Module 2 Up To Date Articles:
GENDER ISSUES
2.1
Male Reproductive Physiology
James E. Griffin, MD, Jean D. Wilson, MD; February 3, 2010
1. Explain spermatogenesis and its regulation.
SPERMATOGENESIS AND ITS REGULATION — Each spermatogonium that undergoes
differentiation after puberty gives rise to 16 primary spermatocytes, each of which then enters meiosis and
gives rise to four spermatids and finally four spermatozoa (figure 6). Thus, the 3 million spermatogonia
that begin the process each day give rise to approximately 200 million spermatozoa [48]. Since about onehalf of potential sperm die during this process, 100 million sperm are produced each day [48]. A
spermatogonia-specific transcription factor, Plzf, identified in mice, is the first mammalian gene known to
be required for stem cell self-renewal [49,50].
Transformation of the spermatid into a mature sperm requires restructuring of the blood-testis barrier and
involves reorganization of the nucleus and cytoplasm and development of a flagellum [51]. The nucleus
relocates to an eccentric position at the head of the spermatid and is covered by an acrosomal cap. The
cilial core of the sperm tail consists of nine outer fibers and two inner fibers surrounded in the middle
section by mitochondria and in the terminal section only by a cell membrane.
Sperm motility is due to the sliding action of the fibers in the axial structure of the tail. The fibers (or
microtubules) are attached to each other by arms that contain the protein dynein, an ATPase. Hydrolysis
of ATP generated in adjacent mitochondria provides energy for motility.
Sperm formation takes approximately 70 days from the spermatocyte stage, and the transport of sperm
through the epididymis to the ejaculatory ducts requires about 14 days. Some maturation of sperm occurs
during passage through the epididymis, as evidenced by enhancement of motility, but the final maturation
(or capacitation) of sperm may take place after ejaculation into the female urogenital tract.
Normal spermatogenesis requires the lower temperature of the scrotum compared to that in the abdomen.
However, a slight increase in scrotal temperature of about 1ºC, as for example with the wearing of athletic
scrotal supports, does not appear to impair sperm number or quality [52].
2.1
Male Reproductive Physiology
James E. Griffin, MD, Jean D. Wilson, MD; February 3, 2010
2. Define the transport of gonadal steroids.
Transport of gonadal steroids — Gonadal steroids are transported in the plasma largely bound to
albumin and sex hormone-binding globulin (SHBG, also called testosterone-binding globulin or TeBG).
In normal men, approximately 2 percent of plasma testosterone is free or unbound, 44 percent is bound to
SHBG, and 54 percent is bound to albumin and other proteins [36]. Although it has about 1000-fold lower
affinity for testosterone binding than does SHBG, albumin binds half or more of plasma testosterone
because of its high concentration. Since nearly all of the albumin-bound testosterone is available for tissue
uptake [37], bioavailable testosterone in plasma approximates the sum of free plus albumin-bound
hormone.
The concentration of SHBG in men is about one-third to one-half that in women, and prepubertal boys
and hypogonadal men have higher SHBG levels than normal men. The serum SHBG concentration is
decreased by androgen administration and by hypothyroidism and increased by estrogen administration
and hyperthyroidism. Alterations in the SHBG concentration do not affect androgen physiology in the
steady state in normal men because the hypothalamic-pituitary system responds to acute changes in
concentrations of bioavailable testosterone by altering testosterone synthesis and reestablishing a normal
serum level of bioavailable testosterone.
2.1
Male Reproductive Physiology
James E. Griffin, MD, Jean D. Wilson, MD; February 3, 2010
Describe testicular function during different stages of life.
TESTICULAR FUNCTION DURING DIFFERENT PHASES OF LIFE — Distinct phases of male
sexual life—fetal, neonatal, pubertal, and adult—can be defined in terms of the plasma testosterone level.
In the fetal phase, testosterone production by the testes commences during the seventh week of gestation,
and serum testosterone concentrations reach 300 to 400 ng/dL (10.4 to 13.9 nmol/L), which are
maintained through the second trimester then fall, so that at the time of birth serum testosterone is similar
in males and females.
During the neonatal phase, serum testosterone rises in the male and remains elevated for three to six
months, again falling to a low level by one year of age and remaining low until the pubertal phase when it
rises and reaches adult levels by age 17 (300 to 1000 ng/dL [10.4 to 34.7 nmol/L]). The neonatal surge in
testosterone secretion results from a rise in plasma LH levels. Inhibin B levels also rise during the
neonatal period and reach concentrations exceeding those in normal adults [59].
During adulthood, sexual maturation of the male is complete, and sperm production is sufficient to allow
reproduction to take place. The serum concentration of bioavailable testosterone remains constant until
the fifth decade when it begins to decline at a rate of about 1.2 percent per year; however, total
testosterone levels do not decline appreciably until later. (See "Overview of testosterone deficiency in
elderly men".)
The physiologic events during these various phases differ, as do the pathologic consequences of
derangements in testicular function. Male phenotypic sex differentiation takes place during the fetal phase
of male sexual life. (See "Normal sexual differentiation".) The role of the neonatal surge in testosterone
production is not certain but may involve the imprinting of male gender identity. The roles of testosterone
in male puberty and the evaluation of testicular function in adult men are discussed separately. (See
"Normal puberty" and "Clinical features and diagnosis of male hypogonadism".)
2.1
Male Reproductive Physiology
James E. Griffin, MD, Jean D. Wilson, MD; February 3, 2010
List the major action of androgens in males.
Androgen action — As described above, the physiological actions of testosterone are the result of the
combined effects of testosterone itself plus its active androgenic and estrogen metabolites. The major
functions of androgens in males include the following:
•
•
•
•
Regulation of gonadotropin secretion by the hypothalamic-pituitary system
Initiation and maintenance of spermatogenesis
Formation of the male phenotype during embryogenesis (see "Normal sexual differentiation")
Promotion of sexual maturation at puberty and its maintenance thereafter
In addition, testosterone increases lean body mass and decreases fat mass. The reciprocal change in lean
and fat mass is thought to be a result of promotion of development of mesenchymal stem cells into
muscle rather than into adipocytes [38].
HOMOSEXUALITY
2.2
Primary Care of Gay Men
Harvey J. Makadon, MD; November 2, 2012
1. Distinguish the terminology used in the gay patient population.
TERMINOLOGY AND IDENTITY — The population that has come to be referred to as "gay" in the
West is not a descriptive term that would be recognized by all men who have sex with men (MSM).
While gay culture is increasingly open and discussed, the world of MSM consists of a diverse population
that often may respond differently depending on how communications in clinical settings are framed [10].
Sexual orientation is generally thought of as having three components: identity, behavior, and desire.
"Gay" is generally used to describe how people identify themselves, while "men who have sex with men"
(MSM) describes a behavior. MSM may identify themselves as gay, bisexual, queer, same-gender loving,
or heterosexual. Additionally, some who are just beginning to come out may experience desire to be
intimate with other men, but may not yet have been sexually active with men or even identify as being
gay.
Some MSM do not even regard sex with other men as sexual activity, a term they reserve for sexual
relations with women. This is particularly true among individuals from non-Western cultures [11].
Nevertheless, it is also common in the United States.
Some natal men may identify themselves as belonging to a gender that varies from the sex they were
assigned at birth. They may identify as transgender, using a term such as trans woman, or use a term such
as “genderqueer,” which blurs the gender male-female binary. Other terms are used around the world, but
transgender is often used as an umbrella term to describe individuals whose gender varies from their
assigned sex at birth. Care of transgender involves both general primary care as well as behavioral,
hormonal, and surgical care relating to eliminating gender dysphoria. (See"Transsexualism:
Epidemiology, pathophysiology, and diagnosis".) It is important that primary care clinicians know
whether their patients are transgender so they can manage these issues as well as preventive and other
care related to natal anatomy, such as screening for cancer.
These issues are important for healthcare, because issues related to sexual desire, sexual activity, and
sexual identity may lead to distinct psychological concerns and may affect risks for sexually transmitted
infections and certain cancers. Understanding a patient's sexual orientation, including one’s identity,
behavior, and desires, all have a bearing on the ability to provide quality care.
It is also important to recognize that gay men are an extremely diverse group with respect to race,
ethnicity, and socioeconomic status [12].
2.2
Primary Care of Gay Men
Harvey J. Makadon, MD; November 2, 2012
2. Interpret the studies done on the prevalence of the gay population.
PREVALENCE — Kinsey's study Sexual Behavior in the Human Male in 1948 was the first report on
homosexual experiences among men in the US [13]. More current studies suggest that about 3.5 percent
of the population identify as gay while higher percentages engage in same-sex sexual activity (8 percent)
and an even greater number are attracted to people of the same sex (11 percent) [14].
Regardless of the precise numbers, in the United States (US) census figures confirm that "same sex"headed households are widespread through the country. Such households were found in over 93 percent
of counties in every state [15]. Thus, all clinicians, at least in the US, should be considering "gay" or MSM
sexual behavior when seeing patients.
2.2
Primary Care of Gay Men
Harvey J. Makadon, MD; November 2, 2012
3. Recognize and summarize the medical issues targeted towards the gay population.
ISSUES TO TARGET — There are few population based studies of health issues in gay men. Based on
clinical experience and epidemiology, we identify a number of areas in which clinicians providing primary
care to gay men should provide additional emphasis beyond what they might focus on in heterosexual
men. A 2011 monograph published by the Institute of Medicine that highlights studies of disparities
among LGBT people in general and gay men specifically highlighted that important issues to target
include: HIV/AIDS; cancer; immunizations and infectious diseases including sexually transmitted
infections; substance and tobacco abuse; behavioral health, mental disorders, and domestic violence
[16].
HIV — In the United States (US), the incidence of new cases of HIV has remained stubbornly stable at
50,000 cases per year for many years. The HIV incidence has increased in populations of MSM,
particularly African American and to a lesser extent Hispanic adolescents and young men [17]. The
reason for the high incidence among black MSM is not due to increased unsafe sexual practices or drug
use, but related to lack of awareness of HIV status, lack of access to care, delayed recognition and
treatment of sexually transmitted infections, and increased prevalence of HIV in black MSM social
networks making the risk of any single encounter greater [18]. Statistics from the Centers for Disease
Control and Prevention (CDC) show that 67 percent of new cases of HIV in 2011 were among MSM,
including MSM who also use intravenous drugs [14,17]. The highest prevalence of HIV is found among
transgender women [19,20], who also experience high rates of sexually transmitted infections.
While a combination of prevention activities seem most effective, key interventions are universal
screening, treatment as prevention, and post and pre-exposure prophylaxis (PEP and PrEP) [21].
In the US, the CDC recommends that for effective HIV prevention [22-25]:
●Sexually active MSM should be tested at least annually for HIV and other sexually transmitted
infections.
●Sexually active MSM can take steps to make sex safer such as choosing less risky behaviors,
using condoms consistently and correctly if they have vaginal or anal sex, reducing the number of
sex partners, and if HIV-positive, letting potential sex partners know their status.
●For some MSM at high risk, taking postexposure prophylaxis can reduce risk. The CDC issued
new guidance on use of PrEP in May 2014.
●For sexually active MSM at substantial risk, pre-exposure prophylaxis (PrEP) is recommended as
one option.
●Healthcare providers and public health officials should work to ensure that:
•Sexually active, HIV-negative men are tested for HIV at least annually (providers may
recommend more frequent testing, for example every three to six months).
•HIV-negative MSM who engage in unprotected sex receive risk-reduction interventions.
•HIV-positive MSM receive HIV care, treatment, and prevention services.
Universal screening — HIV screening has long been a core prevention strategy, and can be of particular
importance in MSM. Recommendations for universal screening are discussed separately.
(See "Screening and diagnostic testing for HIV infection" and "Screening for sexually transmitted
infections", section on 'Human immunodeficiency virus (HIV)'.)
Treatment with virologic suppression for all HIV infected individuals — One of the major preventive
benefits of HIV testing is the identification of individuals who are infected and are therefore candidates for
antiretroviral therapy (ART). In the United States, ART is recommended for everyone with HIV, regardless
of CD4 count, because it may help halt the progression of disease and prevents HIV transmission by
lowering viral loads and making transmission to uninfected individuals less likely. (See "When to initiate
antiretroviral therapy in HIV-infected patients", section on 'Impact of ART on HIV transmission'.)
Use of barrier methods — For individuals who are uninfected, it continues to be important to counsel for
use of condoms whenever there is vaginal or anal intercourse. There is a small risk of HIV transmission
with oral sex, which is highest when an HIV infected man ejaculates into the mouth of someone who has
open mouth sores. While it makes sense to inform patients that routine use of condoms can decrease the
risk of HIV transmission, it is also important to recognize that many patients do not use condoms for sex
on a regular basis and that, in the US, there has been an increase in unprotected anal intercourse
[22].This suggests the need to consider recommending use of post- or pre-exposure prophylaxis
accompanied by ongoing counseling and monitoring for adherence.
Postexposure prophylaxis — MSM should be educated about getting postexposure prophylaxis in the
event of an unsafe sexual encounter (eg, condom breakage). Repeated exposures suggest the need for
additional counseling about risk reduction and safer sex. (See "Nonoccupational exposure to HIV in
adults".)
Pre-exposure prophylaxis — Pre-exposure prophylaxis is referred to as PrEP. PrEP most commonly
consists of using daily oral tenofovir-emtricitabine (TDF-FTC) and has been evaluated in several large
clinical trials in a range of high-risk populations, including men who have sex with men and
serodiscordant heterosexual couples (ie, couples in which one partner is infected with HIV and the other
is not). Overall, these studies demonstrated that the effectiveness of TDF-FTC is highly contingent upon
medication adherence. (See "Pre-exposure prophylaxis against HIV infection".)
Sexually transmitted infections — Clinicians can play an important role in prevention of sexually
transmitted infections (STIs) by discussing risk reduction and safe sexual practices with patients [26].
Individuals need reassurance that close physical contact, kissing, and hugging are safe. While there is
only a small risk of HIV transmission associated with oral sex, the same is not true for other STIs like
syphilis and chlamydia. STIs are largely transmitted during oral, vaginal, or anal intercourse. Clinicians
should spend more time on such discussions when there is a concern that a patient may have multiple
sexual partners, has not been practicing safe sex, has been recently diagnosed with an STI, or engages
in drug abuse while having sex.
In the US, the CDC recommends screening asymptomatic sexually active gay men for HIV, syphilis,
chlamydia, and gonorrhea at least annually [27,28]. Although there are few data to show that these
screening tests improve outcomes, it is reasonable to perform screening on at least an annual basis given
the high prevalence rates of these STIs in MSM. It should be noted that, in the US, routine STI screening
may not be covered by all insurance plans. (See "Screening for sexually transmitted infections", section
on 'Men who have sex with men'.)
The CDC and United States Preventive Services Task Force also recommend screening MSM for
hepatitis B virus (HBV) infection [27,29,30]. Serologic testing and diagnosis of HBV infection are
discussed elsewhere. (See "Diagnosis of hepatitis B virus infection".) If patients are negative for HBV
infection or immunity, they should be vaccinated. (See 'Immunizations'below.)
Cancer — Gay men experience increased rates of anal carcinoma. Anal carcinoma is more common in
HIV infected men, but it has also been found in those without HIV infection. (See "Classification and
epidemiology of anal cancer", section on 'Sexual activity' and "Classification and epidemiology of anal
cancer", section on 'HIV infection'.)
The putative cause is infection with human papilloma virus (HPV) which appears to progress through
stages of anal dysplasia to anal carcinoma in much the same way as cervical HPV infection progresses to
cervical carcinoma in women [31]. Certain subtypes of HPV appear to predispose more to this
progression. A 2012 systematic review showed that there is a higher prevalence of anal HPV infection in
MSM, regardless of HIV status [32].
Screening with anal cytology to look for precancerous lesions related to HPV infection or anal cancer,
while practiced by many, is not widely recommended by clinical guidelines [33,34], but at least one study
has suggested that such screening is cost effective, at least in HIV infected men [35]. We suggest
discussing with MSM that anal cytology is used to evaluate the anal transition zone for anal squamous
intraepithelial lesions; however, evidence on screening outcomes is lacking. This issue is discussed in
detail separately along with a description of how to perform anal cytology and how to follow up when it is
abnormal. (See "Anal squamous intraepithelial lesions: Diagnosis, screening, prevention, and treatment".)
HPV is also associated with oropharyngeal cancer (see "Human papillomavirus associated head and
neck cancer"). No special screening beyond that which occurs with routine medical exams and dental
care is recommended at this time.
HPV vaccine has been recommended for boys and young men to prevent HPV and anal cancer. Use of
the HPV vaccine in MSM is discussed elsewhere. (See "Recommendations for the use of human
papillomavirus vaccines", section on 'Efficacy and immunogenicity in males'.)
Immunizations — In addition to routine adult immunizations, we recommend that MSM who are sexually
active receive the additional vaccines:
●Hepatitis A and B vaccines in light of the sexual transmission of both of these viruses [36,37].
(See "Approach to immunizations in healthy adults" and "Hepatitis A virus vaccination and
postexposure prophylaxis" and "Hepatitis B virus vaccination".)
●In the fall of 2012, an outbreak of invasive meningococcal meningitis was detected in MSM in New
York City. Some states in the US have recommended meningococcal vaccination to prevent
infection in MSM (particularly if HIV-infected) who have had contact with MSM from New York City.
[38,39](See "Meningococcal vaccines" and"Immunizations in HIV-infected patients", section on
'Meningococcal vaccine'.)
HPV vaccine has been approved for boys and young men to prevent anal cancer. Use of the HPV
vaccine in MSM is discussed elsewhere. (See "Recommendations for the use of human papillomavirus
vaccines", section on 'Efficacy and immunogenicity in males'.)
Substance and tobacco abuse
Tobacco abuse — Smoking is more common among gay men than in heterosexual men in the US [40].
Younger gay men are smoking more now than ever. Clinicians can counsel and assist with smoking
cessation. (See "Overview of smoking cessation management in adults".)
Alcohol use — Alcoholism is more prevalent among gay men in the US than in the general population
[41], and has been thought to contribute to some of the disinhibition that leads to riskier sexual behavior
and exposure to HIV. Clinicians can often be the ones who first detect evidence of this problem through
discussion. A multidisciplinary approach to stopping alcohol use is necessary. (See "Psychosocial
treatment of alcohol use disorder" and "Pharmacotherapy for alcohol use disorder" and "Screening for
unhealthy use of alcohol and other drugs" and "Brief intervention for unhealthy alcohol and other drug
use".)
Drug abuse — In the US, drugs for abuse are not different among the gay populations than among
others. There are, however, trends of drug use that do predominate in the gay community. These drugs
are frequently used in clubs and at circuit parties (large events held in different communities at different
times of the year). Depending on what drugs are being used, these may lead to significant short and longterm morbidity. The disinhibition associated with these has been one explanation for rising rates of HIV
infection and STIs among gay men after years of decline [42].
Trends in drug use change over time. Several years ago, commonly used drugs were MDMA (Ecstasy)
and ketamine (K). While these are still in use, their popularity has been outstripped by an epidemic of
methamphetamine hydrochloride use [43]. According to the 2003 National Survey on Drug Use and
Health, 12.3 million Americans age 12 and older had tried methamphetamine at least once in their
lifetimes (5.2 percent of the population), with the majority of past-year users between 18 and 34 years of
age [44].
Chemically related to amphetamines, this variant, which can be produced in small local labs from
common ingredients, has greater central nervous system (CNS) effects and a high potential for abuse
and addiction. It can be taken orally or intranasally, smoked, or injected. The form that can be inhaled
resembles crystals and is referred to as "crystal meth" or "ice.” It is a stimulant that can cause an
immediate pleasurable rush, euphoria, and increased sexual desire. Methamphetamine has a number of
significant deleterious short and long-term effects.
In many gay clubs found throughout New York City and elsewhere, methamphetamine is often used in an
injectable form, placing users and their partners at risk for transmission of HIV, hepatitis C, and other
STIs.
Behavioral health and mental disorders — It was only in 1973 that homosexuality was declassified as
a mental disorder. In 1986, the term "ego-dystonic homosexuality" was removed from the Diagnostic and
Statistical Manual of Mental Disorders (DSM-III). There have been no major studies of mental health
issues in the gay and lesbian population. However, smaller studies have identified higher rates of major
depressive disorders and bipolar disorders in gay men [45]. There also appears to be an increased
prevalence of anxiety disorders particularly in relation to a man's growing consciousness of being gay and
struggling to come out [46].
Although there has been debate about whether gay men are at higher risk for suicide, many studies show
increased suicidal ideation and suicide attempts among gay men [47]. Rates are particularly high among
gay youth; suicidal ideation and attempts are three to seven times higher among gay youth than among
heterosexuals. Gay adolescents and men have also been found to have increased disorders of body
image as well as eating disorders [48].
Despite the lack of clear data from solid research, the environment in which many gay adolescents and
adults grow up, the violence faced by many at times in their lives, and the anxiety and fear during the
process of coming out can leave emotional scars that often need to be addressed during adolescent or
adult life. As a result, discussion of these and related issues is important and referral for
counseling and/or psychopharmacological intervention is often warranted. Many continue to struggle to
come out and integrate a gay identity. Nevertheless, many gay men demonstrate great resilience and are
able to incorporate a gay identity with no sign of related behavioral impact [49].
Since the legalization of gay marriage in a number of countries, as well as in a number of US states,
issues of family commitment, marriage, and adoption are emerging as important topics for discussion with
patients who will often look to clinicians for information about issues such as ways that same sex couples
can parent children. In the US, this is an issue which is generally governed by state law, and varies
greatly across the map.
Domestic violence, sexual assault, and hate crimes — Studies suggest rates of domestic violence
among intimate gay couples at approximately the same rate as among heterosexual couples [50,51].
(See "Intimate partner violence: Epidemiology and health consequences".)
Two striking differences are that informal discussions with local victims suggest that there is little
screening done for this among gay couples, and facilities designed to accommodate victims of domestic
violence are rarely able to accommodate men [52].
A related and significant issue is sexual assault among gay men in general which tend, due to the shame
of the victim as well as bias among some law enforcement officers, to go underreported. Rape crisis
programs are often unprepared to deal with male victims of sexual assault and rape and some legal
definitions of rape exclude male victims. (See "Evaluation and management of adult sexual assault
victims".)
On a broader scale, studies have shown that gay men are perhaps the most frequent victims of violence.
Finding a sympathetic place to go can be difficult. One study showed that only a small percentage of
violent incidents were reported due to fear that open discussion would lead to further injury [53]. There is
some justification for this belief in that an analysis of surveys of antigay violence showed a significant
number of victims had been victimized by police [53].
Primary care clinicians in the US should be aware of the relatively high prevalence of violence and hate
crimes against gay men in the community. Although, as with heterosexual domestic violence and violence
in general, there is little evidence about the benefits of screening or intervention, we believe that it is
important to discuss with patients whether they have ever been physically or emotionally assaulted so
that appropriate interventions can be designed.
2.2
Primary Care of Gay Men
Harvey J. Makadon, MD; November 2, 2012
4. Explain how to make medical care accessible to gay men while being culturally sensitive.
MAKING CARE ACCESSIBLE — Gay men, like all patients, must be made to feel welcome in order to
increase the likelihood that they will be honest with their providers and follow advice for preventive care.
Perhaps the most important feature of care is application of an open and nonjudgmental approach to
finding out about each patient, supplemented by appropriate questions.
The same applies to the office environment. Educational materials in waiting areas can give subtle signs
that a practice may not be sensitive to same-sex issues if they do not include information on avoidance of
STIs and HIV or the availability of resources for Domestic Violence.
Some centers are now routinely asking patients to volunteer information on sexual orientation and gender
identity at the time of registration. This information is confidential and can then be used by clinicians to
guide them in taking a patient history. Similarly, registration forms which ask for information in language
that suggests only traditional family structures can be off-putting not only to gay people, but to many who
live in committed relationships but remain unmarried. It is important that rather than just asking if a patient
is married, single, or divorced, there be an option to indicate a significant other or domestic partner.
Similarly in countries and states where same sex marriages are recognized, staff must understand to treat
this information in the same way they would treat information about spouses on forms submitted by
heterosexual couples [54,55]. Facilities for children have to recognize that increasing numbers of children
will now register with two same sex parents. Clinicians must be culturally sensitive to insure that all of our
patients do not experience psychological barriers to care.
In the US, the Joint Commission and Department of Health and Human Services are looking at ways to
improve the care environment for gay men and to collect more data routinely in clinical settings
[16,56,57]. The Joint Commission has already implemented policies to allow patient choice of visitors in
hospitals and to prohibit discrimination based on sexual orientation, gender identity, and gender
expression.
2.3
Medical Care of Women Who Have Sex with Women
Nina M. Carroll, MD; May 14, 2012
1. Indicate the reasons for women who have sex with women (WSW) to underutilize clinical
care services.
INTRODUCTION — The delivery of routine primary health care to lesbian, gay, bisexual, and
transgender women (LGBT) can be complicated by the patient’s inability to disclose their sexual identity
and the health care provider’s lack of cultural competence when approaching these patients [1]. LGBT
women often underutilize clinical care services and present later for healthcare than heterosexual women
[2]. The reluctance to obtain healthcare is facilitated by providers who lack awareness of their health
issues, discriminate against them, and create negative experiences [3]. In addition, these women are often
of lower socioeconomic status than men who have sex with men (MSM) and they often do not have
spousal or family benefits, such as health insurance. Because they are less likely to use services that focus
on contraception and reproduction than young heterosexual women, they are less exposed to women’s
traditional points of entry into the healthcare system.
Understanding a patient's sexual orientation, behavior, and identity has a bearing on the ability to provide
quality care. Issues related to sexual desire, sexual behavior, and sexual identity are important because
they may increase a woman’s risk of some health problems, such as sexually transmitted diseases (STDs)
and certain cancers
2.3
Medical Care of Women Who Have Sex with Women
Nina M. Carroll, MD; May 14, 2012
2. Explain the terminology used in approaching WSW.
TERMINOLOGY — Some terms women may use to describe themselves include lesbian, gay, queer,
partnered with a woman, homosexual, and others. The term lesbian is generally used to describe sexual
orientation, while women who have sex with women (WSW) describes a behavior. Some women who are
just beginning to “come out,” or differentiate from heterosexual identity/behavior, may experience a
desire to be intimate with other women, but may not yet have been sexually active with women or even
identify as being lesbian.
Sexual orientation and behavior — Sexual orientation relates to erotic attraction and defines whether an
individual is attracted is individuals of the same or the opposite biological sex. While there are three main
categories of sexual orientation (heterosexual, homosexual [lesbian or gay], and bisexual), sexual
behavior may not be so clearly categorized.
Women who have sex with women (WSW) embraces a complex spectrum of attraction, or experiences of
romantic or sexual feelings towards other women, behavior or patterns of romantic or sexual activity, and
identity, which is a personal self-concept that establishes oneself within a social or collective group.
Studies surveying self-identified lesbians show a wide range of sexual behaviors (eg, celibacy,
heterosexuality, bisexuality, homosexuality). Many dichotomies exist regarding sexual behaviors: past
versus present, volitional versus nonvolitional, and admitted versus practiced. Furthermore, behavior is
not always concordant with self-identification and can be fluid over time. For example, a self-identified
lesbian may also be attracted to, and engage in, sex with individuals who identify as transgender.
2.3
Medical Care of Women Who Have Sex with Women
Nina M. Carroll, MD; May 14, 2012
3. Explain how to approach a woman who has sex with women during the interview process
including the adolescent population.
APPROACH TO THE LGBT PATIENT — There is no stereotypical profile that easily identifies lesbian,
gay, bisexual, and transgender women (LGBT) patients. They are found in every ethnic group and
socioeconomic class; they may be single, celibate, partnered, or divorced; they may be mothers,
teenagers, career women, or senior citizens. Professionalism and confidentiality are key components for
enabling these women to identify themselves, as well as for better interactions between them and their
healthcare providers [13-15]. Some women choose not to identify themselves as LGBT because of
awareness of cultural biases, societal constraints, and familial rejection [16]. Others are unwilling to
disclose their sexual identity due to negative encounters with physicians that led to suboptimal care.
There are many ways that healthcare providers can demonstrate openness/willingness to discuss LGBT
issues. For example, new patient intake history forms should have inclusive language that demonstrates
sensitivity regarding sexual orientation and questions about marital status, insurance subscriber or
emergency contact, and healthcare proxies. When obtaining a social and sexual health history, it is
important that the clinician demonstrates that she/he is willing to invite disclosure of sexual orientation.
Conversely, respecting the patient’s right not to disclose is important in order to build rapport. Being
avoidant is as unhelpful as being probing.
Information on sexual identity can often be obtained by using leading statements, gender-neutral
questions and terms, and nonjudgmental acceptance [17]. Patients should be informed that questions
related to sexual identity and behavior are asked of everyone. The discussion should start with general
questions, then an attempt to gauge the patient’s comfort level with disclosure. If the clinician explains
that sexual orientation can impact specific health risks and had relevance to healthcare and preventive
medicine decisions, patients may be more willing to disclose. Once the information is disclosed, clinicians
should ask about and respect the patient’s choice of how she wants that information handled; some
patients may prefer not to have the information documented in the medical record or revealed in referral
letters.
The appropriate level of detail in obtaining the sexual history depends on the provider’s comfort level with
the subject of sexuality and their perception of the patient’s comfort level around disclosure, in addition to
what is necessary to provide appropriate medical evaluation and therapy. The Centers for Disease
Control and Prevention (CDC) provides guidance for taking a nonjudgmental sexual history, including
frank questions about partners, sexual practice, prevention and history of sexually transmitted diseases
(STDs), and prevention of pregnancy [18]. Several other resources are available in print [19,20] and
online [21-25] to help clinicians interview and care for LGBT patients.
Some examples of questions to ask in obtaining this history include:
●Are you single, married, partnered, widowed, or divorced? How would you like to be addressed?
●People identify themselves in different ways: male, female; straight, gay, lesbian, transgender, etc.
How do you identify yourself?
●Are you having sex?
●With whom are you having sex? Anyone else?
●Do you have a primary relationship? How many partners have you had in the past month? Six
months, 12 months, over your lifetime?
●Do you know whether your current partner(s) has had sexual contact with anyone other than you?
●How do you protect yourself against STDs? When did you last have sex without a condom or other
barrier? If using condoms, when were they used, throughout the sexual act or just at the end?
●Have you or any of your partner(s) ever been treated for any STDs? When and what was the
treatment?
●Have you or any of your partner(s) been tested for human immunodeficiency virus (HIV)? When
and where?
●Have you or any of your partner(s) ever used needles to inject drugs? Have you or any of your
partner(s) ever exchanged sex for money/drugs?
●What kinds of sex do you have? Hand-on-genital? Mouth-on-genital? Mouth-on-anus? Penis-invagina? Penis-in-anus?
Adolescents — Clinicians seeing adolescent girls have a unique opportunity to interact in a way to
inspire trust and confidence. This opportunity is important since LGBT youth are at an especially high
risk of suicide related to isolation and low self esteem from societal, familial, and peer rejection at a
fragile time in their psychosexual development. They are also at increased risk of physical harm from
peers, substance abuse and other risk-taking behaviors, depression, and homelessness.
Like heterosexual adolescents, young self-identified lesbians may engage in unprotected sexual behaviors
with male and female partners, putting them at high risk for STDs including HIV, and unwanted
pregnancy from heterosexual sex. The Minnesota Adolescent Health Survey found that lesbian or
bisexual respondents were as likely to have had penile-vaginal intercourse, and were more likely to use
either an ineffective method or no method of contraception and to experience pregnancy, as heterosexual
or unsure adolescents [26]. Adolescents self-identified as lesbians also reported higher rates of a history
of sexual abuse and prostitution.
The Committee on Adolescence of the American Academy of Pediatrics has developed guidelines,
summarized below, about how health care providers can address the issue of homosexuality with their
patients in a supportive and nonjudgmental way [27]:
 Be aware that some youth are homosexual or have concerns about sexual orientation.
 Provide factual, current, nonjudgmental information about homosexuality, STDs, and substance
abuse.
 Probe psychosocial needs and issues related to school, family, and community. Provide
counseling and offer referral, as needed.
 Perform a thorough history and physical examination. Screen for STDs. (See "Screening for
sexually transmitted infections", section on 'Women who have sex with women'.)
2.3
Medical Care of Women Who Have Sex with Women
Nina M. Carroll, MD; May 14, 2012
4. Recognize and summarize the preventive health care issues targeted towards the WSW
population.
PREVENTIVE HEALTH CARE — Lack of health insurance or insensitive encounters with health care
providers may alienate lesbian, gay, bisexual, and transgender women (LGBT) women from seeking
preventive health care services [28]. These women are not biologically at higher risk for any particular
health problem simply because they have this sexual orientation; differential risks for disease may arise
because of behaviors that may be more common among this population. For example, the rate of current
smokers is 12.2 percent in the general population, but 28.7 percent in lesbians and 26.9 percent in
bisexual women [29]. Rates of alcohol consumption, and particularly rates of “heavy drinking” defined as
60 or more drinks in a month, are 4.5 percent for lesbians compared with 2.3 percent for heterosexual
women [5,30].
There are few population based studies of health issues in women who have sex with women (WSW) on
which to base recommendations. Based on clinical experience and epidemiology, we feel that there are a
number of areas in which clinicians providing primary care to these women should provide additional
emphasis beyond what they might focus on in heterosexual women. We agree with a monograph
published as a companion document to the US Surgeon General's report Healthy People 2020 by the Gay
and Lesbian Medical Association that important issues to consider targeting include: cancer; human
immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS); immunizations and
infectious diseases including sexually transmitted diseases (STDs), substance and tobacco abuse,
behavioral health and mental disorders, and domestic violence.
Healthy weight — Overweight and obesity predispose to increased cardiovascular risk. When body mass
index (BMI) was analyzed by sexual orientation in population-based studies, the National Survey of
Family Growth (NSFG), the Nurses’ Health Study II, and the Women’s Health Initiative noted that
obesity was more prevalent among lesbians than among heterosexual women [5,31,32].
There is some evidence that weight gain and having a higher BMI may be more culturally acceptable to
lesbians as they may not share the mainstream aesthetic goal of very thin women. Therefore, in
addressing weight with WSW, it is important to emphasize the significant health risks of obesity,
including diabetes, cardiovascular disease, and hypertension. (See "Health hazards associated with
obesity in adults".)
Prevention of unplanned pregnancy — The majority (75 to 90 percent) of lesbians have been sexually
active with men at some point in their lives. In surveys, 3 to 23 percent of WSW age 30 to 50 years report
having sex with men during the previous year [33]. Sex with men may take place at any age, but during
adolescence is common since sexual identity is being explored.
Sexual activity frequently occurs without contraception or prophylaxis against STDs [34-36]. Data from
the Women’s Health Initiative showed that 35 percent of lesbians and 81 percent of bisexual women have
been pregnant [34]. Thus, it is always appropriate to say: “Do you have a need for contraception? If not
now, remember to use condoms. Emergency contraception is available without a prescription until you
can start a more reliable form of contraception.” (See "Overview of contraception" and "Emergency
contraception".)
Screening — Most epidemiologic studies of women have not included sexual orientation or identity
among the demographic factors investigated, making WSW an invisible component of the analysis.
Actual risk cannot be calculated, but can be inferred by extrapolating from well-described risk factors for
various cancers. According to large-scale national surveys, WSW are more likely to smoke and drink
alcohol, have a high BMI, be nulliparous or of low parity, and have fewer preventive health screenings
than heterosexual women [5,16,37,38]; in addition, they are less likely to have used oral contraceptives or
to have breastfed. These characteristics constitute high risk factors predisposing to colon, lung,
endometrial, ovarian, and breast cancer, as well as cardiovascular disease and diabetes.
Screening for cervical cancer, breast cancer, and ovarian cancer is discussed below. Screening and
counseling of general medical issues are discussed separately.
Cervical cancer — WSW have lower rates of screening for cervical cancer than heterosexual women,
even in urban settings. This may be linked to the perception, shared both by health care providers and
WSW, that they are at lower or no risk of acquiring human papillomavirus (HPV). Among WSW with
cervical cancer, half had never had cervical cancer screening and 10 percent had not been screened in
over five years [39]. The Women’s Health Initiative Study noted higher rates of cervical cancer among
bisexual women (2.1 percent) and lifetime lesbians (2.2 percent) than in heterosexual women (1.3
percent); the higher rate correlated with their having fewer cervical cancer screening tests [31].
Like all women, WSW need to undergo routine screening for cervical cancer [40]. The risk of cervical
neoplasia is highest in WSW who:
•
•
•
•
•
Have a history of incest or early age at first coitus with men
Have had sex with more than one male sexual partner
Have been infected with high oncologic risk HPV types
Smoke cigarettes
Have been treated for abnormal cervical cytology in the past
High oncogenic risk HPV infection, which has the potential to develop into cervical cancer, and, less
commonly, vulvar, vaginal, anal or oral cancer, can be transmitted from woman to woman by skin-to-skin
or skin-to-mucosa contact. In a pilot study of 149 WSW in Seattle, Washington, the prevalence of HPV
was 30 percent, and was 19 percent among women reporting no prior sex with men [40]. (See "Screening
for cervical cancer: Rationale and recommendations", section on 'HPV testing' and "Cervical cancer
screening tests: Techniques and test characteristics of cervical cytology and human papillomavirus
testing".)
Cervical cancer screening guidelines have been formulated based upon age and risk factors for cervical
cancer. Increasing the screening interval or not screening WSW can lead to lost opportunities for health
maintenance and prevention, or to delayed diagnosis and treatment of high-grade squamous intraepithelial
neoplasia and cervical cancer, as well as other anogenital and oral cancers. (See "Screening for cervical
cancer: Rationale and recommendations".)
Breast cancer — The theoretical lifetime risk of breast cancer in WSW is estimated to be as high as one
in three WSW compared to one in eight women overall [41]. This alarming figure was inferred by
analyzing demographic profiles and health histories of WSW in several national surveys. In the Women’s
Health Initiative Study, bisexuals had the highest rates of breast cancer (8.4 percent), although women in
the other non-heterosexual groups also had higher rates than heterosexual women [31]. Patient
information brochures, such as “Cancer Facts for Lesbians and Bisexual Women,” available at
www.cancer.org, can be useful for educating these women.
Since parity and age less than 30 years at first full term pregnancy both lower breast cancer risk and
WSW may never become pregnant or may have children at an older age than heterosexual women, WSW
constitute a group at higher risk. (See "Risk prediction models for breast cancer screening".) In addition,
WSW may obtain mammograms and undergo clinical breast examinations less often than heterosexual
women, thereby reducing the chance of detection at an early stage of disease.
Current recommendations are for WSW to undergo breast cancer screening according to guidelines
published for the general female population. (See "Screening for breast cancer".)
Ovarian cancer — WSW have higher theoretical risks of developing ovarian cancer because of risk
factors such as a lower likelihood than heterosexual women of having been pregnant or using hormonal
contraception for a prolonged period of time [42]. WSW with a personal history of breast cancer
(particularly at a young age) or a family history of either breast or ovarian cancer may consider the
potential benefits of using hormonal contraception to reduce the risk of ovarian cancer. (See "Risks and
side effects associated with estrogen-progestin contraceptives", section on 'Ovarian cancer'.)
Recommendations for screening for ovarian cancer are controversial and based upon risk factors, not
sexual orientation. They are discussed separately. (See "Screening for ovarian cancer".)
Sexually transmitted diseases — Screening for STDs should be performed in women with symptoms, or
periodically according to national guidelines in those with risk factors (eg, more than one partner or a
partner with other partners, previous pelvic inflammatory disease [PID], anal sex). WSW with STDs
should be encouraged to inform their sexual partner(s) regarding the need for screening, diagnosis, and
treatment. (See "Screening for sexually transmitted infections".)
Infectious agents can be transmitted between women through sexual behaviors resulting in the exchange
of vaginal secretions on hands or objects, such as finger-to-vagina contact, genital-to-genital contact or
sharing objects (sex toys) without condom use or cleaning between partners. Sex toys and fingers can also
transmit bacteria from the anal region to the vagina. STDs can be acquired from female sexual partners,
even with a remote or absent history of male sexual partners [40,43-49]. The risk of infection with STDs
(eg, gonorrhea, chlamydia, hepatitis B virus, HIV, syphilis, HPV, herpes simplex virus, trichomoniasis)
varies widely, depending upon sexual orientation, number of partners, and specific sexual practices.
A meta-analysis including 12 studies found a consistent association between bacterial vaginosis (BV) and
a history of female sexual partners (RR 2.0. 95% CI 1.7-2.3) [50]; in the studies that quantified partners,
there was a trend towards increasing risk of BV with a higher number of female sexual partners. WSW in
monogamous relationships are usually concordant for the presence or absence of BV; this has led some
investigators to believe that BV, which is not considered a STD in heterosexual women, is probably
transmitted between female sexual partners through exchange of vaginal secretions [45,51]. For reasons
that remain unclear, oral-genital sex, oral-anal sex, and sex toys may be more important risk factors for
infection than penile intromission. Although it is not necessary to treat male sexual partners of women
with BV, female partners should be advised to undergo screening and, if results show infection, they
should be treated. (See "Bacterial vaginosis".)
The rapidly increasing rate of HIV acquisition in heterosexual women has challenged original concepts
about risk groups. Women of color, their partners, and WSW who are or were intravenous drug users or
sex workers may be at highest risk of HIV infection. Woman-to-woman transmission of HIV has been
documented, although we know little about the incidence of transmission [52,53]. (See "HIV and
women".)
All patients being evaluated for STDs should be offered counseling and referral for HIV testing. The
frequency of screening in other settings is arbitrary, but annual or more frequent testing has been
recommended for individuals at high risk. (See "Serologic screening for HIV infection", section on
'Frequency of testing'.)
Prevention of sexually transmitted diseases — Preventive measures, often referred to as suggestions for
“safer sex,” include avoiding mucous membrane contact with a partner's blood or vaginal secretions by
using a dental dam during oral sex, using a latex barrier or plastic wrap as a barrier, and washing sex toys
with hot soapy water between uses (or covering the toy with a fresh condom).
Pharmacoprophylaxis includes:
 Offering valacyclovir prophylaxis to the affected partner in herpes simplex virus (HSV)discordant couples (see "Prevention of genital herpes virus infections", section on 'Chronic
suppressive therapy in discordant couples')
 HPV vaccination (see "Recommendations for the use of human papillomavirus vaccines")
2.3
Medical Care of Women Who Have Sex with Women
Nina M. Carroll, MD; May 14, 2012
5. Recognize the psychosocial issues prevalent in the WSW population.
PSYCHOSOCIAL ISSUES RELATED TO SEXUAL ORIENTATION — Women who have sex with
women (WSW) may experience social stress generated by stigmatization and nonacceptance by family
members, peers, and friends. A systematic review that extracted data about 214,344 heterosexual and
11,971 non-heterosexual individuals found that lesbian, gay, and bisexual individuals were at significantly
higher risk of mental health issues (depression, anxiety), suicidal ideation, substance misuse, and
deliberate self-harm than heterosexual individuals [55]. Results were similar in both sexes, but metaanalyses revealed that lesbian and bisexual women were particularly at risk of substance dependence
(alcohol, 12 months: RR 4.00, 95% CI 2.85-5.61; drug dependence: RR 3.50, 95% CI 1.87-6.53; any
substance use disorder: RR 3.42, 95% CI 1.97-5.92). Higher rates of suicidality and depression are most
common in WSW who have not disclosed their sexual orientation, suggesting that fear of stigmatization
regarding sexual orientation was a significant risk factor for mental health morbidity in this cohort [56].
The environment in which many of these individuals live, the violence they may face many times in their
lives, and their anxiety and fear during the process of coming out can leave emotional scars that often
need to be addressed. In one survey, 86 percent of lesbian, gay, bisexual, and transgender women
(LGBT) women experienced verbal harassment, 44.1 percent experienced physical harassment, and 22.1
experienced physical assault [57]. Discussion of these and related issues is important, and referral for
counseling and/or psychopharmacological intervention is often warranted. Referral to mental health
professionals with expertise in working with the homosexual patient is advantageous.
Same sex couples, like other couples, are at risk for intimate partner violence. When same sex couples
are in legally recognized relationships, they report having more meaning in their lives, fewer symptoms of
depression, and less overall stress [58]. Conversely, same sex couples living in states where same sex
marriage is not legal experience increased stress.
2.3
Medical Care of Women Who Have Sex with Women
Nina M. Carroll, MD; May 14, 2012
6. Describe the parenting concerns and options available to WSW.
PARENTING OPTIONS — Women who have sex with women (WSW) encounter special obstacles in
fulfilling their desires to become parents, including homophobic stigmatization of WSW as inappropriate
mothers, potential rejection by family, limited access to and availability of resources such as sperm banks
and insurance coverage. These obstacles exist despite evidence from studies that have examined the
psychosocial development of children raised by WSW and found no differences in sexual or gender
identity, personality traits, or intelligence compared to children of heterosexual parents [58-60].
WSW have several possible paths to parenthood, including raising children from prior heterosexual
relationships; conception through donor insemination; use of a surrogate; foster parenting; and adoption.
WSW who choose to have children have some needs similar to those of heterosexual couples, and other
needs unique to their circumstances [61].
Issues the clinician needs to address with patients include the logistics, safety, effectiveness, and
family/legal ramifications of various parenting options, as well as referral to appropriate providers of
fertility and parenthood services. The goal is to optimize fertility and minimize pregnancy complications.
As a group, WSW are at higher risk of pregnancy complications than heterosexual women because they
tend to be at an older age at conception, experience more stress, have a higher body mass index (BMI),
and have a higher prevalence of smoking, drug use, and alcohol consumption.
Adoption —
Foster parenting —
Assisted reproductive technology — A report by the Ethics Committee of the American Society for
Reproductive Medicine affirmed the right of single, gay, and lesbian persons to have access to fertility
services [62]. Once they have decided to attempt pregnancy, these patients need information about
fertility, basal body temperature charts, ovulation prediction kits, donor selection from sperm banks
(including a release form for sperm banks signed by a physician), laboratory testing, insemination
methods, preconception counseling, and prenatal care. If the patient's female partner is present, she should
be included in all discussions.
Donor insemination — Donor insemination is an expensive, time-tested method of achieving pregnancy
with a reasonable success rate in fertile recipients. Insemination is timed to take place just prior to
ovulation, typically using kits for home urine luteinizing hormone (LH) measurement. Basal body
temperature, although helpful for analyzing ovulatory patterns, is not helpful for determining timing of
insemination because ovulation has typically already occurred once an increase in temperature is
apparent; therefore, the window has been missed.
Donor insemination can be performed by the woman herself, her partner, or a health care provider. A
prospective randomized crossover study of intracervical (ICI) versus intrauterine insemination (IUI) of
single fertile women choosing to inseminate with frozen donor semen found that IUI was slightly more
effective than ICI in this population (monthly fecundity 14 versus 5 percent with one insemination, 14
versus 9 percent with more than one insemination) [63]. Donor insemination is discussed in detail
separately.
Most health insurers do not cover the costs of semen and office insemination for WSW or single women
who are presumed fertile and want to become pregnant until there have been 12 cycles of insemination
without conception (suggesting infertility, which is a covered benefit in most insurance packages).
Some WSW request insemination from a known male donor who is an acquaintance but who has sex with
men [61]. This can be problematic since sperm banks typically do not accept sperm from such men and
donor insemination programs require directed donors to undergo the same screening and safety
procedures required of anonymous donors (eg, quarantine the sperm specimen for six months and then
retest the donor for human immunodeficiency virus (HIV) and other sexually transmitted infections
before releasing sperm). (See "Donor insemination".)
Issues concerning legal relationships with the sperm donor and the nonbiologic same sex parent should be
addressed before insemination.
Co-maternity — Some couples choose co-maternity. The egg of one partner is aspirated, fertilized as in
an in vitro fertilization (IVF) procedure, and then transferred to the uterus of the other partner, who is the
gestational carrier [64]. Although this allows both partners to biologically participate in the pregnancy, it
is more costly and risky than simple insemination. (See "In vitro fertilization" and "Surrogate
pregnancy".)
Prenatal care, childbirth, and hospitalization — Prenatal care of WSW is the same as for other
women. (See "Initial prenatal assessment and patient education".) The presence of her partner should be
encouraged at antenatal visits, childbirth preparation classes, during labor, and postpartum. In the United
States, hospitals that accept Medicaid and Medicare funding must grant same sex partners visitation
rights. When obtaining the social history, health care providers should remain cognizant that lesbians are
not immune from domestic violence and should be screened for abusive relationships.
Marriage, parenting, and legal issues — Lesbians may have been pregnant in the past, may live with or
without children from a previous heterosexual relationship, or may live with their partner's children,
depending upon custody issues. Others become parents through adoption or foster care. Issues that
lesbians must consider include contracts regarding parenting, durable power of attorney, health proxies,
second parent (or co-parent) adoption, and custody issues in the event of death or separation [65,66].
Although a number of US states have legalized marriage between same sex partners, these marriages are
not always recognized in other states. This discrepancy within the US legal system can create
considerable conflict and stress when relationships dissolve and if one or both sexual partners move to a
state where marriage is not recognized as legal. Advising patients to seek consultation with an attorney
knowledgeable in this area is recommended.
2.4
Transsexualism: Biologic Considerations, Definitions, and Diagnosis
Louis J, G. Gooren, MD; September 9, 2011
1. Describe transsexualism.
INTRODUCTION — Transsexualism is the condition in which a person with apparently normal somatic
sexual differentiation of one gender is convinced that he or she is actually a member of the opposite
gender. It is associated with an irresistible urge to be that gender hormonally, anatomically, and
psychosocially. The biologic considerations, definition, and diagnosis of transsexualism will be discussed
here while treatment will be discussed separately. (See "Treatment of transsexualism".)
2.4
Transsexualism: Biologic Considerations, Definitions, and Diagnosis
Louis J, G. Gooren, MD; September 9, 2011
2. Define sexual differentiation of the brain and how transsexualism has been called a “disorder”
of sexual differentiation.
PATHOPHYSIOLOGY
Sexual differentiation of the brain — Traditionally, transsexualism has been conceptualized as a purely
psychological phenomenon, but research on the brains of male-to-female transsexuals has found that the
sexual differentiation of one brain area, the bed nucleus of the stria terminalis, follows a female pattern
[9,10]. This area of the brain has been proposed to be important for gender identity and may support a
biologic basis for transsexualism.
Sexual differentiation in mammals takes place in distinctly different steps, each with a critical period and
contingent upon the previous one. (See "Normal sexual development".) From studies in rats, mice, and
other lower mammals, it appears that the brain undergoes a sexual differentiation process, similar to
those of the internal and external genitalia. Sexual differentiation of the brain depends upon the presence
or absence of androgens. In the presence of androgens prenatally or perinatally, male brain differentiation
occurs and, in their absence, female brain differentiation occurs.
There is also some evidence that sexual dimorphism of the brain exists in humans [11-13]:


