Introducing a New CONSULTANT Series:

Child abuse is common. Each year in this country, nearly 3 million children are reported to Child Protective Services. Approximately 50% of reports are for neglect, 30% for physical abuse, and 20% for sexual abuse. Retrospective studies suggest that 1 in 4 girls and 1 in 8 boys are sexually abused before age 18.¹ Despite the prevalence of child abuse, very little training in this area is offered in medical schools, primary care residency programs, or through CME programs. It is no surprise that primary care physicians find themselves anxious and unsure of what to do when a child presents to their office with signs and symptoms that may be the result of abuse. Not only does such a patient take an extraordinary amount of time in a busy practice, but communicating with Child Protective Services and law enforcement personnel, and the ultimate possibility of being subpoenaed to testify in court, can be daunting. A general lack of knowledge of normal prepubertal genital anatomy and the variety of cutaneous, infectious, and systemic problems that may become manifest in the anogenital area further complicate the situation. Nevertheless, primary care practitioners must be able to recognize child abuse when it occurs and—just as critical—to recognize medical conditions that can mimic abuse. In the “Child Abuse—or Mimic?” feature that begins on page 769 of this issue, I will describe those conditions that may appear to be the result of abuse, but that can be explained medically. I will also describe appropriate steps in the evaluation of these difficult and often complex cases. Recognition of abuse is one step toward its prevention. Failure to recognize an abusive situation places the child at risk for morbidity and even mortality. It is analogous to missing a serious physical condition that may disable—or even kill—a patient. By the same token, overaggressive or overzealous diagnosis of abuse may separate families, lead to stigmatization, and result in permanent social, emotional, and legal consequences. My goal for this series of cases is to help you recognize usual and unusual presentations of conditions that mimic abuse—and those that are abuse-related.