Physical Examination of Patients with Suspected Sexual Abuse Dafina M. Good, MD Pediatric Emergency Medicine Fellow

The History Adolescent says they were raped Small child disclosed to someone Parental Concern –Child says vagina, penis or bottom hurts? –Redness or irritation to private area? –Just want to get them checked to make sure no one is touching them?

Medical Complaints Genital, Urethral, or Anal Trauma Bleeding or Discharge Dysuria Abdominal Pain Headaches Constipation or Encopresis Foreign Bodies in the Vagina or Anus Pregnancy

Behavioral Indicators Temper Tantrums Sleep Disturbance PhobiasSelf-Injury Substance abuse School problems

Who Should Be Examined in the E.D. ? Sexual abuse within the last 72 hours Remote history of abuse with symptoms (ie. Discharge, dysuria, etc)

History Specific Evaluation Rape Kit Collection is based on specific contact or physical findings –If no oral contact….. No oral swabs –If no anal contact….. No anal swabs –If only penile-vaginal contact….. Then only obtain vaginal/cervical cultures –If pt has showered and changed clothes….. Likely no need for pubic hairs or clothing collection

Preparation for Examination Child Life Specialist –Reduce anxiety –Provide familiarity of equipment and environment Social Work involvement County Specific Police Address concerns Clarify misconceptions Communicate expectations Develop trust

Prior to Examination Know if and what swabs are to be collected Labwork by nursing: –Serum pregnancy, RPR, Hep C, HIV Consents –HIV, Plan B

Documentation At Hughes Spalding there is a separate 49 form which needs to be filled out –* ONLY UPPER LEVEL RESIDENTS CAN DO A “49” EXAM !!! At Egleston there is a sexual abuse template that you should look at prior to going into the room (it has many questions that you may not think to ask)

Initiation of Exam Introduction to the examiner Use an unhurried approach Prepare family for “Our Role” as the ED physician Brief history is taken from the parent (in a separate room) Brief history from school age children and adolescents –Focused history……. When did the alleged assault occur? Where did the event occur? What County? Where did the event occur? What County? What happened? Vaginal contact, anal contact oral contact What happened? Vaginal contact, anal contact oral contact Has the patient showered or changed clothing? Smaller children should await forensic interview to prevent any influence from our questioning –Use the patients terms for body parts (privates, girl parts, pee, etc.) Reassure the patient that this is a “check up” to make sure everything is ok

Examination Start with a familiar head to toe examination - noting: signs of puberty or physical trauma Perform specimen collections (hair combings, nail clippings, DNA swabs) Perform the genital exam as the next step –emphasize that you are “taking a look” –point out to the pt that the colposcope (otoscope) is not touching the pt. –Collect pubic hair combings –Visible Crusty material collections

Examination Speculum exam where appropriate Presently endocervical cultures for N. gonorrhea and C. trachomatis are the “Gold standard” PCR and LCR studies for gonorrhea and chlamydia testing are ongoing Pt should be shown the soft cotton tip of the swab Culture decisions should be made prior to the exam

Supine Frog Leg

Supine Separation Technique

In the supine separation technique, the labia are separated with the tips of the fingers in a lateral and downward movement The vestibule and Hymen should be exposed

Supine Traction Technique

The Examiner grasps the Labia Majora with the thumb and index finger and gently pulls outward and slightly upward This technique helps the examiner visualize the edge of the hymen more easily

Prone Knee Chest

Knee-Chest Position The child rests her head on her folded forearms The examiner presses a thumb outward on the leading edge of the gluteus maximus

Supine Knee Chest

The Rape Kit All clothing should be individually bagged in a paper bag (not sealed plastic) Underwear should be placed in the bag provided Visible blood or semen stains (Wood’s Light Exam) –Moisten one of the enclosed gauze pads or cutips and remove the stain. –Allow the pad to air dry and place it in one of the plastic bags provided Depending on Vaginal, Cervical, Anal or Oral contact –Use 2 Swabs to swab the area to get as much fluid as possible and wipe cotton swabs across the slides marked VAGINAL SMEARS –Allow swabs to air dry and place the actual swabs in the envelope marked SWABS –Each envelope and container will be marked with the victims name and what type specimen is contained

Rape Kit Secretions, Stains, or Forensic Materials on the Body Get a cotton tipped applicator wet and soak against a suspicious bite mark or stain Get a cotton tipped applicator wet and soak against a suspicious bite mark or stain Allow the applicator to air dry and place the swabs in the Questioned Materials envelope Allow the applicator to air dry and place the swabs in the Questioned Materials envelope If there is dried material, scrape the “crusty” material into the plastic material container in the Questioned Materials envelope If history indicates that the assailant was scratched by the victim Collect any visible tissue or blood stains with tweezers and place them in the plastic container in the Questioned Materials envelope Collect any visible tissue or blood stains with tweezers and place them in the plastic container in the Questioned Materials envelope Clip fingernails and place in a piece of paper with a pharmaceutical fold and place in the Questioned Material envelope Clip fingernails and place in a piece of paper with a pharmaceutical fold and place in the Questioned Material envelope

Rape Kit Hair Samples (Reference) Pluck or comb out 25 random hairs from the victims head Use a fine tooth comb to obtain 25 random pubic hairs If there is matted pubic hair or hair with possible human materials on them then clip those hairs and Place in the Pubic Combings envelope

Rape Kit Wrap Up When you are finished collecting the specimens you are to seal the Sexual Assault Evidence Kit with the orange sticker inside and sign the sticker. You will also need to fill out the form on the front of the envelope and assure that the nurse that you are giving the evidence to has done the same There should be a Social Work and DFACS referral for all patients with an Alleged Sexual Assault (ASA) and County Police involvement (family should report) The social worker or DFACS will arrange for follow up which may include a home visit and a forensic interview Referral to Child Protection Center at Hughes Spalding or Scottish Rite

Rape Kit Wrap Up Treatments –Empiric STD treatment Ceftriaxone 125mg/250mg IM, Zithromax 1gm, Flagyl 2gm –PLAN B Must have negative pregnancy test One tab now and second tab dispensed for home to take in 12hrs Dispense with anti-nausea medicine –HIV Prophylaxis? Consider, if story is highly suspicious for HIV infected person or very traumatic exam