Sex differences in size and shape of certain nuclei in the hypothalamus have been described
[11]. One of the sexually-dimorphic nuclei becomes differentiated between the ages of two and
four [11], while the sexual differentiation of the bed nucleus of the stria terminalis may extend into
adulthood [14]. The time of differentiation of the other sex-dimorphic nuclei is not known.
In a sample of male-to-female transsexuals, the bed nucleus of the stria terminalis showed all
characteristics of a female differentiation [9,10]. In the brain of a single female-to-male
transsexual, a male differentiation was found [10].
Longer androgen receptor gene CAG trinucleotide repeats are associated with reduced sensitivity of the
androgen receptor and one study suggests that androgen receptor gene repeat length polymorphism may
be associated with male-to-female transsexualism [15]. These findings support the concept of
transsexualism as a disorder where the sexual differentiation of the brain is not consonant with
chromosomal pattern and gonadal sex [16]. However, these biological findings currently play no role in
the diagnosis of gender dysphoria.
Other influences — It is not known if the mechanism controlling sexual differentiation of the human brain
is exclusively hormonally determined [13,17]. From clinical observations in patients with a disorder of sex
development or cross-sex hormone exposure during pregnancy, the evidence for a hormonal mechanism
alone is not convincing. Postnatal rearing is likely to be a significant factor in the development of gender
identity; this is no longer irreconcilable with the concept of a biological substrate for gender identity, since
early life experiences can shape subsequent brain anatomy and function [12,18].
Some infants with one gonadal sex are born with the external genitalia of the other. Follow-up studies of
these children show that sex of assignment is an important but not the sole prognosticator of future
gender identity and role. It has also been thought that gender identity becomes largely fixed around the
age of three years. Clinical experience shows, however, that this is not universally the case.
Individuals with disorders of sex development may transition to the other sex, which may occur well
beyond the age of three years [19-21]. It happens mainly in subjects with a degree of prenatal androgen
(testosterone) exposure, such as steroid 5-alpha-reductase 2 deficiency. These individuals may develop
a male gender identity at puberty, after having been originally assigned to the female sex on the basis of
the appearance of their female-looking genitalia [19].
2.4
Transsexualism: Biologic Considerations, Definitions, and Diagnosis
Louis J, G. Gooren, MD; September 9, 2011
3. Distinguish the difference between transsexualism, transgenderism, homosexuality, and
juvenile gender dysphoria.
TRANSSEXUALISM, TRANSGENDERISM, AND HOMOSEXUALITY — Transsexualism must
be distinguished from homosexuality:
 Homosexuals are erotically attracted to persons with the same genital morphology.
 Transsexuals experience the physical functioning of their sex organs as estranged from their
selves and seek a reassignment to the desired sex.
 Individuals who want to rid themselves of the natal sex without seeking reassignment to the
opposite sex or want only partial adaptation to the opposite sex (eg, "the lady with the penis")
seek to have an in-between sex status [12]. There may be a social transition to the opposite sex,
which may be part-time. The term transgenderism has been proposed for such patients.
There are difficulties with transgenderism from a medical-ethical viewpoint, including:
 Whether a subject's self-assessment of his/her gender status should prevail
 Whether the medical community must provide care for those who find themselves in an inbetween gender status
2.4
Transsexualism: Biologic Considerations, Definitions, and Diagnosis
Louis J, G. Gooren, MD; September 9, 2011
4. Explain the initial diagnosis process for transsexualism.
DIAGNOSIS — The initial assessment of a patient for transsexualism is based on psychodiagnostic
instruments and is generally done by a mental health professional. Two diagnostic classification systems,
Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) [30] and International
Classification of Diseases 10 (ICD-10), have diagnostic guidelines for transsexualism and related gender
identity disorders. For clinicians, the best guidance is provided by the standards of care of the World
Professional Association for Transgender Health (WPATH) [31]. Core components of the DSM-5
diagnosis of gender dysphoria include long-standing discomfort with assigned gender and interference
with social, school, or other areas of function [30].
The current ICD criteria for transsexualism include (table 1) [32]:



