Child Sexual Abuse What Investigators Need to Know

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1 Child Sexual Abuse What Investigators Need to Know WI CAN Educational Series Dr. Rita Ventura, FNP-BC Children s Hospital of Wisconsin Child Advocacy and Protection Services December 21 st, 2018 DISCLOSURE INFORMATION Dr. Rita Ventura Child Sexual Abuse: What Investigators Need to Know There are no relevant financial relationships related to this presentation/program There is no sponsorship/commercial support of this presentation/program The content being presented will be fair, well -balanced and evidence-based Learners who wish to receive Continuing Education Credit (CME/CLE/CE) must complete and turn in evaluations to successfully complete this program Protection of abused children depends on an effective multidisciplinary response of law enforcement, child protection services, health care providers, and other professionals. 1

2 OBJECTIVES Who should receive a medical evaluation in cases of suspected child sexual abuse and who should complete the evaluation? What is included in this medical evaluation? Where should these medical evaluations occur? When should the medical evaluation occur? Why have a medical evaluation? SEXUAL ABUSE DEFINITION When a child is engaged in sexual activities that the child cannot comprehend, for which the child is developmentally unprepared and cannot give consent, and/or that violate the law or social taboos of society. AAP 1999 Sexual abuse includes sexual intercourse, sexual contact, sexual exploitation, forced viewing of or listening to sexual activity, and permitting, allowing or encouraging a child to engage in commercial sex trafficking; any sex crime involving a child (< 18 years of age) Legal definition HOW CHILDREN PRESENT Disclosure Brought to medical care as part of an investigation Abuse is suspected by a caretaker: Abuse is suspected as an incidental finding during an exam An STI or pregnancy is diagnosed Physical finding is suspicious 2

3 INDICATORS OF SEXUAL ABUSE Indicators of sexual abuse can surface through a child s history, physical symptoms and/or behavior The single most important indicator is disclosure by the child to a friend, classmate, teacher, friend s mother or other trusted adult In most cases, it is a clear disclosure from a child that is the strongest evidence that sexual abuse has occurred Children s disclosures of sexual abuse are rarely fabricated (Sorensen, 1991) WHENEVER THERE ARE CONCERNS OF SEXUAL ABUSE, A MEDICAL EXAM BY SOMEONE FAMILIAR WITH SEXUAL ABUSE IS RECOMMENDED WHO SHOULD COMPLETE CSA EXAM Many medical providers and general pediatricians are uncomfortable dealing with the issues surrounding child sexual abuse Brief training in residency Many medical providers have trouble distinguishing between a normal and abnormal female genital exam 3

LACK OF KNOWLEDGE AND TRAINING Lentsch and Johnson (2000) Objective to determine if physician knowledge and biases regarding sexual abuse had changed

4% Posterior commissure 80.9% 86.7% Hymen 59.1% 61.7% Labia majora 61.5% 79.1% DIAGNOSTIC ACCURACY 2012 Adams, et al.

Professionals who: regularly perform 5 or more pediatric exams per month review cases with an expert keep up to date with current research HEALTH

4 LACK OF KNOWLEDGE AND TRAINING Lentsch and Johnson (2000) Objective to determine if physician knowledge and biases regarding sexual abuse had changed since physicians completed survey Clitoris 89.4% 93.7% Labia minora 76.4% 83.0% Urethral opening 78.4% 72.4% Posterior commissure 80.9% 86.7% Hymen 59.1% 61.7% Labia majora 61.5% 79.1% DIAGNOSTIC ACCURACY 2012 Adams, et al. (CAN 2012) Medical professionals assessed on 20 cases based upon multiple factors Highest diagnostic accuracy in: Child abuse pediatricians Professionals who: regularly perform 5 or more pediatric exams per month review cases with an expert keep up to date with current research HEALTH PROVIDER STANDARDS If the exam is abnormal due to findings suggestive or diagnostic for abuse, the exam photos should be routinely reviewed by an expert in child abuse pediatrics AAP Guidelines NCA Guidelines IAFN Guidelines 4

5 WHERE SHOULD CHILDREN BE EVALUATED? Child Advocacy Centers are ideal locations Often these children are evaluated in Emergency Departments Important to have medical evaluations performed by health care professionals competent in these evaluations (Pediatric trained sexual assault nurse examiners) CAC BENEFITS Safe, child-friendly place to come for professionals to work with them Coordinate activities to assure as little trauma to the child as possible Professionals work together which results in better investigations CAC BENEFITS Experience/ongoing training Special equipment and supplies Providers are willing and able to testify Primary providers often lack the experience, supplies, equipment and comfort level to do these exams 5

HOW DO YOU DECIDE WHERE THE CHILD SHOULD BE EXAMINED?

