A normal genital examination does not preclude sexual abuse.
A 2-year-old girl was brought to a sexual abuse clinic by a social worker and the child’s foster mother. The child had been placed in the foster home 2 days earlier and the foster mother was concerned about a reported history of sexual abuse. The only known history was that the child was from a distant county where there had been allegations of sexual abuse. The family had fled their home when they learned that they were being investigated and had been on the run for 6 months when they were arrested on unrelated charges.
The genital exam was normal and the only physical abnormality was a facial scar (Figure). A phone call to child protective services in the county of origin revealed no useful information other than that the report of abuse had been an anonymous call.
Has this child been abused or is this case a child abuse mimic?
Answer: This was a case of child abuse.Discussion
There was no previous knowledge or documentation of the facial burn. The pattern of the lesion was recognized as similar to that of a burn seen on a child several weeks earlier in the abuse clinic. That child had been forced to stand for an undisclosed amount of time on a hot heater vent. The striking physical finding pertaining to the facial scar was that it was the only mark on the child’s skin. There were no self-protective marks or reflex scars to indicate that the child had tried to move away from the heat source. These concerns were shared with the prosecutor.
Working with the prosecutor and the investigating officer, a series of warrants were issued and the family’s former residences were searched. A large floor vent was found that matched the scar on the child’s face. The investigating officer then searched records of physicians and 3 local emergency departments in the surrounding counties for evidence of burn care. There was no record that the child had been taken for medical care. Finally, consultation was sought with a dermatologist and plastic surgeon. The consultants concurred that this burn would have needed medical care in the acute phase.
The biological mother was interviewed and the facts that were known were presented to her. In a very emotional disclosure she described how the father had forced and held the child’s face on the hot floor vent. She had not sought medical care out of fear of the legal consequences for the father. The parental rights of both were terminated and both were convicted of child abuse.
The judge was so moved by the case that the court ordered plastic repair for the child at the court’s expense because Medicaid did not cover cosmetic surgery.
This case is not offered to illuminate the medical work-up or to highlight a differential diagnostic challenge. Rather, it is a poignant reminder of the need-and the challenge-to view the child who may have been abused in the context of a complex life story. A normal genital examination did not confirm sexual abuse but it satisfied the inquiry made by the referral source. It was the scar left by an old injury, however, that was the key to further investigation that moved the child to a safe environment. It is essential to look beyond the obvious.
In most cases of obvious abuse, careful attention to the known details will result in discovery of the truth.
• Complete a thorough history and examination in all suspected cases of abuse.
• A normal genital examination does not preclude sexual abuse.
• Multiple skill sets-medical, law enforcement, social services, and legal-are needed to provide good care for abused children.