The desire to live and be accepted as a member of the opposite sex, usually accompanied by the
wish to make his or her body as congruent as possible with the preferred sex through surgery and
hormone treatments.
The presence of the transsexual identity persistently for at least two years.
The absence of another mental disorder or a genetic, intersex, or chromosomal abnormality.
The diagnosis of transsexualism must first be made before considering hormone and surgical
reassignment therapy [32]. In addition, it is essential to identify any comorbid psychiatric diagnosis that
may require treatment before considering hormone therapy.
Presently, most cases of transsexualism are diagnosed in adulthood, but increasingly children and
adolescents with gender dysphoria present for diagnosis and treatment.
The clinical presentation of gender nonconformity in children and the management of transsexualism are
reviewed separately.
SEXUAL COERCION
2.5
Evaluation of Sexual Abuse in Children and Adolescents
Kirsten Bechtel, MD; Berkeley L. Bennett, MD, MS; July 26, 2012
1. Define sexual assault and sexual abuse.
DEFINITIONS — Sexual assault is defined as attempted sexual touching of another person without their
consent and includes sexual intercourse (rape), sodomy (oral-genital or anal-genital contact), and fondling
[1].
A generally accepted definition of sexual abuse is when a child engages in sexual activity for which
he/she cannot give consent, is unprepared for developmentally, cannot comprehend, and/or an activity
that violates the law or social taboos of society [2]. This includes fondling and all forms of oral-genital,
genital, or anal contact with the child (whether the victim is clothed or unclothed), as well as nontouching abuses such as exhibitionism, voyeurism, or involving the child in pornography [2-4]. Thus,
child sexual abuse can include acts that would be considered sexual assault. For purposes of this chapter
the term sexual abuse will be used, indicating that the perpetrator is a person of such acts is also
responsible for the child's health and welfare.
It is important to distinguish between sexual abuse and "sexual play" [4]. Sexual abuse occurs when there
is asymmetry in age or development among the participants, with a coercive quality to the event.
"Sexual play" occurs in the absence of coercion and involves children of the same age (separated by no
more than four years [5]) or developmental level who engage in viewing or touching each other's genitalia
because of mutual interest or curiosity. Sexual play is considered normal behavior and does not have the
psychological, developmental, or physical consequences of sexual abuse [3]. In addition to sexual play,
many preschool-aged children mimic behaviors of older family members, such as flirting, batting eyelids,
and "walking sexy." This behavior also is considered part of normal development [6].
2.5
Evaluation of Sexual Abuse in Children and Adolescents
Kirsten Bechtel, MD; Berkeley L. Bennett, MD, MS; July 26, 2012
2. Review the epidemiology of child sex abuse.
EPIDEMIOLOGY — The US Department of Health and Human Services reports that >60,000 children
are sexually abused annually [7]. Each year approximately 1 percent of children experience some form of
sexual abuse [3]. Worldwide, an estimated 25 percent of girls and 9 percent of boys are exposed to any
form of sexual abuse during childhood [8].
The number of reported sexual abuse grossly underestimates the true prevalence. Comparison of the
prevalence of substantiated sexual abuse in developed countries (UK, US, Canada, Australia), as
determined by agency reports, with self-reported sexual abuse by parents or victims who reside in these
countries, suggests that only one in 10 instances of sexual abuse comes to official attention [8]. One US
survey found that 20 percent of high school students experienced sexual assault, but only 50 percent of
these students revealed the incident to someone else [9,10]. Reasons that these events go unreported
include fear of the medical evaluation, social stigma, and desire for privacy [10-12].
Sexual abuse of children occurs primarily in the preadolescent years [13,14]. Girls are more likely than
boys to be sexually abused; however, boys are less likely to report sexual abuse [14].
Perpetrators of sexual abuse are usually male, and often trusted adult acquaintances [5,13,15]. Statistics
from reported cases in the United States indicate that "father" and "other relatives" were responsible for
21 and 19 percent of sexual abuse victims, respectively; mothers acting alone or with another person
accounted for 4 and 8 percent of perpetrators, respectively [16]. Perpetrators report that they gained
access to children through caretaking (eg, babysitting), that they targeted children using bribes, gifts, and
games, and systematically desensitized children through touch, talk about sex, and persuasion [17].
Victims of sexual abuse include children from all social, cultural, and economic backgrounds. However,
some features related to family structure and parenting have been associated with an increased risk of
childhood sexual abuse; the increased risk associated with these features is small, and their absence in no
way precludes sexual abuse as a possibility [14]. These features include poor parent-child relationships,
poor relationships between parents, the absence of a protective parent, and the presence of a
nonbiologically related male in the home [13,14].
2.5
Evaluation of Sexual Abuse in Children and Adolescents
Kirsten Bechtel, MD; Berkeley L. Bennett, MD, MS; July 26, 2012
3. Recognize the presentation of a rape victim with the possible indications of sexual abuse.
(table 1)
PRESENTATION — Victims of sexual abuse may present with a variety of medical complaints. They
may be brought to medical attention specifically for evaluation of possible sexual abuse, or they may
present for routine care or acute evaluation of medical or behavioral concerns that are not obviously
related to the abuse. In the latter scenarios, the diagnosis of sexual abuse depends, to some extent, upon
the willingness of the evaluating physician to consider it as a possibility [3].
Most of the complaints that are possible indicators of sexual abuse are nonspecific (table 1). Those that
are more specific for inappropriate sexual contact or exposure include rectal or genital bleeding and/or
sexually transmitted infections (STIs) that were not acquired perinatally.
Behaviors that may indicate that a child has been sexually abused include perpetration of sexual abuse
and/or sexually explicit acting out, developmentally inappropriate knowledge of sexual activities, or
developmentally inappropriate play (such as repeatedly touching an adult's genitals or asking an adult to
touch the child's genitals). Such behaviors are learned and are not a normal part of childhood fantasy
[13,18-20].
2.5
Evaluation of Sexual Abuse in Children and Adolescents
Kirsten Bechtel, MD; Berkeley L. Bennett, MD, MS; July 26, 2012
4. Discuss the medical evaluation of childhood sexual abuse pertaining to the history and
physical.
EVALUATION — The medical evaluation of childhood sexual abuse has several immediate goals
[21,22]:
 To identify injuries or other conditions that require treatment



