Ethical approach to genital examination in children

Community Paediatrics Committee, Canadian Paediatric Society (CPS)

Paediatrics & Child Health 1999; 4(1): 71
Reference No. CP98-04 (Formerly MS98-04)

Revision in progress June 2009

Index of position statements from the Community Paediatrics Committee

Genital examination in children, as with all interventions, requires ethical standards that should become routine practice in physician’s practices. Especially important are respect for the child, sensitivity to the child's needs, and patience in performing the examination.

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

• Examination of the genitalia should be performed only when specifically indicated, such as during the periodic health exam 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.

• Older children who are competent (mature minors) should be informed about the examination and the reasons why it is necessary and should be asked for consent before examination. Privacy and confidentiality should be respected.

• Remarks of a sexual connotation are unnecessary and must be avoided during the interview and examination.

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

• If the child is not at ease with a genital examination, neither force nor restraint should ever be used. The reason for the examination should be clearly explained to the parents and the child (e.g. cases of alleged sexual abuse, trauma, infection). If the child refuses to cooperate, the examination should be postponed.

• For infants and school-aged children, the child's parent(s) or caregiver should remain close to the child throughout the examination. The child should be assisted with undressing as necessary and be allowed to dress as soon as the physical examination is completed. The examination should be done slowly and carefully so as to minimize discomfort and pain. 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.

• For older school children and adolescents, a parent or nurse should be present, and the reason for the presence should be explained. The child should be allowed to dress and undress in privacy, and be given a gown for the examination. Pelvic examinations are not a routine part of physical examinations in teens who are not sexually active, even if oral contraceptives are being prescribed. A Papanicolaou (Pap) test or a screening test for sexually transmitted diseases is indicated only if an adolescent is sexually active.

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 less threatening, less traumatic experience.

Reference

1. Narendra K, Lazoritz S. Evaluation for possible physical and sexual abuse. Pediatr Clin North Am 1998;45:214-7.

Community Paediatrics Committee

Members: Drs Cecilia I. Baxter, Edmonton, Alberta; Fabian P Gorodzinsky, London, Ontario;  Denis Leduc, Montreal, Quebec (chair); Paul Munk, Toronto, Ontario (director responsible); Peter G Noonan, Charlottetown, Prince Edward Island; Joseph Telch, Unionville, Ontario (liaison from the Community Paediatrics Section); Dr Sandra Woods, Val-d’Or, Quebec
Principal author: Dr Sandra Woods, Val-d’Or, Quebec

Disclaimer: The recommendations in this position statement do not indicate an exclusive course of treatment or procedure to be followed. Variations, taking into account individual circumstances, may be appropriate. Internet addresses are current at time of publication.