Book Review  |   January 2010
Medical Evaluation of Child Sexual Abuse: A Practical Guide
Author Affiliations
  • Ronald V. Marino, DO, MPH
    Winthrop University Hospital, Mineola, New York
Article Information
Book Review   |   January 2010
Medical Evaluation of Child Sexual Abuse: A Practical Guide
The Journal of the American Osteopathic Association, January 2010, Vol. 110, 7-8. doi:
The Journal of the American Osteopathic Association, January 2010, Vol. 110, 7-8. doi:
Professional healthcare providers for children assume the moral and legal responsibilities of advocating for children's well-being. This advocacy begins with the clinician-patient relationship and extends into all aspects of patients' biological, psychological, and social experiences. In addition to the clinical encounter, physician advocates for children must learn to work collaboratively with various other professionals in different institutions and bureaucracies who share the same mission of maximizing a child's potential. 
Child healthcare is a dynamic, stimulating, and ever-changing field. Only in the past 30 years have we come to face the reality that children are often—in fact, more often than anyone would like to believe—victims of nonaccidental trauma and sexual exploitation. 
In the early 1980s, Martin A. Finkel, DO, noticed a disturbing reality—he and other physicians were seeing many children who had a variety of symptoms that ultimately were linked to sexual abuse and exploitation. He further noted that the pediatric community at the time was either blind to this reality or in total denial of it. Many long-time practitioners asserted that the incidence of child sexual abuse was so rare that they had never seen a single case of it during their lengthy careers. Dr Finkel was well aware that these physicians were simply not seeing what was right before them. Thus, a lifelong passion to educate physicians on this matter and to care for abused children was born. Today, Dr Finkel is medical director and founder of the Center for Children's Support at the University of Medicine and Dentistry of New Jersey-School of Osteopathic Medicine in Stratford. 
Little was known about the dynamics of victimization during the 1980s. In fact, so little was known about the medical aspects of child sexual abuse that prepubertal genital anatomy was a mystery to physicians. Dr Finkel and Angelo P. Giardino, MD, PhD—his fellow editor of Medical Evaluation of Child Sexual Abuse: A Practical Guide—do a fabulous job of updating the state of knowledge, experience, and consensus opinions regarding the evaluation and management of child sexual abuse. Dr Giardino, another long-time practitioner and child healthcare advocate, serves as associate chair of pediatrics at Children's Hospital of Philadelphia and assistant professor of pediatrics at the University of Pennsylvania School of Medicine in Philadelphia. This volume is the third edition of Medical Evaluation of Child Sexual Abuse. For the first time, the book is published by the American Academy of Pediatrics, adding to the work's visibility and broadening its access to a larger readership. 
Fifteen other experts on child sexual abuse contributed to authoring the 15 chapters of this new edition, which is substantially expanded over the second edition. The third edition adds new material on child pornography and risks of Internet use; more information on mental health therapy choices; and increased numbers of color photographs, illustrations, and tables. The new volume is well organized and easy to read, with a flow that unifies the contributions from the many authors. All chapters are well referenced. When scientific data is unavailable, the authors clearly note that the text constitutes the best professional opinions. 
The book begins with an overview of the magnitude of the problem of child maltreatment, presenting the paradigm, preconditions, and longitudinal dynamics of the problem. The text then moves to an overview of the medical evaluation process, emphasizing medical history and presenting complaints. An appendix in chapter 2 includes helpful guidelines on approaching the history-taking process with a sensitive, yet objective, manner. 
Chapters 3 and 4 focus on physical examination, including descriptions of examination techniques for boys and girls and information on photographic documentation of findings. An excellent table provides guidance to examiners in the interpretation of physical findings. An appendix shows a remarkable compendium of colposcopic photographs, demonstrating a large variety of normal and pathologic variants. The clear message in these chapters is that a thorough examination by a skilled clinician is crucial and that the absence of abnormal findings does not rule out sexual abuse. 
Chapters 5 through 8 cover a variety of important topics. An up-to-date and medically authoritative review of sexually transmitted infections addresses the likelihood of each kind of infection being contracted in a sexually abusive manner (most can be!) and also provides current treatment guidelines. The forensic aspects of evidence collection, documentation, and handling are described to maximize the legal utility of the medical evaluation. The text also describes several unique aspects of adolescent sexual experiences, including date rape, consent issues, and legal definitions of “minor” used in various states. The anogenital examination is highlighted, with emphasis on diagnostic dilemmas and mimics of abuse. Photographs clearly demonstrate that not all abnormal anogenital findings are related to abuse. 
Chapters 9 through 11 examine special issues related to child abuse as well as prevention and treatment. The role that nurses can play in hospitals, schools, and sexual assault teams—including a review of the Sexual Assault Nurse Examiner (SANE) model—is presented. In a discussion of psychological issues, the text differentiates victim evaluation by the forensic psychologist from that by the therapist. Excellent suggestions for rapport development and interviewing are shared, with the author of chapter 10 noting the following: 

Interviews go through a series of phases, from rapport-building through introductory information—truth and lies, rules and practice interviewing regarding neutral events—before introduction of the topic at hand. The child is encouraged to provide a free narrative of the event before being questioned more specifically for further clarification and detail.

In addition, information relevant to primary, secondary, and tertiary prevention through pediatric care are given, along with examples of suggested conversations between pediatricians and children. 
Chapters 12 through 14 cover interdisciplinary approaches to child maltreatment, legal issues in medical evaluation of sexual abuse cases, and other considerations in child sexual exploitation (eg, cyber enticement, human trafficking, sex tourism). The chapter on legal issues explores such concepts as confidentiality, hearsay, privileged communication, and testimonial comments. Having been written by an attorney, this is the most difficult chapter for this reader to comprehend. However, the information is well worth knowing. 
The final chapter of the book consists of a discussion of the crucial issue of documentation and report formulation, including recommendations for verbiage to use in presenting diagnostic impressions. 
Medical Evaluation of Child Sexual Abuse is a thoughtful, compact, state-of-the-art compendium that presents the issue of child sexual abuse in a historical and current real-world context. It is authoritative and comprehensive and a good introduction to the field for child healthcare professionals. If I can find anything to improve upon for a fourth edition, I might suggest updating the look of the tables. In contrast to the remarkably clear and useful photographs, the font of the tables is not reader friendly. However, that is a small criticism for such an excellent volume. 
If you work with children in a clinical setting, you will want this book on your shelf. 
 Edited by Martin A. Finkel, DO, and Angelo P. Giardino, MD, PhD. 384 pp, $99.95. ISBN-13: 978-1-58110-320-5. Elk Grove Village, IL: American Academy of Pediatrics; 2009.