To screen for or diagnose sexually transmitted infections
To evaluate for, and if possible, reduce the risk of pregnancy
To document findings of potential forensic value
The evaluation for possible sexual abuse includes a history and physical examination and may include
forensic evidence collection and/or screening for sexually transmitted infections. Whenever possible, the
evaluation should be performed by an experienced child abuse team, including a child abuse specialist or
clinician with similar experience. Consultation with a regional child abuse specialist or assessment center
may also be helpful in difficult cases, or in cases that occur in the context of other family problems such
as family violence or substance abuse [3]. (See 'Resources' below.)
Sexual abuse evaluations are best performed in a non-emergent setting, such as a child abuse advocacy
center, where the history and physical examination can be performed in a calm, quiet environment and
proceed at a pace tailored to the victim’s needs.
Urgent evaluation is necessary under the following circumstances and typically occurs in an emergent
setting [3,13,23]:
 The alleged abuse occurred within the previous 72 hours
 There are genital or anal injuries that require treatment
 There is obvious forensic evidence on the patient’s clothes or body that must be collected
 There is danger of continued abuse or reprisal by the alleged perpetrator
 The victim has reported homicidal or suicidal ideation or other emergent complaints
In all other cases, an evaluation by an experienced child abuse team, if available, and in a setting that is
not emergent should be scheduled as soon as possible after the alleged incident or disclosure [3,24]. In
addition to an evaluation for sexual abuse, it is essential that each child receives a thorough general
medical assessment that may identify unmet medical and psychological needs [22].
History — Obtaining an unbiased history from a child who may have been sexually abused may be the
most important part of the evaluation, particularly since diagnostic physical findings are frequently absent
[5,13,20,25]. A history of sexual abuse that is obtained in the course of medical diagnosis and treatment
may be admissible in court as an exception to the laws restricting hearsay testimony. Thus, complete
(verbatim, if possible) documentation of questions and answers is critical [15,26]. (See "Child abuse:
Social and medicolegal issues".)
On the other hand, in the evaluation of nonspecific complaints that are possibly related to sexual abuse,
the history should focus on differentiating among possible explanations for the child's symptoms: sexual
abuse, physical abuse to the genital area, unintentional injury to the genital area, or other medical
conditions [3,27]. (See 'Differential diagnosis' below.)
Caregiver history — The history regarding concerns about sexual abuse and any accompanying
symptoms should be obtained from the parent or caregiver separately from the child, in a calm, unhurried
manner. Many parents are understandably worried and appreciate an opportunity to share their concerns
privately.
The history should be comprehensive and include the child's current and past medical problems, as well
as social and family histories [13]. The review of systems should identify changes in bowel or bladder
habits (such as enuresis or encopresis), sleep disturbances, and behavioral changes and when they were
first noted. Sexual abuse often triggers these symptoms.
Parents should be asked how the abuse came to light or, if the child has not disclosed abuse, why the
parents suspect it [28]. For children who have made a disclosure, the content of statements to parents or
other caregivers should be documented.
Patient interview — Since the history from the child is such an important part of the evaluation, it should
be performed by an experienced professional. For patients who have disclosed sexual abuse, the history
obtained by the evaluating physician may be abbreviated [13]. Investigative interviews should be
performed by the appropriate agencies, and if possible, by forensic interviewers [5,15]. This minimizes
the need for a child to relate painful and distressing information on multiple occasions and also reduces
bias that may be introduced by repeated, suggestive, or leading questions.
In cases where sexual abuse is suspected, but not yet disclosed, the evaluating physician must obtain
additional information from the caregiver. Child Protective Services should intervene to determine the
need for a trained forensic interviewer when there is reasonable concern that abuse has occurred.
During the evaluation of child sexual abuse cases, the role of each clinician should be clearly defined and
based on clinical expertise. As an example, a clinical assistant who is handling laboratory specimens
should not ask the child or family about the details of the abuse. In the situation where the clinician must
obtain a history of abuse from the child, he or she must remember that this should be an opportunity for
the patient to tell the story without guidance or prompting from the parent or examiner.
The following section outlines a common approach taken by trained interviewers when questioning a
child or adolescent who has been sexually abused.
 Children – Children should be interviewed without the parents present, if at all possible.
However, when the child is uncomfortable alone with the examiner, it may be more effective to
permit the parent to stay. The examiner should explain to the parent the importance of obtaining
the history in the child's own words. The presence of a parent can be an opportunity to observe
parent-child interaction. Although there is no consensus regarding the necessity of a chaperone
for the interview, we suggest that it be conducted with either the parent or a Child Life worker in
the room.
In addition to obtaining the patient history, the clinician should explain the reason
for the visit and describe the examination that may follow. As rapport is established, it is
important to determine what words the child uses to describe his or her body parts.
The
accuracy of the history may be improved by asking open-ended questions, such as "Has someone
ever touched you in a way you didn't like or that made you feel uncomfortable?" [13,15]. To
encourage a spontaneous narrative, the examiner should avoid any display of shock or disbelief,
and maintain a "Tell me more." or "And then what happened?" approach [3,4].
When an
incident is disclosed, the following information must be obtained with a gentle and nonthreatening manner, using language that the child can understand [28]:
o Who was the person who did this?
o With what part of his/her body?
o What part(s) of the patient's body was (were) touched?
o How many times was the child touched?
o When was the last time that it happened?
o At what location did the abuse occur?
o Was there any exposure to blood or body fluids?
o Did the child experience pain to the affected body part?
o For male assailants, was there ejaculation?
o Did the child tell anyone about the incident?
Leading and suggestive questions (such
as, "Mr. X touched your bottom, didn't he?" or "Did Mr. X touch your bottom?") should
be avoided. Allowing the child to use a doll or drawing to describe what happened may
be helpful in obtaining and clarifying information. The patient may disclose more details
during the course of the physical examination.
At the end of the history, it is important
that the child understands that he or she did the right thing in telling what happened, that
he or she did nothing wrong, and that he or she is not in trouble [13]. (See "Management
and sequelae of sexual abuse in children and adolescents", section on 'Anticipatory
guidance'.)

