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Physical Signs of Sexual Abuse in Children. 2nd Ed. Report of a working party of the Royal College of Physicians of London. (Pp 97; £16 paperback.) Royal College of Physicians, 1997. ISBN 1-86016-043-3.
In the six years since the publication of the first edition of this report it is unlikely that many paediatricians have become truly comfortable when faced with the request to provide a medical opinion as to whether a child has been sexually abused. However, much has been learnt which if not allowing us to feel comfortable should at least allow us to feel more confident in our attempts to meet the needs of this group of children.
An increasing literature concerned with normal and abnormal findings on examination as well as with examples of good models of practice is reflected in the increase by one third in the size of the report. The number of cited references increases from 38 to 60. It is no surprise that chapters with the greatest increase in material cover the subject areas of normal anatomy and variants in the appearance of female genitalia together with the size of the hymenal orifice. The inclusion of colour photos from colposcopy, rather than line drawings, gives the reader a far more accurate understanding of many points discussed in the text. Interestingly the working party falls short of positively encouraging the use of the colposcope despite the major advantages the technique offers in reducing the need for repeat examination, facilitating expert opinion and peer review and of course in education.
The controversy surrounding the significance of reflex anal dilatation appears to have settled. This edition of the report makes subtle but significant changes in its summary of signs in this respect, suggesting that an increased diameter of dilatation (15 mm rather than 10 mm) should be used as a threshold for suspicion and more importantly emphasising that the finding should be reproducible.
Another area in which the second edition of the report has grown is that of the diagnosis and management of sexually transmitted disease. There is a detailed and comprehensive appendix with more references than the main text. It is likely however that practitioners seeing relatively few cases of sexual abuse outside of specialist centres might better develop arrangements for this complex aspect of assessment and management with their local specialist in genitourinary medicine.
As the working party recommends, an increasing proportion of work in the assessment and management of child sexual abuse is carried out by experienced and well trained individuals. Provision of specialist services remains variable so it continues to be important by providing a guide to the examination of children and interpretation of physical signs. It could have been improved by including recommendations guiding the reader towards comprehensive textbooks able to supply a broader overview of the other aspects of assessment and care that are so important when helping children who have been sexually abused.