Sexual abuse of English boys and girls: the importance of anal examination.

Child sexual abuse is attracting increasing attention in the United Kingdom. In Leeds this is reflected in the work of two pediatricians who receive multiagency, direct referrals for children of all ages. Over two years 1,368 referrals were received for all kinds of abuse and neglect, including 608 for suspected sexual abuse (Hobbs & Wynne, 1987a), of which 337 (243 girls, 94 boys) were confirmed or probable cases. The abuses included genital touching, masturbation, oral, vaginal and anal penetration. Of these abuses, 30% (which were frequently multiple) involved and penetration by finger or penis; and 42% of 337 children exhibited one or more anal findings, rising to 60% of 115 children in the 0-5 years of age group. The diagnosis of abuse was made from results of multidisciplinary assessment including medical examination. Genital findings were present in 3% of boys and 50% of girls. Anal findings included erythema; swelling (tyre); laxity; shortening or eversion; reflex anal dilatation (dilatation); fissures; venous congestion; reversible and permanent skin changes; twitching; funnelling; hematoma and bruising; as well as signs of infection. The pattern of anal signs varied with the age of the child and chronicity of abuse, as judged from the history. Healing and resolution of anal physical findings on follow-up were observed from days to months after initial examination. The general absence of these findings in the group of children judged not to have been sexually abused supports a cause and effect hypothesis, but further research is required. Medical examination of every child where symptoms, signs, or situation raise the possibility of abuse or neglect must include anal inspection, but instrumental or digital examination is not recommended.