Adolescents – The adolescent history should occur without the presence of other family
members. It is helpful to inform the adolescent that this is an opportunity for him/her to ask
questions as well as share details about the event(s).
The patient should be told that
information disclosed in this setting is, to an extent, confidential. Adolescents may receive
confidentiality around some issues (as an example, their sexual activity), but health care providers
are mandated to report disclosures about sexual abuse to a child protective services agency. Many
adolescents are more willing to share information once they realize that the law grants them some
protection of confidentiality. (See "Confidentiality in adolescent health care".)
At the
conclusion of the interview, the examiner should support the adolescent's decision to report the
abuse and reassure the adolescent that he or she has done nothing wrong [13].
Physical examination — As with the history, the nature and timing of the examination depend to some
extent upon the presenting complaint. The examination should be performed by trained and experienced
examiners as soon as possible after the alleged incident [3,24].
The physical examination of the possibly sexually abused child may be more difficult for the examiner
than the child. It is helpful to approach this evaluation as one would any other type of physical complaint.
The tone in the room is often set by the examiner; the more comfortable he or she is, the more
comfortable the patient and his or her parent(s) will be.
The physical examination should not result in additional emotional or physical trauma [3]. The purpose
and noninvasive nature of the examination should be explained to the child and parents before it is
performed [3,24]. Many children and adolescents are comforted by knowing that "adults need to have
these examinations too" and that such examinations can help the child or adolescent know that his or her
body is "okay".
Parents may expect that the physical examination will yield evidence that confirms or excludes abuse. It
is important to explain that physical evidence is rarely present in pediatric patients who are evaluated for
sexual abuse [20]. Even among children who report vaginal or anal penetration, the rate of abnormal
physical examination findings is only 5 to 15 percent [20,28]. The examination is important for assessing
medical problems that require attention, but other aspects of the evaluation (eg, history, laboratory
analysis) may be more helpful in determining whether the child has been abused. (See 'Interpretation of
findings' below.)
During the examination, a supportive adult who is not suspected of involvement in the abuse should be
present [3]. Recognizing that the physical examination may be emotionally difficult for the child,
permitting the child to decide who he or she would prefer to have in the examination room is one way to
empower him or her. Distraction techniques may help the child tolerate the uncomfortable nature of the
evaluation. Respect for the child's modesty whenever possible (such as by using drapes) is important [13].
For children who are extremely anxious or uncooperative, use of a mild sedative, with careful monitoring,
may be considered [3,21]. (See "Procedural sedation in children outside of the operating room".)
The examination should include the mouth, breasts, genitals, inner thighs, perineal region, buttocks, and
anus [3]. Good illumination is essential [15,29]. An otoscope light source often provides sufficient
illumination for direct visualization of genital structures. Colposcopy offers the advantages of
magnification and photographic documentation [13]. It may be helpful in identifying subtle lacerations or
tears, but is not considered essential [21,30]. Signs of trauma should be documented by photographs or
detailed drawings [3]. (See "Child abuse: Social and medicolegal issues".)
An ultraviolet or Wood's lamp may be used for detecting semen within several hours after the abuse.
However, urine and oily fluids also fluoresce under the Wood's lamp [11,31,32]. In addition, semen may
not reliably fluoresce using a Wood's lamp (360 nm wavelength) [31]. Consequently, the Wood's lamp
examination is most helpful for identifying suspicious areas for more definitive forensic testing [21]. An
alternate UV light source, such as one with a 420 to 450 nm wavelength, may be more useful for
identifying semen on the skin. (See 'Forensic evidence collection' below.)
Oral cavity — Examination of the oral cavity should include evaluation for evidence of forced oral
penetration such as bruising or petechiae of the hard or soft palate and/or tears of the frenulum [15].
Female genitalia — The anatomy of the female genitalia is depicted in the figure (figure 1). In all girls,
the labia majora, labia minora, introitus, and hymen should be inspected for erythema, lesions, abrasions,
or tears. The presence of a vaginal discharge in a prepubertal girl should prompt evaluation for sexually
transmitted infections [33,34]. (See 'STI testing' below.)
The female genitalia are best viewed with the child lying supine (either on the examination table or in the
lap of an adult, depending upon the child's comfort) with her hips externally rotated and knees flexed
(frog-leg position). This allows examination of the external genitalia, vaginal vestibule, and hymenal
structures. The prone knee-chest position (figure 2) is helpful in evaluating the anogenital region. In girls,
it permits better visualization of the posterior hymen, vagina, and sometimes cervix [13,24]. The
lithotomy position may be helpful in older girls [20].
Prepubertal girls (Tanner stage 1 or 2 for pubic hair) do not require a speculum examination unless there
is active bleeding of unknown etiology [13,20]. When a speculum examination is required, the child
should be adequately sedated, and the hymenal findings (eg, hymen configuration, presence of tears,
erythema, abrasions) should be clearly documented before insertion of the speculum. (See "Procedural
sedation in children outside of the operating room".)
A speculum examination may be necessary for pubertal adolescent females. Saline or water should be
used instead of petroleum-based lubricants, since petroleum-based lubricants may affect sperm motility
and culture results [9,35]. The vaginal walls as well as the cervix should be visualized to detect any
evidence of trauma and to obtain samples from fluid collections. After the speculum examination is
completed, a bimanual examination should be performed to assess adnexal and cervical tenderness. A
rectal examination may be included as indicated.

