The acute evaluation should be categorized as urgent or semiurgent. Waiting times should not exceed 1 hour for the appropriate medical care provider to be available. Consideration should be given to providing a victim/family waiting area that is separate from that used by the general ED population. Emotional support can begin as soon as the case is recognized, utilizing resources such as the ED’s social worker, a child protection worker, or a rape crisis worker, particularly for teenage victims. Some programs can provide separate support personnel for the patient and the family member.

Child sexual abuse victims are still pediatric patients. Routine triage should include at least an accurate measurement of weight, for use in calculating drug doses. The rest of the basic vital signs should be collected according to existing ED protocols.

A detailed medical history is necessary for the proper assessment of an alleged child sexual abuse case. Starting with familiar medical history collection can ease the patient or family into the details of the alleged incident. When very small children are
involved, the parent’s knowledge of the incident is generally all that is available. If possible, the parent’s comments should be collected at a place that is out of the hearing range of the child. The routine history can be collected and a review of systems conducted with parent and child together so that both may contribute; the practitioner then has the option of asking the parent to step out of the room so that details about the abuse incident can be ascertained from the child. Some children want to keep the accompanying parent in their sight at all times, so each case must be handled individually.

When possible, the child should be alone when asked by the examiner for details about the abuse. The child should never be questioned in the presence of the alleged abuser. Open-ended questions (such as, “Why are you here?”) should be asked whenever possible.

It is not completely clear what level of history collection will be exempted from hearsay rulings and what will not. What patients say to medical care personnel to obtain appropriate medical care is usually protected from hearsay exceptions. What is said to the first medical personnel encountered by the victim after the incident will likely be exempted from hearsay as well, but unfortunately these providers are not necessarily experienced in interviewing young children.

Information about the incident is needed to correctly assess and treat the patient. The time of initial presentation and disclosure is often when the child is most willing to talk about the incident. Children who are freely giving verbal narratives should be allowed to talk, and everything should be documented carefully. Some other children may not want to speak at all in the acute setting, and their wishes should be respected. The practitioner should record the child’s actual words in quotes and, ideally, the question that elicited the response.

In all states, physicians are mandated by law to report cases of suspected child sexual abuse. If sexual abuse is not the presenting complaint but a physical symptom has made the family suspicious (e.g., blood in the underwear, vaginal discharge, “it looks funny down there”), then child protection authorities would be notified only if something in the examination corroborates this suspicion (genital trauma, a sexually transmitted disease [STD] [Table 8-1], disclosure by the child). Professionals who examine children for evidence of sexual abuse must be aware of variants of normal conditions and conditions that mimic sexual abuse. Examples are urethral prolapse, which can cause blood stains in the underwear and vaginal discharge, which can be caused by the onset of puberty at as young as 8 or 9 years of age. In 1996, Kini et al. associated clinical indicators with appropriate levels of concern for use during the physical examination of children in whom sexual abuse is suspected (1) (Table 8-2). Even in the absence of physical symptoms or findings, if the family expresses reasonable concern about sexual abuse, the case should be reported to child protective services. It is reasonable suspicion of assault or abuse, not medical certainty, that is required for making a report to authorities.