Ethical approach to genital examination in children

Genital examination in children requires ethical standards that should become routine practice in physician’s offices.

The following practices are recommended for the genital examination of the paediatric patient.

1. All remarks of a sexual connotation must be avoided during the interview and examination.

2. Patients should not be touched on the genitals or breasts except as part of the physical examination. They should be advised before being touched.

3. If the child is not at ease with a genital examination, force should never be used. The reason for the procedure should be clearly explained to the parents and the child. If the child refuses to cooperate, the examination should be postponed, if it is not urgently required.

4. For infants and school-aged children, a parent or caregiver should remain close to the child throughout the physical examination. The child should be undressed as necessary and be allowed to dress as soon as the physical examination is completed. Examination of the genitalia should be performed if indicated, such as during the annual examination to check for normal development of the external genitalia, to look for endocrine anomalies, to check for physical signs of suspected abuse or if requested by the parents. It should be the last part of the physical examination.

   Girls can sit on the parent’s or caregiver’s lap in the supine frog-legged position. This allows for adequate visualization of the introitus and anus, and is less anxiety-provoking than other positions. The knee-chest position, where the child is on her hands and knees, allows for better views of the hymen and vaginal vault but may be frightening because the examiner is out of view. In boys, the lateral decubitus position allows for an adequate examination.

5. For older school children and adolescents, a parent or nurse should be present. The child should be allowed to dress and undress in privacy, wearing a gown for the examination.

   A Papanicolaou (Pap) test or a screening test for sexually transmitted diseases is indicated only if an adolescent is sexually active. Pelvic examinations are not a routine part of physical examination in teens who are not sexually active even if oral contraceptives are being prescribed.

   In cases of sexual abuse (particularly in young children), a vaginal examination under general anesthesia is often the least traumatic method of assessing injury, and it should preferably be done by an experienced gynecologist.

With careful planning and attention to detail, physicians can convey respect to young patients and gain their confidence, so that the genital examination is a nonthreatening, nontraumatic experience.