Hymen – One of the most challenging aspects of the female genitalia examination is evaluation
of the hymen. Visualization of the hymen is best achieved by gently grasping the labia minora
bilaterally and pulling downward and outward when the patient is lying supine. The redundant
folds of the estrogenized adolescent hymen may be more easily visualized using a moistened
cotton swap or saline drops to fold out the edges [13].
The appearance of the hymen changes
with age and in response to hormonal influences [36]. The prepubertal hymen is characterized as
thin, translucent, and sensitive to touch (figure 3). It becomes thickened, elastic, redundant, and
accommodating in puberty, as the result of a physiologic increase in estrogen exposure. Common
normal variations in the appearance of the hymen include imperforate, microperforate, cribriform,
and septate forms (figure 4) [6].
The significance of notches or clefts in the hymen depends
upon the location and extent of the defect [37]. Superficial notches can occur in the absence of
abuse [6,13,36], whereas deep notches (ie, >50 percent of hymenal diameter) are more
concerning for abuse [6,37,38], although this finding is controversial [28]. (See 'Interpretation of
findings' below.)
Acute lacerations, transections (clefts that extend to the junction of the
hymen and the vestibule), and bruising of the hymen are more specific for penetrating sexual
trauma, as is the absence of hymenal tissue [6,28,37,38]. However, the absence of these findings
is common in girls who have suffered perceived genital penetration [39-41]. For example, an
observational study of 506 girls age 5 to 17 years, who disclosed penile-genital penetrative abuse,
found that most girls did not have definitive physical findings of abuse regardless of the number
of reported penetrations [41]. Specifically, no findings were seen on expert review of
photocolposcopy in all of the girls less than 10 years of age (N=74), 87 percent of girls ≥10 years
of age with no history of consensual sex (358 of 410 patients), and 82 percent of girls ≥10 years
of age with a history of consensual sex (18 of 22 patients).
Attachments or fusions between the
labia minora and hymen may represent prior hymenal injury and are suggestive of abuse [30]. In
contrast, labial adhesions (agglutination or fusion of the labia minora in the midline) normally
occur in children and are not indicators of abuse. (See "Vulvovaginal complaints in the
prepubertal child", section on 'Labial adhesions'.)
Measurements of the hymenal orifice vary
widely among abused and normal children [20,36,42,43]. Consequently, the transverse diameter
of the hymenal orifice is not a marker for whether or not vaginal penetration occurred. (See
'Interpretation of findings' below.)
Male genitalia — Male genitalia may be examined with the patient standing or supine. The anatomy of
the male genitalia is depicted in the picture (picture 1). A younger child may be more comfortable being
examined in his parent's lap. He should be supine in the frog-legged position, so that the penis, scrotum,
perineal area, and anus can be visualized. (See "The pediatric physical examination: The perineum",
section on 'Males'.)
The scrotum and penis should be examined for signs of acute or chronic trauma, including erythema,
bruises, bite marks, or abrasions.
The urethral meatus should be examined for erythema and lacerations. Genital injuries that have been
described in retrospective series include lacerations, bruises, and burns [44,45]. Penile and anal injuries
are much more common than injuries to the scrotum.
Discharge at the urethral meatus may indicate infection. Penile or anal secretions should be obtained via
swabs and cultured when discharge is noted. Anal secretions should be examined for evidence of semen if
anal penetration within the previous 24 hours is suspected or reported. (See 'STI testing' below and
'Forensic evidence collection' below.) Lesions suggestive of sexually transmitted infections should be
noted (eg, ulcerations, condyloma lata). (See appropriate topic reviews).
Perianal area — Examination of the anus in both males and females may be accomplished with the
patient lying in the lateral recumbent position and grasping his or her knees. The examiner separates the
buttocks for approximately 30 seconds, allowing sphincter relaxation and visualization of the anal canal.
If penetration is suspected, a stool guaiac test should be performed [12].
Laxity of the anus may represent abuse [46]. It also can be seen with chronic constipation, neurologic
disorders, or sedation. Dilation greater than 20 mm is suggestive of abuse if there is no stool in the
ampulla [28]. However, consensus regarding the significance of this finding is lacking (see 'Interpretation
of findings' below). Irregularity of anal folds after complete dilation is suggestive of abuse as well.
Evidence of acute anal trauma may be seen if the child is evaluated soon after the abuse; however,
anorectal changes are rarely definitive indicators of abuse. Swelling of the anus with blue discoloration is
suggestive of trauma [46] and may be present up to 48 hours after the event. It is important not to confuse
this finding with hemorrhoids (picture 2A-B). Perianal erythema is suspicious for trauma [46]. It may also
be seen in children with encopresis, poor hygiene, pinworms, or Group A streptococcal or staphylococcal
infection. (See 'Differential diagnosis' below.)
Penetrating injuries causing lacerations of the rectum may heal with scarring, but over time are difficult to
detect. Midline anal tags are not indicative of abuse, whereas deformities outside of the midline may
indicate chronic trauma [12,13].
Forensic evidence collection — Material evidence, when it is identified, is invaluable in the investigation
of allegations of sexual abuse. Every institution that provides care to victims of alleged sexual abuse must
have an organized approach to the collection of forensic evidence. Many states have developed the Sexual
Assault Nurse Evaluator (SANE) system, which utilizes specially trained nurse examiners for evidence
collection from adults and children. (See "Evaluation and management of adult sexual assault victims",
section on 'Trained providers'.)
Forensic evidence is typically collected using kits that are specified by state or hospital protocol. The
instructions for obtaining and labeling specimens must be followed carefully. In addition, the kit must be
sealed, stored, and transferred to law enforcement authorities in a manner that maintains an unbroken
chain of evidence. The forensic examination for victims of sexual assault is described elsewhere. (See
"Evaluation and management of adult sexual assault victims", section on 'Forensic evaluation'.)
Timing — Current guidelines on evidence collection reflect data and conclusions from adult studies that
may not be directly applicable to children [47]. Several retrospective series have demonstrated that the
yield for forensic examinations in children is low and that the majority of forensic evidence is found on
clothing and linens [48-50]. Semen is identified from body swabs more commonly in older children and
rarely identified in any children more than 24 hours after an alleged assault. Some experts suggest that the
interests of prepubertal children would best be served by deferring the forensic examination to centers
with expertise in sexual abuse evaluation in cases where the abuse event occurred more than 24 hours
prior and no obvious injury or infection is present [51,52]. However, protocols regarding when evidence
must be collected vary from state to state.
The decision to collect forensic evidence from children who may have been sexually abused should take
into consideration state protocols, the probability that the examination will yield evidence, and the
potential emotional impact of the collection procedure on the child. Whenever possible, the decision to
perform a forensic examination should be made by individuals with training and experience in child
sexual abuse.
Careful documentation of the decision making process regarding evidence collection is essential. Reasons
for not collecting evidence or modifying the type of evidence that is collected must be documented.
Information should be included regarding the emotional needs of the child and details of the abuse that
are likely to decrease the yield of evidence (such as the use of condoms, lubricant, or showering or
bathing prior to the examination).
For prepubertal children and adolescents who are evaluated within 24 hours of the alleged abuse, forensic
evidence should generally be collected in any of the following situations:
 There is reasonable concern that sexual abuse has occurred.
 The child has a genital injury as the result of alleged sexual abuse.
 Clothing or linen associated with the abuse is available.
 There are other concerning clinical features.
For children who are evaluated more than 24 hours after the incident, state protocols should be followed,
recognizing that the yield in evidence collection often decreases after 24 hours. The clinician must also
consider that evidence may be identified that was unanticipated by the child's history or general physical
examination and that there are reported instances of collection of identifiable DNA samples beyond 24
hours in young children under 10 years of age [48,53,54].
Although limited data suggest that the yield of evidentiary exams after 24 hours is also low for
adolescents, patients in this age group are usually managed according to adult protocols [47]. (See
"Evaluation and management of adult sexual assault victims", section on 'Forensic evaluation'.)
Evidence collection may be modified (as allowed by local protocols) to eliminate procedures that are
unlikely to yield evidence based on details of the alleged abuse. Clothing and linen are very important
sources for semen and other DNA identification and should be collected whenever they are available.
Aspects of the examination itself that should be considered include:
 DNA evidence may be identified from sources other than semen. Consequently, the clinician
should consider the details of the alleged abuse when deciding which parts of the rape kit to
complete. As an example, fingernail scrapings should be obtained when a victim describes
grabbing the assailant or pulling his hair.
 Swabs to confirm the presence of semen should be collected from areas of fluorescence identified
with an ultraviolet light source. (See "Evaluation and management of adult sexual assault
victims", section on 'Forensic evaluation' and 'Physical examination' above.)
 A speculum examination is not indicated to obtain evidence from prepubertal girls. For those who
are postpubertal, collection of semen from vaginal fluid or cervical mucus can be done using
swabs or a pipette facilitated by a speculum examination. (See 'Female genitalia' above.) Motile
sperm may be found in the vagina for eight hours and in the cervical mucus for two to three days
after intercourse. Nonmotile sperm may persist in the vagina and rectum for 24 hours and in the
cervical mucus for 17 days [11,55].
Every effort must be made to collect forensic evidence without traumatizing the child. Some children may
require sedation for the procedure, particularly in the unlikely event that a speculum examination is
necessary. Evidence can be collected in the operating room for those patients with injuries who require
evaluation and/or treatment under general anesthesia.
STI testing — The identification of a sexually transmitted infection (STI) in a prepubertal child or an
adolescent who has not become sexually active may be evidence that the child has been sexually abused
[56]. The prevalence of STIs in pediatric victims of sexual abuse is approximately 5 to 8 percent.
However, the prevalence varies according to physical findings, geographic location, and infectious agent
[57-61].
Among children undergoing evaluation for sexual abuse, positive tests for an STI are found in up to 25
percent of girls with vaginal discharge and 6.5 percent of girls with normal or nonspecific physical
findings [61]. Thus, most sexually abused girls with STIs have normal or nonspecific findings on physical
examination. The prevalence of STIs in boys with normal examination findings appears to be extremely
low [57,61,62].
The decision to test for STIs (which is often made on a case by case basis) is discussed below.
Prophylaxis for STIs, including HIV, is reviewed elsewhere. (See "Management and sequelae of sexual
abuse in children and adolescents", section on 'STI prophylaxis'.)
Prepubertal victims — Experts recommend STI testing in the prepubertal child in the following
circumstances [20,33,61,63-67]:
 High likelihood of sexual abuse based on interview [61]
 The presence of signs or symptoms consistent with STIs (eg, genital discharge) [33,64,65]
 An STI in the patient's sibling or another child in the patient's intimate environment [66,67]
 The suspected perpetrator has an STI or is at high risk for having an STI
 The parents request testing
 There is evidence of anal or genital penetration (eg, acute tears) [20]
 Evidence of ejaculation is present
As a general rule, screening for HIV should be performed for the same indications and in conjunction
with other STI screening [21]. However, before HIV screening is performed, the possibility of vertical
transmission (if the child is found to be positive) and its implications must be discussed with the child's
mother.
It is important to consider the incubation period of potential pathogens when testing for STIs after an
acute event. Testing for gonorrhea, chlamydia, trichomonas, and bacterial vaginosis should be performed
two weeks after the incident for patients who did not receive prophylactic therapy at the initial evaluation
[15]. Serologic testing for human immunodeficiency virus (HIV) should be performed at baseline and 6,
12, and 24 weeks after the incident [15,56].
The appropriate culture method must be used, if and when STI testing is performed. In the United States,
culture in addition to nonculture methods (eg, nucleic acid amplification tests (NAAT)) are preferred
[61,68,69]. In one study of 485 children undergoing evaluation of sexual abuse, the use of urine NAAT
significantly increased the detection of chlamydia and gonorrhea infection in prepubertal children
undergoing evaluation for sexual abuse (4.5 percent positive by NAAT versus 3.3 percent positive by
culture) [70]. Nonculture methods are still not accepted as forensic evidence in some United States
jurisdictions.
However, in Canada, nonculture methods are being used in the evaluation of sexually abused children and
are accepted as forensic evidence [71]. Given that urine NAAT may be more accurate than culture and is
less invasive, it may be the preferred method of detection in children with normal or nonspecific findings
who live in legal jurisdictions that accept such methods as a forensic standard. Confirmation tests of
positive NAAT’s should be done with a second FDA-approved NAAT that targets a different DNA
sequence from the initial test [56].
Depending upon the suspected pathogen, the following specimens may be obtained as guided by the
description of the events and the child's symptoms and physical findings [63]:

Neisseria gonorrhoeae: Rectal, throat, and urethral or vaginal cultures (cervical specimens should
not be collected from prepubertal girls) and NAAT