THAN 72 HOURS SAME DAY APPOINTMENT Concerning social/ placement

6 HOW DO YOU DECIDE WHERE THE CHILD SHOULD BE EXAMINED? CAC or SANE WHEN? EXAMINATION TIMING Symptoms Bleeding/trauma Discharge Dysuria Anogenital pain Suspicion of internal injury Contact recent LESS THAN 72 HOURS SAME DAY APPOINTMENT Concerning social/ placement issues Investigative urgency WHEN? EXAMINATION TIMING APPOINTMENT AS SOON AS POSSIBLE Last episode remote Asymptomatic Safety plan active 6

7 INDICATIONS FOR A FOLLOW-UP MEDICAL EVALUATION Findings on the initial examination are unclear Confirmation of initial findings by a more experienced medical provider (as soon as possible) Pre-pubertal children: testing for sexually transmitted infections needed (2 weeks after last sexual contact) Pregnancy testing/test of cure Documentation of healing/resolution of acute findings WHAT IS INCLUDED IN CSA EXAM? Gather information on purpose of visit CPS, LE, Caregiver, referring professional and child Medical History Includes signs, symptoms, and differential diagnosis General Physical Exam Head to toe: desensitizes Identifies comorbidities Identifies physical abuse/neglect Focused genital exam with colposcopy WHAT IS INCLUDED IN CSA EXAM? Colposcopy Magnification Light Source Video Documentation Avoids need for re-exam Distraction/relaxation Not painful, not forced External exam only unless acute (adolescent) or suspect internal injury We rarely need to sedate a child Boys need exams too 7

8 NORMAL EXAMS 95% of Sexual Abuse examinations show normal or non-specific findings 2.2% non-acute vs. 21.4% acute A normal exam does not rule out sexual abuse! Gallion, et al., 2016; Heger, 2002 WHY ARE EXAMS NORMAL? Distensible tissue Rapid healing Late disclosure Pubertal changes may obscure findings Contact may not cause injury WHY BOTHER TO EXAMINE? 8

9 WHY HAVE A MEDICAL EVALUATION Look for evidence of trauma Look for conditions that might be confused with sexual abuse/provide second opinion regarding genital complaints Collect DNA evidence if it is an acute case Screen for infection Provide prophylaxis for pregnancy and Sexually Transmitted Infections Reassure the family and victim Medical involvement is usually an expectation by the legal system Assess for other problems and provide referrals EVIDENCE OF TRAUMA If you don t look, you won t find it. Video/photo documentation Medical findings are compelling evidence May be the only evidence you have in a preverbal child PHYSICAL INDICATORS OF SEXUAL ABUSE Wide spectrum of findings UNLIKELY Anogenital erythema Dysuria Genital pain Rectal Pain Headaches DIAGNOSTIC Abdominal pain Discharge Trauma/bleeding STI s Pregnancy 9

10 FINDINGS DIAGNOSTIC OF SEXUAL ABUSE Pregnancy Sperm/semen found on/in child s body Adams Classification Table, 2018 WHY HAVE A MEDICAL EVALUATION Look for evidence of trauma Look for conditions that might be confused with sexual abuse/ provide second opinion regarding genital complaints Collect DNA evidence if it is an acute case Screen for infection Provide prophylaxis for pregnancy and Sexually Transmitted Infections Reassure the family and victim Medical involvement is usually an expectation by the legal system Assess for other problems and provide referrals CONDITIONS CONFUSED WITH SEXUAL ABUSE Redness Irritant dermatitis Other medical condition Urethral prolapse Lichen sclerosus et atrophicus Non-sexually transmitted infections Labial adhesions Foreign bodies 10

11 FAILURE OF MIDLINE FUSION Congenital midline defect Base of defect is pink and vascular like mucosal tissue Skin edges bordering defect are smooth, often have a rolled appearance Usually is asymptomatic, seen incidentally May be mistaken for trauma or scar ANAL FISSURES A nonspecific finding Usually associated with constipation, passage of large and/or hard stools Can also be seen with irritation from diarrhea or Crohn s Disease One of the most common causes of rectal bleeding in children Anal fissures generally heal within a few days LINEA VESTIBULARIS Midline avascular area Found in about one quarter of non-abused girls May be mistaken for scar in genital area 11

12 LICHEN SCLEROSUS ET ATROPHICUS Dermatologic condition in which skin becomes thin and atrophic Often see parchment -like skin and decreased pigmentation Fissuring of skin and subepidermal hemorrhages appear alarming and may present with bleeding. Treat with emollients, steroid creams (optional) Usually resolves spontaneously in adolescence URETHRAL PROLAPSE Most common in prepubertal African American girls Presents with bleeding, pain, frequent urination, but often asymptomatic May be associated with constipation Exam reveals eversion of urethra in a donut shape -may be mistaken for swollen hymen May treat with estrogen cream, or just observe STRADDLE INJURY Accidental Injury to external, anterior genital area, often over bony prominence of pubic bone Often unilateral Usually no hymenal injury Expect a consistent history of injury and immediate pain and bleeding Abuse Penetrating trauma Injury to posterior rim of hymen Often no injury to external tissues May have disclosure of abuse, but often presents with no history or inconsistent history 12

