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Child Sexual Abuse Medical Evaluation
Cara Christanell RN, CPNP Child Protection Division
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Sexual Abuse The involvement of children and adolescents in sexual activities that they do not understand, cannot give consent to, or that violate social taboos.
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Sexual Abuse Exhibitionism Fondling Genital viewing Pornography
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Sexual Abuse Oral-genital contact Insertion of objects
Vaginal penetration Anal penetration
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Missouri Statutes Mandated Reporters- any physician, coroner, dentist, chiropractor, optometrist, podiatrist, resident, intern, nurse, hospital or clinic personnel(engaged in examination, care, treatment, or research of persons), and other health practitioner, psychologist, mental health professional, social worker, day care center worker or other child care worker, juvenile officer, probation or parole officer, jail or detention personnel, teacher, principal or other school official, minister, peace officer or law enforcement official, or other person with the responsibility for the care of children, has reasonable cause to suspect that a child has been or may be subjected to abuse or neglect or observes a child being subjected to conditions or circumstances which would reasonably result in abuse or neglect, he shall immediately report or cause a report to be made to the division
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Sexual Abuse WHY KIDS? Respect and obey adults Naturally trusting
Curious Seek attention
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Who should have an evaluation?
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Who Anyone reasonably believed to have been abused
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Disclosure Accidental 74% Purposeful
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Why should a child have an evaluation?
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Why Injury assessment STI treatment / testing Pregnancy issues
Evidence Reassurance Guidance
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When should an examination be conducted?
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When Emergent if assault* within 72 hrs
*good history of significant contact
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When Emergent if assault may have placed child at risk for pregnancy and occurred in the previous 5 days
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When Emergent pain in the genital area or anal area
anogenital bleeding or injury
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When Emergent Child is not safe
Child is experiencing significant behavioral or emotional problems
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When Urgent if assault >72 hrs, but < 2 wks
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When Urgent if recent assault with symptoms bleeding, heavy discharge
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When Non-urgent if assault > 2 weeks
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When Emergent – immediately Urgent – days Non-urgent - anytime
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Where should an examination be conducted?
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Where Emergent = ER Urgent = ER
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Where Emergent = ER Urgent ≠ ER Non-urgent ≠ ER
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Who should perform an examination?
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SAFE-CARE Provider Sexual Assault Forensic Examination-Child Abuse Resource and Education
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Who Providers MD, DO PNP (Pediatric Nurse Practitioner)
PA (Physician’s Assistant) SANE-P (Sexual Assault Nurse Examiner-Pediatric)
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SAFE-CARE Provider Responsibilities
Identify treatable injuries or infections Collect forensics specimans, if abuse was recent Screen for sexually transmitted conditions REASSURE the child that he/she is still “OK”
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SAFE-CARE Provider Responsibilities
Asses the patient and parent’s mental and emotional state and make appropriate referrals Provide accurate documentation, at least drawings Be available for court testimony Know what is normal and when to refer
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SAFE-CARE Provider TEL-LINK 1-800-835-5465
Missouri Department of Health and Senior Services toll-free information and referral line for maternal and child healthcare
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Examination vs Evaluation
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Who Provide “big picture” assessment of child
Medical history, exam, diagnosis
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Varying training, varying experience
Make sure you know who is performing exams in your community and what the community expectation (court) is regarding court experts
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How to explain the evaluation?
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Are exams painful?
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Are exams traumatic?
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Are exams stressful?
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How do kids respond to exams?
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How is an evaluation conducted?
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Evaluation Introductions Parent in room with child Obtain information
Explain examination Answer questions
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Evaluation Complete forensic interview typically not conducted
Medical history is not a forensic interview
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How is an examination conducted?
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A Typical Exam General physical Rarely “invasive” Rarely sedation
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Anogenital Exam Frog Leg Knee Chest Supine
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The Hymen Ὑμέναιος
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Normal Annular Crescent Redundant/Pubertal
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Normal Various irregularities
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A Multicultural Crystal Ball
The Hymen A Multicultural Crystal Ball
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What is the most common physical finding?
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“Taylor has a normal anogenital examination
“Taylor has a normal anogenital examination. This alone does not rule out sexual abuse. Sexual assault can occur without permanent physical injury.”
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Why is the exam so often normal?
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Normal Type of contact Time interval
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Normal Rate of healing similar to face / mouth
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Studies of Normal Berenson, et al 97.5% digital or penile-vaginal
N=192 penetration “highly likely” age 3-8 yrs 97.5% digital or penile-vaginal AmJObGyn, 2000
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Studies of Normal Kellogg, et al 82% normal exams N=36 pregnant teens
mean age 15.1 years [ ] 82% normal exams Pediatrics, 2004
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Penetration does not always result in visible tissue damage
Acute injuries occur but heal
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HISTORY, HISTORY, HISTORY!!!!!
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Injury Types Erythema Bruises Abrasions Tears
Dehiscence, laceration, transection
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Normal Constipated Sodomy
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Evidence Statements Physical findings Bruises, etc STDs Fibers
Chemical analysis DNA
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Evidence Limitations Prepubertal evidence CHOP study STDs rare
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Evidence Limitations “Normal to be normal”
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Anogenital Findings Findings documented in newborns or commonly seen in non-abused children Indeterminate findings Findings diagnostic of trauma and/or sexual contact
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Commonly Seen Erythema Labial adhesion Vaginal discharge
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Indeterminate Anal dilation Vesicles / Ulcers Narrow hymen
Wart-like lesions
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Diagnostic Findings Hymen bruising Complete hymen transection
Deep perianal lacerations Some STDs Sperm / pregnancy
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Some day maybe there will exist a well informed, well considered and yet fervent public conviction, that the most deadly of all possible sins is the mutilation of a child’s spirit. Erik Erickson
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Questions??? Cara Christanell MSN, RN, CPNP ext1215
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