Chlamydia trachomatis: Rectal or vaginal cultures (cervical specimens should not be collected
from prepubertal girls) and urine NAAT
Syphilis: Darkfield microscopy
HIV: Serologic testing of abuser (if possible); serologic testing of child at time of abuse and 6,
12, and 24 weeks later
Hepatitis B virus: Serum hepatitis B surface antigen testing of alleged abuser (if possible);
hepatitis B surface antibody testing of the child to document response to vaccine, if the child
received hepatitis B vaccine
Herpes simplex virus: Culture of suspicious lesion. Routine serology for HSV infections is not
warranted [72].
Bacterial vaginosis: Wet mount, pH, and potassium hydroxide testing of vaginal discharge or
Gram stain
Human papillomavirus: Biopsy of lesion
Trichomonas vaginalis: Wet mount and culture of vaginal discharge
Pediculosis pubis: Identification of eggs, nymphs, and lice with naked eye or using a hand lens
The significance of the identification of a sexually transmitted agent in a child as evidence of possible
child sexual abuse varies by pathogen. (See 'Interpretation of findings' below.)
Postpubertal victims — For adolescents who have been sexually active, testing for sexually transmitted
infection (STI) is controversial. Evidence of infection is generally not necessary for prosecution and
positive tests may be used by the defense as discrediting evidence of promiscuity. In addition,
prophylactic treatment is typically prescribed regardless of culture results [56,63]. (See "Evaluation and
management of adult sexual assault victims", section on 'Laboratory testing'.)
Some experts recommend that all postpubertal patients be screened for STIs, including HIV, because the
prevalence of preexisting asymptomatic infection is high [63]. Others suggest that the decision to test a
victim of sexual abuse for STIs be made on an individual basis [56].
2.5
Evaluation of Sexual Abuse in Children and Adolescents
Kirsten Bechtel, MD; Berkeley L. Bennett, MD, MS; July 26, 2012
5. Interpret the findings in the suspected child sexual abuse case regarding the history and
physical.
INTERPRETATION OF FINDINGS —
Clinical suspicion — As with other forms of child abuse, the interpretation of findings in children with
suspected sexual abuse depends upon the constellation of historical, physical, and laboratory findings.
Isolated examination or laboratory findings are rarely diagnostic, but become more concerning when
combined with a disclosure of sexual abuse, specific behavioral changes, and/or the lack of another
plausible explanation.
History — The history is often the most important part of the evaluation. The provision by the child of a
spontaneous, clear, consistent, and detailed description of sexual molestation is specific for sexual abuse
and should be reported to Child Protective Services (CPS) [33,74]. CPS should also be consulted to
evaluate situations where there is reasonable concern that abuse has occurred, but the initial history is
inconclusive.
Normal physical examination — A normal physical examination does not preclude the possibility that a
child has been sexually abused [34]. The lack of physical findings may be inherent in the nature of the
abuse (eg, fondling of the breast or genitals, oral-genital contact, exposure to pornographic material) or
may be the result of the intrinsic elasticity and rapid healing of the anogenital tissues [74-78].
Furthermore, in retrospective series, there were no differences in the rates of healing of hymenal and other
genital injuries between children with inflicted injuries and those with accidental mechanisms [76,77].
In the event that there are no physical findings consistent with abuse, the report should contain a
statement such as "Normal or nonspecific findings are to be expected in a child who describes this type of
molestation," or "A normal examination neither rules out nor supports an allegation of sexual abuse" [73].
Abnormal physical examination — Abnormal physical examination findings are present in the minority
of children who are evaluated for possible sexual abuse [20,38].
Nonspecific findings — The physical examination in cases of possible sexual abuse may identify
nonspecific findings that are associated with other medical conditions or are normal variants of anogenital
structures (table 2A-B and table 3) [28,36,42,79-87]. (See 'Differential diagnosis' below and
"Vulvovaginal complaints in the prepubertal child".)
In the absence of a disclosure of sexual abuse, these nonspecific findings do not necessarily raise concern
for sexual abuse [28]. The physician should refer the child to a child abuse specialist (usually at an
academic medical center, children's hospital, or child advocacy center) for further evaluation before a
report of suspected abuse is made whenever there is a question regarding the significance of physical
findings.
Suspicious findings — Certain anogenital findings have been noted in children with documented sexual
abuse. However, data regarding the specificity of these findings for sexual abuse is insufficient or
contradictory [28,73].
Suspicious findings include [3,5,28,34,42,46,79,80,88-94]:
 Genital or anorectal injury that requires surgical care is concerning. One observational study of
44 girls found that 25 percent of such injuries were caused by sexual abuse and the other injuries
were associated with straddle or impalement mechanisms or motor vehicle collisions [95].
Sexually abused children had no plausible mechanism by history to explain the severity of
findings.
 Deep notches or clefts (>50 percent of the width of the hymenal rim) in the posterior/inferior rim
of the hymen (below the line drawn through 3 o'clock to 9 o'clock, with the patient supine) may
be caused by previous blunt force or penetrating trauma [5,34,88]. In one case control study, deep
notches were described in none of the controls, but in only 2/192 girls with a history of
penetration [38]. However, deep notches may be an artifact of examination technique and it is
difficult to distinguish between superficial and deep notches [28].
 A thin posterior hymenal rim may also be indicative of penetrating trauma, but accurate
measurement of the hymenal rim is difficult [5,28]. Studies have demonstrated inconsistent
results. The finding was absent in several studies of girls chosen who were not abused [42,79,80].
However, in a series of similar girls who also had not been abused, 22 percent had a posterior rim
estimated to be <1 to 2 mm [87].
 A wide hymenal orifice may be a normal finding [42]. In a large cohort of girls 3 to 12 years of
age being evaluated for sexual abuse, transverse diameter of the hymenal ring did not correlate
with sexual abuse [89].
 Lesions that appear to be genital warts may be skin tags, nongenital warts, or genital warts
acquired by perinatal or nonsexual transmission [3,90,91]. (See 'STIs' below.)
 Vesicular lesions or ulcers in the anogenital area may be caused by STIs (such as syphilis or
HSV) as well as other viruses (including Epstein-Barr virus), Behcet's disease, Crohn's disease,
and others (table 2A-B) [3,90,91]. (See 'STIs' below.)

Marked, immediate anal dilation to a diameter of 2 cm or more, in the absence of other
predisposing factors such as chronic constipation, sedation, anesthesia, or neuromuscular
conditions may be indicative of sexual abuse [46,82,92]. However, there is no clear consensus
among experts regarding the significance of this finding [28].
The history is critical in determining the overall significance of suspicious or indeterminant findings. In
the absence of a history of abuse, children with these findings require further investigation (eg, diagnostic
studies or careful questioning of the child). Consultation with a child abuse specialist may be helpful.
Reporting to Child Protective Services (CPS) should be considered [28,93].
Specific findings — Examination findings that are diagnostic of genital trauma, and in the absence of a
clear, timely, plausible history of accidental injury should be reported to CPS, are listed in the table (table
4).
Laboratory — Laboratory findings that are diagnostic for sexual abuse include:
 Pregnancy in the absence of consensual intercourse [3]
 Identification of sperm, semen, semen-specific antigens (eg, prostate-specific protein p30), or
enzymes (eg, acid phosphatase) in or on a child's body [3]
STIs — The significance of the identification of a sexually transmissible pathogen in the evaluation for
childhood sexual abuse varies according to the pathogen [56]. STIs that are specific for sexual contact in
prepubertal children and should be reported to CPS include [3,28,56,90,93,94]:
 Postnatally acquired gonorrhea
 Postnatally acquired syphilis
 Human immunodeficiency virus infection that is not acquired perinatally or iatrogenically
STIs that are less specific for childhood sexual abuse, either because there are other modes of acquisition
or because perinatal infection may remain asymptomatic, but nonetheless should be reported to CPS,
include [3,94]:
 Herpes simplex virus
 Genital warts
 Chlamydia infection
 Trichomonas vaginalis
Limited observational evidence suggests that children can acquire herpes simplex virus (HSV) through
nonabusive contact (such as diaper changing or autoinoculation) or through sexual contact [96]. Sexual
transmission may be more likely for children ≥5 years of age, for those with only genital lesions, and
when HSV type 2 is isolated from lesions. Genital herpes caused by HSV type 1 can be acquired through
sexual contact [97]. Consequently, the type of HSV isolated from a genital lesion may not be sufficient to
establish whether or not the infection was transmitted through abusive contact. Nevertheless, new herpetic
lesions in children who are beyond infancy and have independent toilet habits are suspicious for abuse
and should be reported [63].
Genital warts (condyloma acuminata) are caused by human papillomavirus (HPV) [98]. The virus may be
transmitted both sexually and nonsexually [99]. In young children, these lesions can develop as the result
of sexual contact or via nonabusive contact with common warts [100]. Infants may acquire HPV
perinatally from infected mothers. In a prospective study of vertical transmission of HPV, the maximum
likelihood of transmission was only 2.8 percent [101]. Perinatally acquired condyloma acuminata may
present any time before 20 months of age. Examination of the mother via colposcopy may be helpful in
determining the etiology [100]. Sexual abuse should be considered in children who develop genital warts
after the age of approximately two years [3,21,90]. A study designed to delineate the clinical
characteristics of pediatric patients with anogenital warts concluded that the modes of transmission of
anogenital warts in children cannot be identified either by the clinical appearance of the lesions or by
human papillomavirus typing, thus highlighting the importance of the clinical history and exam along
with the social context of the family [102].
Chlamydial infection of the vagina, urethra, or rectum that occurs after infancy is suggestive of abuse,
although infection acquired at birth can remain asymptomatic until as late as three years of age [103].
Sexual contact is likely if chlamydia is cultured from anal or genital tissues of a child who is older than
three years via cell culture or comparable method approved by the CDC [3,28,90].
Trichomonas vaginalis can occur in newborns, but is rare in the prepubertal child [104,105]. Sexual
contact is likely in a child older than one year of age if trichomonal organisms are identified (by an
experienced technician or clinician) in vaginal secretions by wet mount examination or culture [3,28,90].
Hepatitis B infection, bacterial vaginosis, scabies, and pediculosis pubis may be transmitted sexually;
however, transmission occurs by other modes. The decision to involve CPS when these organisms are
detected depends upon the complaint or level of suspicion of abuse [63].
2.5
Evaluation of Sexual Abuse in Children and Adolescents
Kirsten Bechtel, MD; Berkeley L. Bennett, MD, MS; July 26, 2012
6. Review the differential diagnosis possibilities in a sexual abuse case.
DIFFERENTIAL DIAGNOSIS — Misdiagnosis of sexual abuse can be traumatic for everyone
involved [33]. Thus, the differential diagnosis of sexual abuse must be carefully considered in all
children, particularly those who present with nonspecific genitourinary complaints or behavioral
disturbances and do not volunteer a history of abuse [27].
The differential diagnosis of child sexual abuse includes other types of genital injury, infection,
dermatologic conditions, congenital conditions affecting the perineum, and other conditions affecting the
urethra or anus (table 2A-B) [13].
Injuries — Unintentional injuries of the perineum include straddle injuries, zipper entrapment, hair
tourniquet, and seat belt or motor vehicle accident injury to the genitalia [13,27,106]. The history in these
unintentional injuries is usually readily available.
Straddle injuries typically involve the anterior structures, such as the clitoris, clitoral hood, mons pubis,
and labial structures, and even posterior fourchette. Penetrating sexual abuse usually results in injury to
the hymen and other more posteriorly located structures such as the posterior fourchette and fossa
navicularis (figure 1) [13]. However, accidental penetrating straddle injuries have been reported [107].
(See "Straddle injuries".)
Other nonsexual mechanisms of injury include:



Zipper entrapment injuries and hair tourniquet injuries. (See "Management of zipper injuries" and
"Hair entrapment removal techniques".)
Vaginal foreign bodies. (See "Vulvovaginal complaints in the prepubertal child", section on
'Foreign body'.)
In girls of African or Middle Eastern descent, female circumcision in infancy or childhood can
cause bleeding and unusual genital adhesions and scars [108]. (See "Female circumcision and
genital cutting".)
Infection — Infections and/or infestations that cause inflammation and erythema of the perineum include
streptococcal vaginitis, candidal infections, varicella, pinworms, and perianal cellulitis [13,27,109,110].
Autoinoculation of common warts or molluscum contagiosum can mimic warts caused by human
papilloma virus (condyloma acuminatum) (picture 3 and picture 4) [73]. (See "Vulvovaginal complaints
in the prepubertal child", section on 'Nonspecific vulvovaginitis'.)
Skin conditions — The following dermatologic conditions may cause ulcers, erythema, friability, and/or
bleeding of the perineum and should be considered in the differential diagnosis of sexual abuse
[13,27,73,111]:







Nonspecific vulvovaginitis (poor hygiene, bubble bath)
Seborrheic, atopic, or contact dermatitis (including diaper dermatitis). (See "Overview of diaper
dermatitis in infants and children".)
Lichen sclerosus, lichen simplex chronicus, or lichen planus (picture 5 and picture 6 and picture
7A-B)
Psoriasis (picture 8)
Bullous pemphigoid
Behcet's disease (picture 9)
Perineal hemangiomas (of the labia, hymen, perihymenal area, or urethra)
Mongolian spots can look like bruises (picture 10). (See "Vulvovaginal complaints in the prepubertal
child".)
Anal conditions — Anal conditions that may be associated with perianal bleeding or bruising and should
be considered in the differential diagnosis of sexual abuse include hemorrhoids (picture 2A-B), Crohn's
disease [112], rectal prolapse (which can be caused by medical conditions as well as sexual abuse) (figure
5), hemolytic uremic syndrome [113], and rectal tumors [13,27]. (See "Clinical manifestations of Crohn's
disease in children and adolescents" and "Overview of rectal prolapse in children".)
Perianal erythema may also be seen as a result of encopresis, poor hygiene, pinworm infection, and Group
A streptococcal or staphylococcal infection. (See "Definition, clinical manifestations, and evaluation of
functional fecal incontinence in infants and children".)
Laxity of the anus may represent abuse, but also can be seen with chronic constipation [46,92], neurologic
disorders [27], and diastasis ani (a normal variant in which there is a slight opening of the visible portion
of the anus when the buttocks are spread) [73].
Urethral conditions — Urethral conditions to be considered in the differential diagnosis of sexual abuse
include urethral prolapse, caruncle, sarcoma botryoides, and ureterocele.




Partial or complete prolapse of the distal urethra may occur in preadolescent girls. Urethral
prolapse appears as an edematous, violaceous, nontender, doughnut-shaped mass surrounding the
urethral meatus; bleeding may be the presenting complaint. (See "Vulvovaginal complaints in the
prepubertal child", section on 'Urethral prolapse'.)
Sarcoma botryoides is a unique form of embryonal rhabdomyosarcoma that arises within the wall
of the bladder or vagina and is seen almost exclusively in infants. It presents as soft nodules that
fill and sometimes protrude from the vagina, resembling a bunch of grapes. (See
"Rhabdomyosarcoma and undifferentiated sarcoma in childhood and adolescence: Epidemiology,
pathology, and molecular pathogenesis".)
An ureterocele is a cystic dilatation of the terminal ureter within the bladder and/or the urethra; a
prolapsed ectopic ureterocele may protrude through the urethral meatus. (See "Ureterocele".)
A caruncle is a small, red, papillary growth, highly vascular, sometimes found in the urinary
meatus in females; it is sensitive to friction and characterized by pain on urination.
RESOURCES — Some communities have a child advocacy center that provides expertise in the
evaluation and treatment of sexual abuse victims and the prosecution of sexual abuse perpetrators. These
centers may provide social services, law enforcement agencies, legal services, and medical evaluation,
and may be a resource for consultation. Local advocacy centers can be identified on the National
Children's Alliance website (www.nca-online.org).
Additional resources that may be helpful in the evaluation and management of suspected child abuse are
listed in the tables (table 5A-B).
SUMMARY AND RECOMMENDATIONS — Children who may have been victims of sexual abuse
should receive a thorough evaluation that includes careful questioning and a complete physical
examination. In some situations, evidence-collection procedures, and/or specialized examination
techniques may be required.









There is reasonable concern that a sexual abuse has occurred.
The child has a genital injury as the result of alleged sexual abuse.
Clothing or linen associated with the abuse is available.
There are other concerning clinical features.

For prepubertal children who are evaluated more than 24 hours after the incident, state protocols
should be followed recognizing that the yield in evidence collection often decreases after 24
hours. The management of adolescents should generally be according to adult protocols. (See
'Forensic evidence collection' above.)
We suggest that prepubertal girls who are likely to have been sexually abused based on history or
physical examination be tested for sexually transmitted infections. (See 'STI testing' above.)
For adolescent girls who have been sexually abused, we suggest that testing for STI be made on a
case by case basis, but that these patients should receive antibiotic prophylaxis regardless of
whether testing is completed. (See 'Postpubertal victims' above.)
Isolated examination or laboratory findings are rarely diagnostic, but when combined with a
disclosure of sexual abuse, specific behavioral changes, and/or the lack of another plausible
explanation, may be consistent with sexual abuse. (See 'Interpretation of findings' above.)
The differential diagnosis of child sexual abuse includes other types of genital injury, infection,
dermatologic conditions, congenital conditions affecting the perineum, and other conditions
affecting the urethra or anus (table 2A-B). (See 'Differential diagnosis' above.)




