation. Erythema, pigmentation,
and venous congestion are common ndings in the anal region as

well as constipation associated with dilation and presence of feces

in reto [28,29]. Sporadic cases of introduction of foreign bodies in
the rectum have been described [30,31].
Anal ssures are breaks in the anal mucosa that may extend to
the perianal skin and can be caused by constipation. It may be
supercial or deep. The surface heals quickly (in a few days) and
leaves no scars. The deep ssures take longer to heal and leave a
linear scar or white appendages anais [32,33].
For the forensic medical expert, many difculties are encountered in cases of sexual abuse in children because, in most cases,
the evidence is mainly subjective [34]. The child victim of abuse
may have anogenital symptoms and signs, such as bleeding, pain,
inammation, and vaginal discharge. The differential diagnosis of
genital lesions arising from sexual abuse should be done with those
caused by trauma and those resulting from clinical pathologies,
such as atrophic lichen sclerosus, vulvar pemphigus, vaginal
hemangiomas, urethral polyps, Behcets syndrome, Crohns disease, perianal lymphangioma, aphthous ulcers, perianal streptococcal cellulitis, infantile perineal protrusion, and congenital
anomalies [3537].
Pillai [38] classied the ndings as normal (remaining hymen,
appendices, and slots) and nonspecic (erythema, vaginal secretions, friability of the posterior commissure, close hymen, anal
ssures, venous congestion, anal dilatations smaller than 2 cm, and
fecal soiling), and diagnosis of sexual abuse (positive culture for
Neisseria gonorrheae outside the neonatal period) conrmed
diagnosis of syphilis (discarded vertical transmission) or Trichomonas vaginalis infection in children older than 1 year; positive
culture for Chlamydia in child older than 3 years, HIV infection,
ruling out other causes of contamination, pregnancy, and sperm in
the body of a child. In prepubertal children who are victims of
abuse, a description of the forensic examination is usually normal
or nonspecic. For the past 20 years, there has been a considerable
increase in understanding of child sexual abuse. While disputes
and disagreements still exist, a body of knowledge has been
developed on the epidemiology, manifestations, and consequences
of the attacks. We have learned that physical examination most
often is normal, even in the face of a history that suggests genital
injuries [38].
There are a number of reasons to explain why the physical
ndings are uncommon in children who are victims of abuse: the
abusive acts are usually different from those committed against
adults, the perpetrator is usually known to the child, and the
perpetrators interest is not to hurt the child. Most young children
have no concept of the degree of penetration, and they are usually
slow to report the fact, giving time for supercial lesions to heal.
Partial lacerations of the hymen can heal with the formation of
notches, which also are seen in children who were not abused.
Hymeneal transections often can only be differentiated from
abusive or traumatic history [28,39]. In pubertal children, estrogen
makes the hymen tissue thicker and more compliant, so the
detection of trauma may be more difcult [10]. The violence
caused by unknown are less common but more violent, often
involving the use of physical force.
The main objectives of forensic examination are to maximize
the ability to collect and preserve material evidence for potential
use in the legal system and to identify injuries and minimize the
physical and psychological trauma [40]. During the rst 72 h of
testing, attention should be given to clothing, secretions in the
skin, oral swabs, vagina, penis, and rectum. Tests for sexually
transmitted diseases should include search for Neisseria gonorrheae, Chlamydia trichomonas, genital warts, herpes, syphilis,
hepatitis, and HIV [41].
The presence of semen, sperm, and acid phosphatase and
positive serologic test for syphilis or HIV and culture for gonorrhea
are considered absolute positive evidence of sexual abuse because

M.E.S. Modelli et al. / Forensic Science International 217 (2012) 14

congenital or acquired conditions secondary to transfusion are

excluded. Swabs should be taken from the vulva, vagina, rectum,
and pharynx [41].
In acute cases of sexual abuse, it is important to remember that
testing for gonorrhea, Chlamydia, Trichomonas, and bacterial
vaginosis should occur two weeks after the fact if the patient
has received prophylactic treatment at the time of initial
examination. Serologic tests should be performed for syphilis,
HIV, and hepatitis B (depending on the immunization with six, 12,
and 24 weeks) [10].
Antimicrobial therapy should be started in prepubescent child
based on the results of laboratory tests. For sexually active
adolescents, having a framework of acute sexual abuse, prophylactic antibiotics for the treatment of gonorrhea, Chlamydia,
Trichomonas, and bacterial vaginosis should be given. Following
a case of sexual abuse, pregnancy prophylaxis should be offered to
teenagers after informed consent was obtained and pregnancy
tests are negative, with the exclusion of pregnancy before the fact.
Prophylactic treatment should be started within 72 h of the attack
and immediately after taking two tablets of emergency contraceptive pills (Ovral or Preven) and another two tablets 12 h later.
Because nausea is a normal side effect, antiemetics should be
prescribed [10].
5. Conclusion
Unfortunately, the silence is the trademark of domestic violence
against children and adolescents. In these cases, the health
professional is, by law, obliged to notify the Guardianship Council
whenever there is suspicion or conrmation of a case of abuse. The
general practitioner (often, the rst physician to be consulted) has
a key role in assessing the child abuse victim. Knowledge of
patterns of abuse and the childs normal anatomical variations is
essential for the proper conduct of cases. The history of the child
should be valued because the physical signs are scarce, and the
interpretation of ndings is highly variable, depending on the
degree of professional training of the one examining the child. The
normal physical examination does not mean anything accountable
[42].
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