13 GROUP A STREP Same type of Strep that causes Strep throat and impetigo May be spread by contaminated nasopharyngeal secretions Possible transmission with oral-genital contact? Very red, tender rash, possible discharge Treatment is same as for strep throat ANO-GENITAL VASCULAR LESIONS Lesion blanched, therefore not a bruise. Possible venous engorgement/pooling (most commonly seen in anal area, particularly when traction placed) Possible vascular lesion MOLLUSCUM CONTAGIOSUM A poxvirus infection Painless, dome-shaped, skin-colored papules with umbilicated center Easily transmitted among children, or can be selfinoculated by touching or scratching a lesion May be linked to sexual activity in adults/adolescents, but not considered an STI in children Can be treated by dermatologist but will selfresolve 13

14 LABIAL ADHESIONS Relatively common condition Usually clinically silent Can cause bleeding if lysed during normal activities, genital exam (!) OR sexual abuse Adherence of labia minorae to each other May obscure hymenal opening. VAGINAL FOREIGN BODIES An intravaginal foreign body can develop minor infection with purulent discharge and/or bleeding (at least 50% have bleeding) Toilet paper is the most common culprit FB may be extruded, or may need to be removed under anesthesia (irrigation alone may fail) WHY HAVE A MEDICAL EVALUATION Look for evidence of trauma Look for conditions that might be confused with sexual abuse/provide second opinion regarding genital complaints Collect DNA evidence if it is an acute case Screen for infection Provide prophylaxis for pregnancy and Sexually Transmitted Infections Reassure the family and victim Medical involvement is usually an expectation by the legal system Assess for other problems and provide referrals 14

15 COLLECT DNA EVIDENCE Collect forensic evidence in acute cases Prepubertal: < 72 hours Postpubertal: < 120 hours (depends on contact and other information) Semen, Blood, Saliva (Swabs) Clothing, Linens Other physical injuries that may support the history Date Rape Drugs ACUTE ASSAULT: EVIDENCE KIT Kit is for forensic purposes only Must do separate medical testing Medical providers do not see these results Detailed instructions provided on kit Buccal swab for patient DNA Swabs: oral, vaginal, cervical, rectal Fingernail clippings, pubic hair clippings Woods lamp to detect semen Clothing/linen collection WHY HAVE A MEDICAL EVALUATION Look for evidence of trauma Look for conditions that might be confused with sexual abuse/provide second opinion regarding genital complaints Collect DNA evidence if it is an acute case Screen for infection Provide prophylaxis for pregnancy and Sexually Transmitted Infections Reassure the family and victim Medical involvement is usually an expectation by the legal system Assess for other problems and provide referrals 15

16 WHAT ABOUT SEXUALLY TRANSMITTED INFECTIONS (STI) Urine tests Swabs for anal/throat cultures Laboratory testing Many Sexually transmitted infections can be asymptomatic, but have serious long term consequences Approximately 5% of children that are victims of SA acquire an STI WHAT ABOUT SEXUALLY TRANSMITTED INFECTIONS (STI) Adolescents victims of sexual assault are typically offered prophylaxis for STIs (Gonorrhea, Chlamydia, Trichomoniasis) Prepubertal children should not be treated prior to confirming STIs in most cases The presence of a sexually transmitted infection in a prepubertal child is powerful evidence of sexual abuse HIV post exposure prophylaxis (PEP) and/or Hepatitis B immunization is sometimes indicated after an acute sexual assault WHY HAVE A MEDICAL EVALUATION Look for evidence of trauma Look for conditions that might be confused with sexual abuse/provide second opinion regarding genital complaints Collect DNA evidence if it is an acute case Screen for infection Provide prophylaxis for pregnancy and Sexually Transmitted Infections Reassure the family and victim Medical involvement is usually an expectation by the legal system Assess for other problems and provide referrals 16

17 PROVIDE PROPHYLAXIS STI prophylaxis Adolescents victims of sexual assault are typically offered prophylaxis for STIs (Gonorrhea, Chlamydia, Trichomoniasis) Within 120 hours Prepubertal children should not be treated prior to confirming STIs in most cases HIV prophylaxis within 72 hours for HIV (high risk) May consider medications/immunizations for tetanus and Hepatitis B Pregnancy prophylaxis Within 5 days WHY HAVE A MEDICAL EVALUATION Look for evidence of trauma Look for conditions that might be confused with sexual abuse/provide second opinion regarding genital complaints Collect DNA evidence if it is an acute case Screen for infection Provide prophylaxis for pregnancy and Sexually Transmitted Infections Reassure the family and victim Medical involvement is usually an expectation by the legal system Assess for other problems and provide referrals REASSURANCE, REASSURANCE, REASSURANCE!!! Children who are sexually abused have concerns about their body. They need to know its not their fault Caregivers need reassurance too 17