2.6
A generally accepted definition of sexual abuse is when a child engages in sexual activity for
which he/she cannot give consent, is unprepared for developmentally, cannot comprehend, and/or
an activity that violates the law or social taboos of society. (See 'Definitions' above.)
Sexual abuse occurs primarily in preadolescent children, more often in girls. Perpetrators are
usually males who are known to the victims. (See 'Epidemiology' above.)
Most of the complaints that are possible indicators of sexual abuse are nonspecific (table 1).
The evaluation of children who may have been sexually abused requires careful questioning and a
complete physical examination. Such evaluations are best performed in a non-emergent setting,
such as a child abuse assessment center, where the history and physical examination can be
performed in a calm, quiet environment and proceed at a pace tailored to the victim’s needs.
Victims who present within 72 hours of the incident, have obvious forensic evidence on their
clothes or bodies, have continued risk of harm from the perpetrator, have genital or anal injuries,
or other emergent complaints (eg, suicidal ideation) should receive an urgent evaluation. (See
'Evaluation' above.)
Forensic evidence (usually as a rape kit) should generally be collected from children who are
evaluated within 24 hours of the incident in the following situations (see 'Forensic evidence
collection' above):
Evaluation and Management of Adult Sexual Assault Victims
Carol K. Bates, MD; November 5, 2012
1. Review the epidemiology of sexual assault, defining the same.
EPIDEMIOLOGY — According to an extensive systematic review of studies of sexual violence
perpetrated by non-partners, sexual violence against women is common throughout the world [1]. The
review noted that data is scant in particular regions (central sub-Saharan Africa, Middle East, Eastern
Europe, Asia Pacific) and therefore data must be interpreted cautiously, but reported that the prevalence
appeared to be highest in central sub-Saharan Africa (21 percent; 95% CI 4.5-37.5) and southern subSaharan Africa (17.4 percent; 95% CI 11.4-23.3). When interpreting this study, it is important to
remember that sexual violence perpetrated by intimate partners was not included, and that were such
data added the overall prevalence would be much greater.
The lifetime prevalence of sexual assault in the United States is approximately 18 to 19 percent in women
and 2 to 3 percent in men [2,3]. In a national phone survey of college women, 2.8 percent reported
completed or attempted sexual assault in a year; the estimated cumulative rate in four years may be as
high as one in four [4]. In one series, almost 30 percent of undergraduate women reported a drug-related
assault, with alcohol the most common substance involved [5]. About 50 percent of sexual assault victims
have some acquaintance with their attackers. Two-thirds of assaulted women over 55 are assaulted in
their own home or in a care facility [6]. In men, the prevalence of assault appears to be higher among
those who are gay, bisexual, veterans, prison inmates, or seeking mental health services [7].
Statistics from the United States federal government only include assaults upon women in the category of
"forcible rape," which excludes statutory rape and male victims. Reports of sexual assault using this
definition have generally declined annually since 1994 [8]. Reported sexual assaults, however, probably
represent only a fraction of those committed [9]. Only 10 to 15 percent of all sexual assaults will be
reported to police and women who know their assailant are less likely to report the assault [10]
2.6
Evaluation and Management of Adult Sexual Assault Victims
Carol K. Bates, MD; November 5, 2012
2. Review the evaluation of the sexual assault victim pertaining to the history and physical.
History — The history should focus upon precise details of the sexual assault for forensic purposes in the
event of sexual assault prosecution. Details will also guide the trauma assessment and will help to assess
the risk of pregnancy and sexually transmitted disease.
Histories must be obtained in a sensitive and supportive manner. Advocates can support patients and help
them articulate their needs and questions during the history but advocates should not respond to
questions. Family members or other patient supports should be counseled that they might be subpoenaed
as witnesses if present and that they should remain passive and silent for the evaluation [12].
The following details of the history should be obtained:






Circumstances of the assault, including date, time, location, use of weapons, force, restraints, or
threats
Whether or not the victim experienced loss of consciousness or memory loss
The assailant's physical description along with the assailant's use of drugs or alcohol
Specifics regarding oral, vaginal, or anorectal contact or penetration along with presence or
absence of ejaculation and/or condom use
Areas of trauma should be ascertained focusing especially upon the victim's mouth, breasts,
vagina, and rectum
Bleeding on the part of either assailant or victim may be relevant in assessing the risk of hepatitis

or HIV transmission. The source of genital bleeding must be ascertained as it can be life
threatening
Recent consensual sexual activity before or after the assault including details about site of contact
(oral, genital, anorectal) and condom use
Victims should be asked if they have wiped, showered or bathed, changed clothing, eaten, used toothpaste
or mouthwash, used enemas, changed or removed a tampon, sanitary pad, or barrier contraceptive device
since the assault. Such activities can lower the yield of forensic specimen collection.
Physical examination — Note that some states require specific forms for documenting the history and
examination.
The patient should undress for the examination with a sheet beneath her to capture any falling debris for
medical evidence. The physical examination should describe the patient's emotional state. The examiner
should document any evidence of trauma. If possible, photographs of injuries should be taken, with the
patient's consent. A ruler or an easily identified object is helpful for indicating the size of objects in
photographs. Physical examination evidence of trauma is more likely to be present with examination
within 72 hours or assault, and when assaults occurred out of doors or were perpetrated by strangers
[15].
Extragenital trauma may be more common than anogenital trauma (70.4 versus 26.8 percent) with
bruises, abrasions, or erythema on the thigh, upper arm, face or neck particularly common [16]. In
women, the breasts, external genitalia, vagina, anus, and rectum should be carefully examined. Common
sites of genital injury include the posterior fourchette and the labia minora. As compared to women who
have had consensual sex, assaulted women are more likely to have genital lesions at sites other than the
posterior fourchette, and are more likely to have multiple areas of trauma [17]. Genital trauma occurs
more commonly in postmenopausal women and adolescents [10,18], and detectable trauma is more likely
in women reporting vaginal or anal penetration and in virgins [19]. Suggested terminology for describing
examination findings includes the TEARS categorization: Tears (defined as any break in tissue including
fissures and lacerations), Ecchymoses,Abrasions, Redness and Swelling [20].
Colposcopic examination can enhance detection of areas of milder genital trauma and is now performed
by most SANE programs [21,22]. A Wood's lamp or other UV light source may help identify foreign debris
and semen on the skin. Evidence of anogenital trauma is enhanced with colposcopy or use of toluidine
blue dye (TBD). However, toluidine dye can be difficult to use and is not endorsed in all United States
jurisdictions.
In male victims, close attention should be paid to the penis and scrotum, evaluating for erythema,
ecchymosis, excoriation, laceration, or suction marks [23]. Penile examination should focus particularly on
the glans and frenulum, and should also assess for urethral discharge. Rectal examination should be
considered, and performed if there was anal penetration. The prostate should be assessed for
tenderness.
2.6
Evaluation and Management of Adult Sexual Assault Victims
Carol K. Bates, MD; November 5, 2012
3. Review the treatment during the sexual assault investigation which pertains to initial therapy,
infections, pregnancy, psychosocial issues, and long term implications.
TREATMENT
Initial therapy — Fractures, soft tissue injuries, and other traumatic injuries should be treated
appropriately. In one series, hospital admission was required more often in older than younger women,
with 15.7 percent of women over 55 hospitalized [8]. (See "Initial management of trauma in adults".)
After urgent attention to trauma, the remainder of the initial treatment regimen should focus upon
sexually transmitted diseases (including hepatitis B and HIV) and psychosocial issues (see 'Psychosocial
issues' below) [9].
Sexually transmitted infections — There is some controversy regarding empiric prophylactic
postexposure treatment for sexually transmitted infections. However, the United States Centers for
Disease Control and Prevention (CDC) and others recommend empiric antibiotic prophylaxis since many
assault victims will not return for a follow-up visit, and treatment based upon culture results is therefore
problematic [24,28]. In addition, patients often prefer immediate treatment.
The risk of acquiring a sexually transmitted infection is difficult to measure due to the poor follow-up in
many studies, and the fact that an infection transmitted during an assault may be present during the
baseline examination since the initial evaluation can occur days after the event. The risk of chlamydial
infection is estimated to be 3 to 16 percent, with an 11 percent risk of pelvic inflammatory disease and
bacterial vaginosis, and a 7 percent risk of trichomoniasis [29].
Empiric therapy includes ceftriaxone 250 mg IM or cefixime 400 mg PO for gonorrhea and either
azithromycin 1 gram PO (single dose) or doxycycline 100 mg PO twice daily for seven days for
chlamydia. Metronidazole 2 grams PO (single dose) is also recommended to treat trichomoniasis [24].
(See "Trichomonas vaginalis", section on 'Treatment' and "Treatment of uncomplicated gonococcal
infections" and "Treatment of Chlamydia trachomatis infection", section on 'Treatment of uncomplicated
genital chlamydia infection'.)
Hepatitis B infection — The CDC recommends postexposure hepatitis B vaccination without hepatitis B
immune globulin (HBIG) as adequate protection against hepatitis B [24]. If the assailant is known to be
hepatitis B infected, HBIG is recommended [30]. Follow-up doses of hepatitis B vaccine should be
administered one and six months after the first dose. Vaccination is not necessary if the patient has had
previous hepatitis B vaccine and documented immunity. (See "Epidemiology, transmission, and
prevention of hepatitis B virus infection".)
HIV infection — Prophylactic treatment with antiviral drugs for HIV following sexual assault is
controversial [25,31], although there is consensus that the risks and benefits of HIV prophylaxis should be
addressed with every patient. There are no good data on the risk of acquiring HIV from an unknown
assailant, although there are case reports of HIV transmission after sexual assault [31]. The risk of HIV
transmission from a single episode of consensual vaginal intercourse with an HIV infected man is
estimated at 0.1 percent, and from a single episode of consensual anal intercourse at 2 percent. (See
"Nonoccupational exposure to HIV in adults".) The risk of transmission after sexual assault by an HIV
infected man is likely to be higher, since there may be associated trauma and bleeding [25].
However, most assailants from countries with low population seroprevalence rates are unlikely to be
infected with HIV. In a study of men incarcerated at a Rhode Island state prison from 1994 to 1999, of
1524 charged with a sexual offense only 1 percent were infected with HIV [32]. Other data, however,
indicate that Rhode Island prison inmates overall had a low prevalence of HIV in 1994 compared with
New York State inmates (3.8 percent versus 12.4 percent) [33]. HIV seroprevalence rates among
prisoners have since declined nationally. The highest prevalence in 2008 was 5.9 percent in New York
State, with many states reporting rates less than one percent [34].
While the overall risk of acquiring HIV after an assault by an unknown assailant is likely low, the risk
may be increased by certain aspects of the assault:





Male on male rapists might be expected to have a higher prevalence of HIV infection
Sexual assault in a region or country with a high background prevalence of HIV increases the
likelihood that an assailant will be HIV infected
Multiple assailants presumably increase the risk, since any of the assailants might be infected
with HIV
Anal sexual assault may be more likely to transmit HIV
Sexual assault where either the assailant or the victim has trauma, bleeding, or genital lesions
may increase the likelihood of transmission
Despite the presumed low risk of transmission and the lack of evidence proving the efficacy of
antiretroviral drugs after sexual assault, most believe that they should be offered.
Generalizing from the model of occupational HIV exposure, it is thought that antiretroviral drugs are best
started within four hours of assault, and should probably not be prescribed if more than 72 hours has
passed [31]. Options for prophylactic regimens used in postexposure prophylaxis (PEP) for healthcare
workers are suitable for patients who choose to take HIV prophylactic treatment following sexual assault.
(See "Management of healthcare personnel exposed to HIV", section on 'Postexposure prophylaxis'.)
We suggest consultation with a specialist familiar with PEP regimens. The United States Centers for
Disease Control (CDC) recommends that patients be given an initial prescription for PEP for only three to
seven days, with short-term follow-up for further counseling [35].
Pregnancy — The risk of pregnancy after a single episode of vaginal intercourse varies during the
menstrual cycle (table 1). Postcoital emergency contraception should be offered without regard to the
menstrual cycle, given the uncertainty in the timing of ovulation.
In the United States, available regimens for emergency contraception include levonorgestrel alone, the
Yuzpe regimen and the progestin antagonist/agonist ulipristal. Levonorgestrel (0.75 mg and repeated in
12 hours, or 1.5 mg as a single dose) is more effective than the Yuzpe regimen and is associated with
fewer side effects. The Yuzpe regimen (100 mcg of ethinyl estradiol and 0.5 mg of levonorgestrel given
as two Ovral contraceptive pills or its equivalent and repeated in 12 hours) is 75 to 80 percent effective if
administered within 72 hours of intercourse [36]. Ulipristal, where available, is effective up to 120 hours
after intercourse and is the preferred drug beyond 72 hours after unprotected intercourse. (See
"Emergency contraception".)
Outside of the United States, mifepristone (600 mg single dose) is also available for emergency
contraception [36].
Many patients will experience nausea and vomiting from the combination of antibiotics and
contraceptives; antiemetics should be offered.
Psychosocial issues — Sexual assault victims require extensive emotional support and should be offered
mental health services. Symptoms may include anger, fear, anxiety, physical pain, sleep disturbance,
anorexia, shame, guilt, and intrusive thoughts.
Additionally, they may experience musculoskeletal, genital, pelvic, and/or abdominal pain. Anorexia and
insomnia can persist. Dreams and nightmares are common, and phobias may develop. Victims may find it
very difficult to resume their habits, lifestyles, and sexual relationships [37]. Patients may develop
posttraumatic stress disorder, depression, or anxiety syndromes. (See "Posttraumatic stress disorder:
Epidemiology, pathophysiology, clinical manifestations, and diagnosis".)
The medical evaluation and evidence collection process itself can be traumatizing and may compound the
victim's sense of shame and loss of control. Providers should not force evaluation or treatment and should
allow the victim some control in the evaluation process. A chaperone or advocate should be present
during the evaluation.
Acute crisis counseling should include safety planning. Victims should be referred for ongoing
counseling ideally through sexual assault crisis programs.
Long-term implications — Women with prior sexual assault are at increased risk for a number of
psychological, physical, and behavioral adverse effects. These include:
 Posttraumatic stress disorder, anxiety, depression, and suicide attempt [41].
 Misuse of prescription sedatives, stimulants, steroids, and analgesics [42].
 For women with PTSD, anxiety related to pelvic examination and avoidance of cervical cancer
screening [43].
 Irregular menses, pelvic pain, dyspareunia, and urinary infections [44,45].
 Decreased sexual satisfaction [46]
 Increased risk for cervical cancer [47].