18 WHY HAVE A MEDICAL EVALUATION Look for evidence of trauma Look for conditions that might be confused with sexual abuse/provide second opinion regarding genital complaints Collect DNA evidence if it is an acute case Screen for infection Provide prophylaxis for pregnancy and Sexually Transmitted Infections Reassure the family and victim Medical involvement is usually an expectation by the legal system Assess for other problems and provide referrals LEGAL EXPECTATIONS Expectation that children have an exam Dispel myths educate juries Medical information can be powerful WHY HAVE A MEDICAL EVALUATION Look for evidence of trauma Look for conditions that might be confused with sexual abuse/provide second opinion regarding genital complaints Collect DNA evidence if it is an acute case Screen for infection Provide prophylaxis for pregnancy and Sexually Transmitted Infections Reassure the family and victim Medical involvement is usually an expectation by the legal system Assess for other problems and provide referrals 18

19 ASSESS FOR OTHER PROBLEMS/PROVIDE REFERRALS Other medical conditions Developmental concerns Psychological concerns Behavior problems REFERENCES Adams, J.A., Harper, K., Knudson, S. et al. (1994). Examination findings in legally confirmed cases of child sexual abuse: it s normal to be normal. Pediatrics 94, 310. Adams, J.A., Farst, K. J., & Kellogg, N. D. (2018). Interpretation of medical findings in suspected child sexual abuse: An update for J Pediatr Adolesc Gynecol, 31, 225e231. Adams, J.A., Kellogg, N.D., Farst, K.J., Harper, N.S., Palusci, V.J., Frasier, L.D., Levitt, C.J., Shapiro, R.A, Moles, R.L., and Starling, S.P. (2015). Updated Guidelines for the Medical Assessment and Care of Children Who May Have Been Sexually Abused. Journal of Pediatric and Adolescent Gynecology, doi: /j.jpag.1-7. Adams, J.A., Starling, S.P., Frasier, L.D., Palusci, V.J., Shapiro, R.A., Finkel, M.A., & Botash, A.S. (2012). Diagnostic accuracy in child sexual abuse medical evaluation: Role of experience, training, and expert case review. Child Abuse and Neglect, 36, REFERENCES Berenson A, Heger, A., Andrews, S. (1991). Appearance of the hymen in newborns. Pediatrics 87: 458. Christian, C.W., Lavelle, J.M., De Jong, A.R. et al (2000). Forensic findings in prepubertal victims of sexual assault. Pediatrics 106: 100. Gallion, H.R., Milam, L.J., & Littrell, L.L. (2016). Genital findings in cases of child sexual abuse: Genital vs. vaginal penetration. J Pediatr Adolesc Gynecol, 29:604. Heger, A., Ticson, L, Velasquex, O., et al. (2002). Children referred for possible sexual abuse: Medical findings in 2384 children. Child Abuse and Neglect 26:

20 REFERENCES Kellogg, N.D., Menard, S.W., Santos, A. (2004). Genital anatomy in pregnant adolescents: normal doesn t mean nothing happened. Pediatrics 223: e67. Lentsch, K.F. & Johnson, C.F. (2000). Do Physicians have Adequate Knowledge of Child Sexual Abuse? The Results of Two Surveys of Practicing Physicians, 1986 and Child Maltreatment, 5:1. Sorenson, T. & Snow, B. (1991). How Children Tell: The process of disclosure in child sexual abuse. Child Welfare 70: 1. QUESTIONS? Contact Information: Dr. Rita Ventura, DNP, FNP-BC Kenosha: / Racine: Rventura@chw.org To report your attendance for the live webinar, text TUXKOS to This code will work for the 12/21/18 session only. It will be active after 12:30 p.m. Once your attendance is tracked, you should login to your account at to complete your evaluation and print a certificate. If viewing the December 21 st session on-demand, please enter access code CABTAS when prompted. 20

Disclosures. Case 1: Objectives: Case 1 11/4/13. Doctor, was there penetration? Why we usually can t tell by looking.

Disclosures. Case 1: Objectives: Case 1 11/4/13. Doctor, was there penetration? Why we usually can t tell by looking. Doctor, was there penetration? Why we usually can t tell by looking. Joyce A. Adams, MD Professor of Clinical Pediatrics University of California, San Diego Rady Children s Hospital San Diego 1 Disclosures